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Has your license ever been revoked?: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.

 
Enter You Name as Proof of Signature: