Employment Application, Resume, and Cover Letter

Thank you for your interest in employment. Blue Cross and Blue Shield of Vermont employs on the basis of qualifications and with assurance of equal opportunity and treatment regardless of race, religion, color, sex, age, marital status, national origin, sexual orientation, physical or mental disability or limitation.

Required fields are marked by an asterisk ( * ).
Please fill in all relative information so that we can have a better understanding of your qualifications.

1. Personal Information

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Date of Application: 2015-09-03
*First Name:
Middle Name:
*Last Name:
*Address:
*City:
*State/Province:
*Zip/Postal Code:
*Phone Number:
Work Number:
*E-Mail Address:

* Have you ever worked under another name? Yes No
(This information is needed for references purposes only.)

    If yes, please include

* Can you, after offer of employment, submit verification
of your legal right to work in the USA?
* Yes No

Are you currently employed? Yes No

    If "Yes" where?

    May we contact your present employer? Yes No

Were you previously employed by this or any Blue Cross and Blue Shield Plan? *
Yes No

    If "Yes," where, in what department and what dates?

Do you know anyone who works at Blue Cross and Blue Shield of Vermont?
Yes No

    If "Yes" please list name(s).

*Are you 18 years old or older? Yes No

    If not, state your age

Have you ever been convicted or pled guilty to a criminal charge? * Yes No

    If "Yes" please state where and when, and provide details.

    NOTE: A conviction record will not necessarily be a bar to employment, and such factors as age and time of the offense, nature of the violation as related to qualifications of the job applied for, and rehabilitation will be taken into account.

    You are not required to disclose information about physical or mental limitations that you believe will not interfere with your capability to do the job. On the other hand, if you would like Blue Cross and Blue Shield of Vermont to consider special arrangements to accommodate a physical or mental limitation, you may identify that limitation in the space provided and suggest the kind of accommodation that you believe would be appropriate.



2. Employment Desired

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Position(s) applying for:
1st choice
2nd choice
Full-Time
Part-Time
Temporary
Summer

When would you be available for employment?

Salary desired?



3. Education

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Please indicate your level of education.
( or list in your resume - See Attach Resume below )

High School


(Name & Location)
Last grade completed:
9 10 11 12

College


(Name & Location)
Years completed:
Fresh. Soph. Junior Senior
Subject studied & degree received:

Graduate School


(Name & Location)
Subject studied & degree received:

Other


(Name & Location)
Subject studied & degree received:


4. Employment History

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Please list your last three (3) employers (if applicable) starting with the most recent. ( or list in your resume - See Attach Resume below )

Current/Most Recent Employer:

Company:
City, State
Your Job Title:
Brief summary of duties:
Phone Number:
Dates From/To: -
Supervisor's Name:
Pay Rate - if still employed:
Pay Rate - upon leaving:
Reason for leaving:

Next Most Recent Employer:
Your Job Title:
Address:
Phone Number:
Dates From/To: -
Supervisor's Name:
Pay Rate - upon leaving:
Reason for leaving:
May we contact this employer?
Yes No If "No", state reason

Next Most Recent Employer:

Company:
Your Job Title:
Address:
Phone Number:
Dates From/To: -
Supervisor's Name:
Pay Rate - upon leaving:
Reason for leaving:
May we contact this employer? Yes No
If "No", state reason

Please list other positions previously held and organizations at which employed.
( or list in your resume - See Attach Resume below )



5. Volunteer Work - Community / Civic Work

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Please state any additional information you feel may be helpful for us in considering your application, such as business and professional organizations, community and volunteer work, special talents, etc. (You may omit those which would indicate race, color, sex, national origin, ancestry, age, physical or mental disability or limitation.

( or list in your resume - See Attach Resume below )


6. Military Experience

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Did you serve in the U.S. Armed Forces? Yes No
Branch
Period of active duty (month and year)
from: To:
Rank at discharge
Date of discharge
Describe your duties or special training
Are you in the military reserve?


7. Computer / Technical Skills

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Please list any computer, or other technical skills. List systems and software applications which you have experience with.


( or list in your resume - See Attach Resume below )

8. References

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If you have had little or no previous work experience or have been self-employed, list three persons, other than relatives, who have a thorough knowledge of your character or work performance/occupations. ( or list in your resume - See Attach Resume below )

Reference 1

Name:
Address:
Phone Number:
Business:
Years Acquainted:

Reference 2

Name:
Address:
Phone Number:
Business:
Years Acquainted:

Reference 3

Name:
Address:
Phone Number:
Business:
Years Acquainted:


9. Additional Information

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10. Attach Resume and Cover Letter

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File sizes all limited to a maximum of 1 MB for both files.



I certify that my responses on this application are true and I understand that any misrepresentation or omission of facts may disqualify me for employment or constitute grounds for my termination. I voluntarily give Blue Cross and Blue Shield of Vermont (BCBSVT)/The Vermont Health Plan (TVHP) and any of its agents or employees the right to make a thorough investigation of my past employment, education and references and agree to cooperate in such investigation. I herby release BCBSVT/TVHP from any and all liability whatsoever caused by reason of a request for information from any persons, companies or operations. I also release from all liability or regulations of BCBSVT/TVHP, and understand that my status as an employee shall not create any contractual right, express or implied, to remain in the company?s employ. I also understand that my employment may be terminated, at any time, at the unlimited an unrestricted option of either the company or myself. I understand that no person in management, without the written approval of the President, has the authority to enter into any agreement for any specified period of employment, nor am I obligated to work for BCBSVT/TVHP for any specified period of time.

By typing my name in the box below, I make the above certification.

Please Enter Your Full Legal Name

The foregoing is intended as my electronic signature within the meaning of Title 9, Ch. 20 of the Vermont Statutes Annotated.

    Thank you for your time and interest in
    Blue Cross and Blue Shield of Vermont.

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