Fill and Sign the Jackson National Life Insurance Forms

   A Professional Employer Organization EMPLOYMENT APPLICATION All applicants will receive consideration for employment without regard to race, color, religion, sex, age, marital status, arrest and court record, national origin or disability. The following information is requested in order to help us make the best possible placement within the company. Our company subscribes to a DRUG FREE WORKPLACE. YOU MAY BE REQUIRED TO SUBMIT TO A DRUG SCREEN AS PART OF YOUR INITIAL APPLICATION PROCESS. All portions of this application pertaining to you must be completed. Please do not refer to your resume. WE APPRECIATE THE TIME YOU SPEND IN COMPLETING THIS APPLICATION. POSITION DESIRED Position Applied For: Location: Date You Can Begin Work: Check () One: Social Security #:  Full-Time  Part-Time PERSONAL Name: Mailing Address: Telephone: Message: CONSENT FOR BACKGROUND INVESTIGATION It is the intent of the company to keep all information we receive during any background investigation private and confidential. Please read and sign the following statement below allowing the company to verify past employment information given on this application. "I hereby agree to have an assigned company representative contact anyone necessary to investigate or verify any information I have given on this application, or to discuss my background, past performance or my suitability for employment. I further agree to having my work background discussed by any person so contacted, and waive all my rights to bring any action for defamation, invasion of privacy, or any other similar cause of action, against anyone contacted as a result of what is said about me. I also understand that the information I supply will be checked and that any false statement or omission of fact or facts in connection with this Application for Employment will result in no offer of employment or dismissal from the company if I am employed." Signature: Date: Hawaii Kai Corporate Plaza 6600 Kalanianaole Hwy.  Suite 200  Honolulu, Hawaii 96825 Ph: (808) 394-8878  Fax: (808) 394-6592 Toll Free Ph: (888) 892-8878  Toll Free Fax: (888) 783-8333 Revised 05.13.02 WORK EXPERIENCE Please account for all time for the last five (5) years. Include periods of unemployment and any prior employment by this company. Begin with your most recent job. Use a separate piece of paper if needed. DO NOT REFERENCE YOUR RESUME. Present Employer: Address: From Month/Year: To Month/Year: Starting Wage/Salary: Ending Wage/Salary: Supervisor: Telephone: Title and Description of your duties: Employer: Address: From Month/Year: To Month/Year: Starting Wage/Salary: Ending Wage/Salary: Supervisor: Telephone: Title and Description of your duties: Employer: Address: From Month/Year: To Month/Year: Starting Wage/Salary: Ending Wage/Salary: Supervisor: Telephone: Title and Description of your duties: Employer: Address: From Month/Year: To Month/Year: Starting Wage/Salary: Ending Wage/Salary: Supervisor: Telephone: Title and Description of your duties: Hawaii Kai Corporate Plaza 6600 Kalanianaole Hwy.  Suite 200  Honolulu, Hawaii 96825 Ph: (808) 394-8878  Fax: (808) 394-6592 Toll Free Ph: (888) 892-8878  Toll Free Fax: (888) 783-8333 Revised 05.13.02 REFERENCES Please list two former supervisors and/or associates who are acquainted with your work performance. Name & Title: Organization: Working Relationship: Telephone: Name & Title: Organization: Working Relationship: Telephone: GENERAL INFORMATION Federal law prohibits the employment of unauthorized persons. Should you be hired, satisfactory proof of employment authorization and identity will be required within three (3) working days of hire. Failure to submit such proof within the required time will result in immediate dismissal. If hired, can you furnish proof of citizenship/authorization to work? If you are under the age of 18 years old, do you have a work permit? If required, would you be willing to work shifts? If required, would you be willing to work weekends? If required, would you be willing to work holidays? Are you able to perform the essential functions of the job, which you are applying, with our without reasonable accommodations, in a safe and efficient manner? Do you have any relatives/personal friends working for the company? If yes, who?  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No MOTOR VEHICLE OPERATION If this box has been checked, your job requires the operation of a motor vehicle. Please complete the following: Driver’s License State & Number: Expiration Date: Have your driving privileges ever been suspended or revoked? Type/Class:  Yes  No SKILLS & LICENSES List all office, technical or professional skills and/or certificates, licenses and bilingual ability you possess that are relevant to the position which you are applying. MILITARY SERVICE  Yes Were you a member of the military services?  No If yes, please give dates: Branch of Service: Rank or Grade: Hawaii Kai Corporate Plaza 6600 Kalanianaole Hwy.  Suite 200  Honolulu, Hawaii 96825 Ph: (808) 394-8878  Fax: (808) 394-6592 Toll Free Ph: (888) 892-8878  Toll Free Fax: (888) 783-8333 Revised 05.13.02 EDUCATION High School: Years Attended: Graduated? College: Years Attended: Graduated? Years Attended: Graduated? Years Attended: Graduated? Area of Study? College: Area of Study? Trade/Business School: Area of Study? PLEASE READ THIS SECTION BEFORE YOU SIGN THIS EMPLOYMENT APPLICATION FORM. I certify that answers given in this application are true and complete to the best of my knowledge. I understand that any false statements or omissions on this application could result in my separation from the company. I understand the employer is not obligated to offer the position to me, even after completing this application for a job interview. I understand that the company has certain rules and procedures that must be followed. I agree that if I am employed I will follow the company rules subject to disciplinary action. I understand the company is an atwill employer, which means that any term of employment is for no definite period of time regardless of the date or payment of wages. If I am employed, such employment may be ended with or without cause or notice. No verbal agreement made during this application or interview process can be relied upon unless such agreements are in writing and signed by the owner or the president of the company. Rather than engage in the delay and expense of courts, we agree to submit to binding arbitration any dispute relation to this application or to my employment or separation from employment resulting from this application. Any arbitration will be before a single arbitrator, selected by mutual consent, and will take place in the jurisdiction where the dispute arises. The National Rules for the Resolution of Employment Disputes of the American Arbitration Association will govern the arbitration procedure and the Federal Arbitration Act and the laws of the State of Hawaii will govern the substance of the dispute. I understand that if the company hires me, my employment is conditional on my ability to provide proof of work authorization and identity as required by Federal Law and the completion of any post employment requirement of the employer. Employee Signature: Date: Hawaii Kai Corporate Plaza 6600 Kalanianaole Hwy.  Suite 200  Honolulu, Hawaii 96825 Ph: (808) 394-8878  Fax: (808) 394-6592 Toll Free Ph: (888) 892-8878  Toll Free Fax: (888) 783-8333 Revised 05.13.02