Employment Application

Tejas Insurance Agency
Employment Application
7728 Long Point Rd Ste 100
Houston, TX 77055
(713) 686-1006 - Fax (713) 686-1228

First Name *

Last Name *

SSN

E-Mail Address *

Primary Phone Number *

Street *

City *

State *

ZIP / Postal Code *

Prior address if less than 7 yrs (Street, City, State Zip):

Position Applying for: *

Desired Salary: $

Are you eligible to work in the United States? *

Applying for: *

Date available to begin work: *

Do you speak Spanish? *

If yes, fluently?

Do you have a valid driver's license? *

If yes, indicate license #

State issued:

Expiration date:

Class:

Endorsements:

Do you own a vehicle? *

If not, what form of transportation do you use?

POLICE AND DRIVING RECORDS WILL BE CHECKED

With the exception of any offense committed before your 18th birthday, list below all offenses against the law (other than minor traffic violations) where you have been found guilty,

where charges are pending adjudication, where you pled guilty or nolo contendere, where adjudication was withheld, or where you were placed on probation or in a supervised program.

You do not have to list charges that were dropped or of which you were found innocent. Criminal convictions are not an automatic bar to employment and will only be considered in relation to the position for which you are applying.

However, omissions or deceptive statements may disqualify you from examination, certification, appointment or retention.

Date - Charge - City/County/State - Disposition

Highest Grade Completed *

High School

Name of School

Dates attended (From - To)

Did you graduate? *

If no, do you have an Equivalency Certificate (GED)?

Issued by (State):

Issue date:

College / University

Name of School

Dates attended (From - To)

Degree

Associates
Bachelor's

Did you graduate?

Graduate date:

Major:

Minor:

College / University

Name of School

Dates attended (From - To)

Degree

Associates
Bachelor's

Did you graduate?

Graduate date:

Major:

Minor:

Graduate studies

Name of School

Dates attended (From - To)

Master's degree

Other:

Did you graduate? *

Vacation or Business

Name of School

Dates attended (From - To)

Major study:

Hrs Completed:

Certification/Diploma received?

Computer training

Name of School

Dates attended (From - To)

Course title:

Hrs Completed:

Certification/Diploma received?

Other occupational licenses or Certificates:

Languages other than english:

Spoken fluently:

Written fluently:

List any other additional information that may help us consider your application, including special training, equipment that you can operate and the number of years of experience,

computer applications and skill level, typing speed (if applicable), and any awards and professional organizations that relate to the job for which you are applying:

In case of emergency notify (Name, Address, Phone No.)

All applicants must complete the following even if you have sent or attached a resume. Please complete all information requested, beginning with your most recent employer.

List employers separately, including military service and any periods of unemployment. If your immediate supervisor is no longer with the employer,

list someone who knows your work. If you were employed under another name, please indicate. Explain any gaps in employment.

Present or Most Recent Employer:

Name of employer:

Job Title:

Address:

City

State

Zip

Start date:

Last date:

Ending salary:

Name, title, and telephone number of your immediate supervisor:

May we contact your present employer regarding your employment record?

Describe specific duties and responsibilities:

Reason for leaving:

Next Previous Employer:

Name of employer:

Job Title:

Address:

City

State

Zip

Start date:

Last date:

Ending salary:

Name, title, and telephone number of your immediate supervisor:

May we contact your present employer regarding your employment record?

Describe specific duties and responsibilities:

Reason for leaving:

Next Previous Employer:

Name of employer:

Job Title:

Address:

City

State

Zip

Start date:

Last date:

Ending salary:

Name, title, and telephone number of your immediate supervisor:

May we contact your present employer regarding your employment record?

Describe specific duties and responsibilities:

Reason for leaving:

Please Read Before Signing Application Form

By applying for this position and signing this application, I voluntarily authorize and grant full consent to Tejas or its agent to conduct a thorough investigation into my prior employment and any other area of my background,

including criminal background (regardless of adjudication) and driver’s license checks which Tejas believes to be relevant to my employment.

I do further consent to the release and disclosure to Tejas or its agent from any persons, companies, corporations or government agency any information sought concerning my background and do further release from liability Tejas or its agents for actions

taken in connection with this investigation, as well as any persons, companies and corporations or government agencies disclosing such information.

I understand that job offers extended by Tejas Insurance in some or all job classifications are conditioned upon successful completion of a physical examination by an authorized physician who will determine whether I can perform

the essential functions of the position offered, with or without reasonable accommodations. In addition, I voluntarily consent and agree to pre-employment drug testing and the results of the test to be released to Tejas Insurance.

I understand that if I fail the pre-employment drug test, Tejas may withdraw my employment offer. Furthermore, Tejas Insurance Agency will pay the cost of my physical examination and drug screening will be deducted from my final paycheck.

I acknowledge that any false information provided by me to Tejas may constitute grounds for immediate discharge, regardless of when the false information is discovered by Tejas. Similarly, I understand that my continued employment is contingent

on successfully passing a background investigation as determined by Tejas.

Any information discovered about me during this investigation, which was deemed by Tejas to be unsatisfactory, may constitute grounds for immediate discharge, regardless of when discovered.

Signature *

Date *

Tejas Insurance Agency is an Equal Opportunity Employer. Qualified applications are considered for emplyment and treated without regard to race, color, religion, sex, national orgin, age, disability, marital status, sexual preference.

*YOU MAY INCLUDE A COPY OF YOUR RESUME IN ADDITION TO THIS APPLICATION.

Upload Resume

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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