UAI Employment Questionnaire

Please complete all required fields and attach your resume – if available.

Personal Information

red color - denotes required fields

Name:

Address:

City:

State:

Zipcode:

Email:

Primary Phone:

Have you ever been previously employed by UAI?

Are you bilingual -- English and Spanish?

Are you bilingual -- English and Polish?

Computer Skills:

Education Level:

School Name:

City:

Potential Start Date:

Desired Salary:

Desired Salary Type:

How did you hear about this job listing?:

Resume ? if available:

Is There Anything Else You Want To Tell Us?:

Employment History

Starting with your MOST CURRENT Employer, please provide the following information:

Employer #1:

Address:

City:

State:

Zipcode:

Starting Date:

Ending Date:

Starting Salary:

Starting Salary Type:

Ending Salary:

Ending Salary Type:

Starting Job Title:

Ending Job Title:

Summarize your duties/responsibilities?:

What do you like BEST about the position?:

What do you like LEAST about the position?:

Why did you leave?:

Employer #2:

Address:

City:

State:

Zipcode:

Starting Date:

Ending Date:

Starting Salary:

Starting Salary Type:

Ending Salary:

Ending Salary Type:

Starting Job Title:

Ending Job Title:

Summarize your duties/responsibilities?:

What do you like BEST about the position?:

What do you like LEAST about the position?:

Why did you leave?:

Equal Opportunity Employment

The following voluntary information is requested by United Auto Insurance to evaluate its hiring practices and to prepare reports required by law for the State and Federal Government. This information is confidential and will NOT be used to make a decision about your employment.

Ethnicity:

Date of Birth:

You may leave "Date of Birth" blank if you prefer not to answer.

Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account. NOTE: You are not obligated to disclose sealed or expunged records of conviction or arrest or expunged juvenile records of conviction or arrest.

Have you ever pleaded "guilty" or "no contest" to or been convicted of a felony?

If YES, please provide date(s) and details: