List employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment.

By my signature below, I certify that all information provided on this application is true and accurate. I understand that any false statements, misrepresentation, or omissions made on this application will be considered sufficient cause for Merrill Insurance Group, Inc. to deny or terminate my employment upon discovery. I understand that employment with Merrill Insurance Group, Inc., is “at will” and therefore for an indefinite period of time. If employed, I may terminate my employment at any time and Merrill Insurance Group, Inc., may terminate or modify the employment relationship at any time, with or without motive or cause. I understand that I am not guaranteed a specific shift, schedule or work assignment or to work overtime. If employed by Merrill Insurance Group, Inc., I will abide by its rules, regulations, policies and procedures.

I hereby authorize all individuals and organizations named or referred to on this application to answer all questions that may be asked and give all information that may be sought in connection with this application. This may include, but is not limited to work history, criminal records, licensure, certification, education and driving record. I also certify that any individual or organization furnishing information concerning me shall not be held accountable for giving this information. I hereby release said individuals and organizations from any and all liability that may be incurred as a result of furnishing such information.

Finally, I freely and voluntarily agree to undergo drug testing as part of the application process, or at any time during my employment with Merrill Insurance Group, Inc., I understand that either refusal to submit to the test or failure of the test per Merrill Insurance Group, Inc., policy will disqualify me from consideration and/or continuation of my employment.