County FB Application for Employment

County Farm Bureau Application for Employment
Basic Contact Information
Select the position you are applying for *
There are currently 2 open coordinator positions
Name

Prefix First Name Middle Name Last Name Suffix
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone *

Area Code Phone Number
E-mail *
I certify that I am authorized to work in the United States: *

Yes No
Salary Requirements
Per

Hourly Monthly Annually
Type of Employment

Full Time Part Time Temporary
Date Available:

Month Day Year
Are you willing to travel, if required by this position?

Yes No
Educational Background

University/College/Institution:
Degree:

Yes No
Area of Study:
Level Achieved:

BA/BS Masters Doctorate Other

Click to add another University/College/Institution
Entry 2
University/College/Institution:
Degree:

Yes No
Area of Study:
Level Achieved:

BA/BS Masters Doctorate Other

Click to add another University/College/Institution
Entry 3
University/College/Institution:
Degree:

Yes No
Area of Study:
Level Achieved:

BA/BS Masters Doctorate Other

Other Education
Other Education / Training / Certifications
School/Entity Providing Training:
Certification/License:

Click to add another Education/Training/Certification
Entry 2
School/Entity Providing Training:
Certification/License:

Click to add another Education/Training/Certification
Entry 3
School/Entity Providing Training:
Certification/License:

Employment History Section
Employment History

(This section may be omitted if a resume is uploaded at the end of the form)

Current or most recent employer
Employer
From

Month Day Year
To

Month Day Year
Supervisor's Name & Title:
May we contact this Employer for a reference?

Yes No
If it is possible to contact this employer, please provide their phone and email below
Employer's Phone Number

Area Code Phone Number
Employer's Email
Your Job Title:
Job Title
Summary of your job responsibilities:

Click to add another prior employer
Employer
From

Month Day Year
To

Month Day Year
Supervisor's Name & Title:
May we contact this Employer for a reference?

Yes No
If it is possible to contact this employer, please provide their phone and email below
Employer's Phone Number

Area Code Phone Number
Employer's Email
Your Job Title:
Job Title
Summary of your job responsibilities:

Click to add another prior employer
Employer
From

Month Day Year
To

Month Day Year
Supervisor's Name & Title:
May we contact this Employer for a reference?

Yes No
If it is possible to contact this employer, please provide their phone and email below
Employer's Phone Number

Area Code Phone Number
Employer's Email
Your Job Title:
Job Title
Summary of your job responsibilities:

References
References
List name and phone number of three business/work references who are not related to you and are not already included as an immediate supervisor on your Employment History. If you have no prior employment history, please list three non-related school or personal references.
Reference Name
Reference Phone number

Area Code Phone Number
How are you acquainted with this individual?
Reference Name
Reference Phone number

Area Code Phone Number
How are you acquainted with this individual?
Reference Name
Reference Phone number

Area Code Phone Number
How are you acquainted with this individual?
Submitting your information
You have the option to attach a cover letter and/or resume below:
Cover Letter
Resume
Affirmation to the Truthfulness of the Information Provided on this Application and Agreement Permitting the "Employer" to Seek Additional Job-Related Information

It is understood and agreed upon that any misrepresentations by me in this application is sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed. Furthermore, I understand employment within the organization (hereafter "Employer") is at-will. That means I am free to resign at any time and the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary. I affirm that I have a genuine intent and no other purposes in applying for a job with this company. I give the Employer the right to investigate all references and to secure additional information about me, if job-related. I hereby release from liability the Employer and its representative for seeking such information and all other persons, corporations or organizations for furnishing such information. The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law. This application is current for 90 days. At the conclusion of this time, if I have not heard from the Employer and still wish to be considered for employment, it will be necessary to re-apply by completing a new application for employment.
Take this moment to go back through your application and check for errors.

You will receive an email confirmation with all the information you submitted. If you have something you need to correct after submitting, there is a link in that email you can click to edit your original submission.
Check this box to verify that you have read and agree to the terms above and that you are ready to submit your application *

I agree
Type your name below to serve as an electronic signature *
Date

Month Day Year
Should be Empty:

County Farm Bureau Application for Employment

Basic Contact Information

Educational Background

Other Education / Training / Certifications

Employment History

References

Submitting your information