R&R Insurance - Application For Employment

APPLICATION FOR EMPLOYMENT

R&R Insurance is an Equal Opportunity Employer.

Personal
Name: First: Last: Middle:			Date:
Mailing Address:			Email:
City:		State:	Zip:

Daytime Phone:	Cell Phone:	Are you 18 or older? Yes no

		SocialSecurity Number:

Available:	Full Time Part Time Temporary		Date Available (MM/DD/YYYY):

Are you currently employed?			Yes No

How did you become aware of this position?

Have you previously worked for R&R Insurance as either a regular or temporary employee?			Yes No

Name of Manager:	Department:		Date (MM/YYYY):

Do you have any friends or relatives currently working for R&R Insurance?			Yes No

Name(s):		Relationship:

Are you legally eligible for employment in the United States? Note: Proof of eligibility will be required at the start of employment.			Yes No

Have you ever been convicted of a felony or misdemeanor (other than minor traffic violations)? Note: A conviction will not necessarily disqualify an applicant from employment. The nature and date of the offense, the surrounding circumstances and relevance of the offense to the position applied for may, however, be considered.			Yes No

If yes, please explain, including date:

EDUCATION

	Name/Location	Number of Years Completed	Did you graduate?	Degrees, Licenses, Certifications

High School
College/University
Tech, Vocational, Business, Other

SKILLS
Please list any specialized training, skills, and experience, which may be of value to R&R Insurance. Include all factory, office and computer equipment, bi-lingual skills and software programs in which you are competent:

Licenses and Certifications
License or Certificate	Date	Issuing Authority	County	State

EMPLOYMENT DATA

Give past employment record as completely as possible starting with your current or most recent employer (include Military service). Explain any gaps in employment in the Duties / Comments section below

Employer:	Supervisor:
Your Position:	Employer Phone:
Employer Address:
Employed from:	(MM/YY) to: (MM/YY) Full-time Part-time
Your Salary (hourly):	Starting: Ending:
Reason for leaving:
May we contact for a reference? Yes No Later
If later, please indicate when the reference could be contacted:

Duties/Comments

Employer:	Supervisor:
Your Position:	Employer Phone:
Employer Address:
Employed from:	(MM/YY) to: (MM/YY) Full-time Part-time
Your Salary (hourly):	Starting: Ending:
Reason for leaving:
May we contact for a reference? Yes No

Duties/Comments

Employer:	Supervisor:
Your Position:	Employer Phone:
Employer Address:
Employed from:	(MM/YY) to: (MM/YY) Full-time Part-time
Your Salary (hourly):	Starting: Ending:
Reason for leaving:
May we contact for a reference? Yes No

Duties/Comments

Employer:	Supervisor:
Your Position:	Employer Phone:
Employer Address:
Employed from:	(MM/YY) to: (MM/YY) Full-time Part-time
Your Salary (hourly):	Starting: Ending:
Reason for leaving:
May we contact for a reference? Yes No

Duties/Comments

Employer:	Supervisor:
Your Position:	Employer Phone:
Employer Address:
Employed from:	(MM/YY) to: (MM/YY) Full-time Part-time
Your Salary (hourly):	Starting: Ending:
Reason for leaving:
May we contact for a reference? Yes No

Duties/Comments

Employer:	Supervisor:
Your Position:	Employer Phone:
Employer Address:
Employed from:	(MM/YY) to: (MM/YY) Full-time Part-time
Your Salary (hourly):	Starting: Ending:
Reason for leaving:
May we contact for a reference? Yes No

Duties/Comments

Professional References (Please provide at least three (3) professional references that are not related to you)

Name	Position	Company	Phone

Copy & Paste Your Resume (Optional)

Please Read Carefully Before Signing This Form

All information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired.

I authorize the company to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment.

I understand that upon receiving a job offer, a physical examination and drug screening may be required. (Note: If this is a job requirement, you will be notified).

Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment. I understand that employment at the company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the company's, unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed, written document.
Signature: Date: (MM/DD/YYYY)

R&R INSURANCE SERVICES, INC.

PRE-PLACEMENT DRUG-FREE WORKPLACE POLICY

I. POLICY

R&R Insurance Services, Inc. provides a safe and healthy working environment for all its employees with the expectation that all employees will be free from illegal drugs and/or alcohol use. Use of illegal drugs and/or alcohol can endanger the employee's safety and the safety of other employees or the community.
Our goal, and the purpose of this Policy, is to establish and to maintain a safe, healthy and efficient workforce free from the effects of substance and alcohol use. The presence or use of illegal drugs or alcohol in the workplace conflicts with these vital interests. Therefore, R&R Insurance Services, Inc. requires a pre-employment drug test be successfully completed for an individual to commence employment at R&R Insurance Services, Inc. This program covers all applicants for prospective employment, both full time and part time, temporary employment, consulting employment, contracting employment, and internships.

II. DEFINITIONS

"Legal Drugs" - includes medically authorized prescription drugs and over-the-counter drugs which have been legally obtained and are being used in the prescribed doses and for the purposes for which they were prescribed or manufactured.
"Illegal Drugs" - means any drug (a) which is not legally obtainable; (b) which is legally obtainable but is not being used in the doses prescribed or for the purpose for which they were prescribed.

III. PROCEDURE

Prospective Employees:

1. Prospective employees will be advised of R&R Insurance Services, Inc.'s policy.
2. Prospective employees, who have been extended a conditional offer of employment, will receive copies of this Policy, plus a Consent and Waiver Form to release information. Employment offers are contingent upon successful completion of the drug test.
3. Tests will be conducted by an independent laboratory within 24 hours after the offer of employment is extended. Upon arrival at the test location, the prospective employee will be asked to present proof of identification (two forms). The specimen will be provided to a medical person and all results will be reviewed by a Medical Review Officer. The test will be for the following substances: Amphetamines; Barbiturates; Benzodiazepines; Cocaine: Marijuana; Methadone; Methaqualone; Opiates; Phencyclidine (PCP); and Propoxphene. Prospective employees who fail the test (which will include GC/Ms confirmation) will not be considered for employment for a period of one (1) year and must the re-submit to the entire test. R&R Insurance Services, Inc. will afford prospective employees with a post-testing opportunity to discuss positive results with the Medical Review Officer.
4. Should a testing date need to be re-scheduled, a new date will be no later than 24 hours after the original date. An offer of employment will become null and void should the time period extend past the 24 hours.
5. Prospective employees who refuse to submit for testing will not be further considered for employment for a period of one (1) year and must then re-apply.
6. A prospective employee may appeal the test results within five (5) business days by submitting a written appeal to R&R Insurance Services, Inc.
7. In-house temporary employees and interns who would be on R&R Insurance Services, Inc. payroll must submit to these same procedures.
8. Contract/temporary employees, interns or consultants from agencies must also submit to the above outlined procedures if their assignment if scheduled for more than five (5) business days.

IV. OVERALL

1. All test results/correspondence will be maintained in a file separate from employee personnel file.
2. All information is considered confidential.
3. Upon written request, test results will be furnished to the prospective employee.
4. This policy also applies to all rehires, both temporary or regular who have been separated from the company for ninety (90) days or more.
5. This policy is not intended to create any contractual obligation or relationship between R&R Insurance Services, Inc. and each candidate/employee/vendor. The relationship remains at-will and can be terminated, with or without cause, and with or without notice at any time, at the option of either R&R Insurance Services, Inc. or the employee.

R&R Insurance Services, Inc. reserves the right to make changes in its policies, practices or benefits when it deems necessary or useful to do so.

Signature: Date: (MM/DD/YYYY)