Position applying for: Specific Job #
Which area would you like to work?
Daytona Beach, FL
Ft. Lauderdale/Hollywood, FL
Ft. Myers/Cape Coral, FL
Lake City, FL
Melbourne/Palm Bay, FL
Panama City, FL
Port St Lucie/Ft Pierce, FL
St. Augustine, FL
St Petersburg/Clearwater, FL
West Palm Beach/Boca Raton, FL
La Grange, GA
Bowling Green, KY
Baton Rouge, LA
Lake Charles, LA
New Orleans, LA
Rocky Mount, NC
Hilton Head, SC
Myrtle Beach, SC
Johnson City, TN
Have you ever applied to CCI before?
If you were referred to CCI by an existing employee or
Level of Education Completed
What type of Drivers License do you currently have?
Issued in what state?
How many accidents have you been involved within the
previous 5 years?
6 or more
How many claims have you presented to YOUR insurance company
in the last 5 years?
6 or more
Are you currently employed?
How much notice do you need to give?
None - Not currently working
None - ready to leave with no notice
Less than 1 week
More than 2 weeks
List jobs starting with most
Date of Contract
Are you bondable?
Have you ever filed for bankruptcy?
Have you ever been convicted of a felony?
Are you willing to submit to a drug screen?
Please review your
information before submitting for accuracy. Because this form is being
submitted via a server that is not secure, your Social Security Number and Driver License
Number are not being requested. If contacted for an interview based on the
information provided via this form, you will be asked to complete a standard CCI
By clicking on the Send
button below you are electronically signing this form and stating that you
misrepresentation or omission of facts requested in this form is cause for
dismissal, if hired, and
hired, employment is for no definite period and regardless of the date of payment
of wages and salary, you may be terminated at any time without prior notice.