1 | P a g e

Vspec Vehicle Claim Specialists EMPLOYMENT APPLICATION

We are an equal opportunity employer and do not discriminate in any aspect of employment on the basis of any protected status in accordance with the requirements of federal, state, and local law.

FOR MANAGERS USE ONLY

Starting Date:

Starting Pay:

Position:

Location:

Full Time Part Time Temporary Seasonal

DATE:

PERS

ONA

L

LAST NAME FIRST NAME MIDDLE INITIAL

ADDRESS CITY STATE ZIP CODE

EMAIL ADDRESS AREA CODE/TELEPHONE NO.

ARE YOU AT LEAST 18 YEARS OF AGE? HOW DID YOU LEARN OF THIS OPENING? ARE YOU WILLING TO WORK OVERTIME?

YES NO YES NO

HAVE YOU PREVIOUSLY WORKED WITH THIS COMPANY? ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES?

YES NO YES NO

IF YES, WHEN? IF NO, PLEASE EXPLAIN.

PREF

EREN

CES

POSITION(S) APPLIED FOR Full Time Part Time

Temporary Seasonal

MAY WE CONTACT YOUR PRESENT EMPLOYER BEFORE YOUR EMPLOYMENT ENDS?

YES NO

DATE AVAILABLE FOR WORK STARTING PAY DESIRED

EDUC

ATIO

N

NAME OF INSTITUTION ATTENDED CITY AND STATE OF INSTITUTION SELECT LAST YEAR COMPLETED

SENIOR HIGH SCHOOL LOCATION DIPLOMA GPA 09

10

11

12

YES NO

COLLEGE LOCATION Type of Degree Major GPA 1 2 3 4

COLLEGE LOCATION Type of Degree Major GPA 1 2 3 4

OTHER LOCATION Type of Degree - Certificate GPA No. of Mos.

PROFESSIONAL CERTIFICATIONS OR DESIGNATIONS

2 | P a g e

LIST BELOW ALL PRESENT AND PAST EMPLOYMENT, BEGINNING WITH YOUR MOST RECENT. EM

PLO

YMEN

T H

ISTO

RY

1 NAME, ADDRESS, AND

PHONE NUMBER OF EMPLOYER

FROM TO POSITION(S) HELD

DESCRIBE THE WORK YOU DID

STARTING PAY

REASON FOR LEAVING MO YR MO YR

LAST PAY NAME OF SUPERVISOR

(AREA CODE) TELEPHONE

2 NAME, ADDRESS, AND

PHONE NUMBER OF EMPLOYER

FROM TO POSITION(S) HELD

DESCRIBE THE WORK YOU DID

STARTING PAY

REASON FOR LEAVING MO YR MO YR

LAST PAY NAME OF SUPERVISOR

(AREA CODE) TELEPHONE

3 NAME, ADDRESS, AND

PHONE NUMBER OF EMPLOYER

FROM TO POSITION(S) HELD

DESCRIBE THE WORK YOU DID

STARTING PAY

REASON FOR LEAVING MO YR MO YR

LAST PAY NAME OF SUPERVISOR

(AREA CODE) TELEPHONE

4 NAME, ADDRESS, AND

PHONE NUMBER OF EMPLOYER

FROM TO POSITION(S) HELD

DESCRIBE THE WORK YOU DID

STARTING PAY

REASON FOR LEAVING MO YR MO YR

LAST PAY NAME OF SUPERVISOR

(AREA CODE) TELEPHONE

5 NAME, ADDRESS, AND

PHONE NUMBER OF EMPLOYER

FROM TO POSITION(S) HELD

DESCRIBE THE WORK YOU DID

STARTING PAY

REASON FOR LEAVING MO YR MO YR

LAST PAY NAME OF SUPERVISOR

(AREA CODE) TELEPHONE

6 NAME, ADDRESS, AND

PHONE NUMBER OF EMPLOYER

FROM TO POSITION(S) HELD

DESCRIBE THE WORK YOU DID

STARTING PAY

REASON FOR LEAVING MO YR MO YR

LAST PAY NAME OF SUPERVISOR

(AREA CODE) TELEPHONE

3 | P a g e

PR

OFE

SSIO

NA

L RE

FER

ENC

ES

PROVIDE THE NAMES AND PHONE NUMBERS OF THREE FORMER EMPLOYERS OR INDIVIDUALS WHO CAN SPEAK OF YOUR WORK PERFORMANCE

NAME NAME NAME

ADDRESS ADDRESS ADDRESS

CITY, STATE, ZIP CITY, STATE, ZIP CITY, STATE, ZIP

TELEPHONE YEARS KNOWN TELEPHONE YEARS KNOWN TELEPHONE YEARS KNOWN

OCCUPATION OCCUPATION OCCUPATION

TRAI

NING

AND

EXP

ERIE

NCE

OTHER TRAINING AND EXPERIENCE

Describe any training, experience, or qualifications (not previously covered) that might be of interest to the company in considering your application.

SUPERVISORY EXPERIENCE

Have you ever supervised people? YES NO

If yes, explain nature of supervision:

AGRE

EMEN

T

APPLICANT’S STATEMENT

By signing below, I certify that the answers and information set out above are true, accurate and complete. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired, or if hired, I may be discharged. I authorize any person, organization, or company listed on this application to furnish the Company any and all information concerning my employment history, education, and qualifications for employment. I also authorize the Company to request and receive such information. I also acknowledge that any offer or acceptance of employment may be withdrawn, or if hired, my employment may be terminated, at any time, with or without cause, and with or without prior notice at my discretion or the discretion of the Company. I also understand that any offer of employment may be conditional upon my passing a post-offer physical examination including a drug screen administered by a health care professional selected by the Company, to which I hereby consent. This application will be retained by the Company for 90 days. After 90 days, if I wish to be considered for employment it will be necessary for me to complete another application. I understand and agree to all of the conditions and statements set forth above, and throughout this application.

Signature of Applicant Date

Printed Name