<%Option Explicit%>
Andreini & Company - Contact Information
<%'Contact_Us_Form.asp
'
' Created: 03/03/2004
' Author: Jon Board
'
' This form accepts user input and posts it to a request handler.
'*********************************
'Form Globals
'form values
dim jobfilename
'configuration settings
jobfilename = "joblist.txt"
dim errorLevel
dim firstName
dim middleName
dim lastName
dim companyName
dim street1
dim street2
dim city
dim state
dim zip
dim homePhone
dim cellPhone
dim workPhone
dim mayWeContactYouAtWork
dim emailAddress
dim insuranceTypeList
dim businessList
dim numOfEmps
dim renewalDate
dim businessRisks
dim officeChoice
dim jobList
dim counter
dim mailMsg
dim CRLF
dim strFileName
dim strLine
dim objFSO
dim TS
dim attachPath
dim upl
CRLF = Chr(13) & Chr(10)
buildJobDropdown()
sub buildJobDropdown()
strFileName = Server.MapPath(jobfilename)
Set objFSO = Server.CreateObject("Scripting.FileSystemObject")
Set TS = objFSO.OpenTextFile(strFileName)
If Not TS.AtEndOfStream Then
Do While Not TS.AtendOfStream
strLine = TS.ReadLine ' Read one line at a time
jobList = jobList & ""
Loop
end if
TS.Close
Set TS = Nothing
Set objFSO = Nothing
end sub
%>
Andreini & Company provides insurance, Risk Management and Employee
Benefits to clients throughout California and Nevada. Please contact the
office nearest to you for more information about our services.
Position(s)
Applied For:
Contact
Information
Full
Name:
(First, Middle Initial, Last)
Company Name:
Current
Address 1:
Address
2:
City,
State, Zip:
Home
Phone:
Cell
Phone:
Work
Phone:
May we contact your at work?
Yes
No
E-mail
Address:
Education
and Licensing
Check
the boxes that indicate all levels of completed education:
High
School Graduate
Some College
Graduate School
Trade or Business School
Do you currently hold an active insurance license in any state?:
Yes
No
If
Yes, please give us your license information:
(License Type, State, Number)
Has your license ever been revoked?:
Yes
No
Any restrictions?:
Yes
No
If Yes, give reason:
List
any other licenses, certificates or designations you currently hold:
Do you speak another language?:
Yes
No
If yes, what language?:
General
Information
Have you ever been employed with this company before?:
Yes
No
If
yes, what dates?:
Do
you have any relatives that are already employed?:
Yes
No
Date
available for work:
Desired
salary range:
If
hired, would you have a reliable means of transportation to and from
work?
Yes
No
Are
you at least 18 years old?
Yes
No
If
hired, can you present evidence of your U.S. citizenship or proof
of your legal right to live and work in this country?
Yes
No
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?:
Yes
No
If
No, please describe the functions that cannot be performed:
Have
you ever been convicted for a msidemeanor or felony?
Yes
No
(Exclude convictions for marijuana-related offenses for personal use more than two years old; convictions that have been sealed, expunged or legally eradicated, and misdemeanor convictions for which probation was completed and the case was dismissed.)
If
yes, please briefly describe the nature of the crime(s), the date
and place of conviction and the legal disposition of the case:
This company will not deny employment to any applicant solely because the person has been convicted of a crime. The company, however, may consider the nature, date and circumstances of the offense as well as whether the offense is relevant to the duties of the position applied for.
Are
you currently out on bail, the subject of a current warrant for arrest
or released on your own recognizance pending trial?
Yes
No
Additional
Information
Please
list any additional professional information:
Please exclude memberships that would reveal race, color, religion, sex, sexual orientation, national origin, citizenship, age, mental or physical disabilities, veteran/reserve national guard or any other similarly protected status.
PLEASE
READ CAREFULLY, INITIAL EACH PARAGRAPH AND SIGN BELOW:
I
hereby certify that I have not knowingly withheld any information
that might adversely affect my chances for employment and that the
answers given by me are true and correct to the best of my knowledge.
I further certify that I, the undersigned applicant, have personally
completed this application. I understand that any omission or misstatement
of material fact on this application or on any document used to
secure employment shall be grounds for rejection of this application
or for immediate discharge if I am employed, regardless of the time
elapsed before discovery.
I
hereby authorize Andreini & Company to thoroughly investigate
my references, work record, education, criminal background and other
matters related to my suitability for employment and, further, authorize
my past employers I have listed to disclose to Andreini & Company
all letters, reports and other information related to my work records,
without giving me prior notice of such disclosure. In addition,
I hereby release Andreini & Company, my former employers and
all other persons, corporations, partnerships and associations for
any and all claims, demands or liabilities arising out of or in
any way related to such investigation or disclosure.
I
understand that nothing contained in the application, or conveyed
during any interview which may be granted or during my employment,
if hired, is intended to create an employment contract between me
and Andreini & Company. In addition, I understand and agree
that if I am employed, my employment is for no definite or determinable
period and may be terminated at any time, with or without prior
notice, at the option of either myself or Andreini & Company,
and that no promises or representations contrary to the foregoing
are binding on Andreini & Company unless made in writing and
signed by me and Andreini & Company's designated representative.
