Please complete and submit the following form for each previous place of employment.

Your Full Name*

Position(s) applying for at McHarrie Life:*

Previous Company Name*

Previous Company Address*

Start Date*

End Date*

Previous Position Title*

During this period of employment, I was known by the name:*

PLEASE SIGN BELOW:

I authorize McHarrie Life to contact my present and previous employers and schools, and unless otherwise indicated, I further authorize my former employers to give any information as to my character and work or school record, including employment dates and positions held. I hereby release from all liability, and damages, all these individuals or companies which are providing such information. I further understand that all hiring commitments are conditionally based upon satisfactorily meeting statutory standard through a job related post-offer, physical examination, and satisfying pre-employment requirements.*

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