Louisiana Citizens Property Insurance Corporation Application Form

We consider applications without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status or any other legally protected status.

Basic Information:

Position(s) Applied For:

Date of Application

Enter today's date in the following format: dd/mm/yyyy

How Did You Learn About Us?

Other:

Describe 'Other' if selected.

Last Name:

Address 1:

Apartment Number:

Zip:

Telephone Number:

Enter a phone number in the following format: 000-000-0000

First Name:

City:

State:

Enter a 2 digit state abbreviation

E-Mail Address:

Background Survey:

If you are under 18 years of age, can you provide required proof of your eligibility to work?

Yes No

Best Time to Contact You:

Example: 8:00am - 4:00pm

Have you ever filed an application with us before?

Yes No

If Yes, give date:

If yes, enter the date in the following format: dd/mm/yyyy

Have you ever been employed with us before?

Yes No

If Yes, give date:

If yes, enter the date in the following format: dd/mm/yyyy

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May we contact your present employer?

Yes No

Do any of your friends or relatives, other than spouse, work here?

Yes No

Are you currently employed?

Yes No

What is your desired salary range?

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.

Yes No

Date Available for Work:

Enter the date in the following format: dd/mm/yyyy

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Are you available to work:

Full Time
Part Time
Temporary

Are you currently on "lay-off" status and subject to recall?

Yes No

Can you travel if a job requires it?

Yes No

Have you been convicted of a felony within the last five years?

Yes No

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Education:

Education History

Select the Highest Level of Completed Education:

Name of School

Address

Course of Study

Number of Years Completed

Diploma Degree

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Describe any specialized training, apprenticeship, skills and extra-curricular activities:

Specialized training, apprenticeship, skills and extra-curricular activities

Enter the name of your specialized skill, training, apprenticeship and any other extra-curricular activites

Date Completed:

Enter the date in the following format: dd/mm/yyyy

Details

Describe the specialized training, apprenticeship, skills and extra-curricular activities in detail.

..........................................................................................................................................................

Describe any job-related training received in the United States Military.

Specialized training, apprenticeship, skills and extra-curricular activities

Enter the name of your specialized skill, training, apprenticeship and any other extra-curricular activites

Date Completed:

Enter the date in the following format: dd/mm/yyyy

Details

Describe the specialized training, apprenticeship, skills and extra-curricular activities in detail.

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Employment Experience:

Employment History

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.

Employer:

Address:

Enter the address, city, state and zip code

Dates Employed:

mm/yy - mm/yy

Supervisor:

Job Title:

Telephone Number:

Enter a phone number in the following format: 000-000-0000

Hourly Rates/Salary:

Reason for Leaving:

Work Performed:

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Employer:

Job Title:

Address:

Enter the address, city, state and zip code

Dates Employed:

mm/yy - mm/yy

Telephone Number:

Enter a phone number in the following format: 000-000-0000

Hourly Rates/Salary:

Supervisor:

Reason for Leaving:

Work Performed:

..........................................................................................................................................................

List professional, trade, business or civic activities and offices held.

You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

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Additional Information:

Other Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

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Typewriter Words Per Minute

Shorthand Words Per Minute

Production/Mobile Machinery (List)

Other (List)

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State any additional information you feel may be helpful to us in considering your application.

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Note to Applicants: DO NOT ANSWER THIS QUESTION BELOW UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation?

YesNo

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References

Name

Reference First and Last Name

Telephone Number:

Enter a phone number in the following format: 000-000-0000

Address:

Enter the address, city, state and zip code

Name

Reference First and Last Name

Telephone Number:

Enter a phone number in the following format: 000-000-0000

Address:

Enter the address, city, state and zip code

Name

Reference First and Last Name

Telephone Number:

Enter a phone number in the following format: 000-000-0000

Address:

Enter the address, city, state and zip code

Name

Reference First and Last Name

Telephone Number:

Enter a phone number in the following format: 000-000-0000

Address:

Enter the address, city, state and zip code

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Applicant's Statement:

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days.

Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless other wise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant

Date Completed:

Enter the date in the following format: dd/mm/yyyy

..........................................................................................................................................................

FOR PERSONNEL DEPARTMENT USE ONLY

Arrange Interview:

Remarks:

Interviewer:

Date:

Enter the date in the following format: mm/dd/yyyy

Employed:

Date of Employment

Enter date in the following format: mm/dd/yyyy

Job Title

Hourly Rate / Salary:

Department:

By (Name and Title) :

Date:

Enter date in the following format: mm/dd/yyyy

Position(s) Applied For is Open:

Date:

Enter date in the following format: mm/dd/yyyy

Position(s) Considered For:

Upload Resume

Please attach a resume to accompany your submitted job application.

Generate New Image

Type the code from the image

We consider applications without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status or any other legally protected status.

Basic Information:

How Did You Learn About Us?

Background Survey:

..........................................................................................................................................................

..........................................................................................................................................................

..........................................................................................................................................................

Education: Education History

..........................................................................................................................................................

Describe any specialized training, apprenticeship, skills and extra-curricular activities:

..........................................................................................................................................................

Describe any job-related training received in the United States Military.

..........................................................................................................................................................

Employment Experience: Employment History

..........................................................................................................................................................

..........................................................................................................................................................

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Additional Information:

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References

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Applicant's Statement:

..........................................................................................................................................................

FOR PERSONNEL DEPARTMENT USE ONLY

Education:

Education History

Employment Experience:

Employment History