Cooper, Simms, Nelson, & Mosley, Insurance

Online Employment Application

To send us your resume, please fill in the form below and select the Submit Resume button.

Please provide a street address (no P.O. Box)

Last Name:	First: MI:
Address1:
Address2:
City:
State/Province:	ZIP/Postal:
Country:
Home Phone:	-- Ext.
Work Phone:	-- Ext.
Email:

Experience:

Fill in your job experience starting with your most recent position. Enter dates using this format: MM/YY

1.	Current place of employment
	From:	To:	Position:	Employer:
	Your Responsibilities:
2.	From:	To:	Position:	Employer:
	Your Responsibilities:
3.	From:	To:	Position:	Employer:
	Your Responsibilities:

Education:

1.	School:	Graduation Date:
	Major:	Degree:

2.	School:	Graduation Date:
	Major:	Degree:

3.	School:	Graduation Date:
	Major:	Degree:

Job Desired:

Position:
Salary:
Date you can start:	(mm/dd/yy)

Licensing Information:

	Property and casualty :
	Life and health:
C.S.R. Designation:

"I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT THAT THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE."

	I have read the above statement, and both understand and agree to it.

Date:	(mm/dd/yy)