| Please print, fill out and FAX this form for consideration for employment or appointment as a sales representative working with HealthCare Associates of CT. Please FAX to (860) 295-6433. |
| Name: |
| Address: |
| City: |
| State: Zip: |
| Phone #: |
| Email: |
Position Requested:
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Do you currently hold a license to sell insurance?
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If yes, what lines of authority?
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Sales experience (products, how long, etc.)
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| Are you currently working? Date Available:
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Why do you want to work with us?
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| Thank you for your interest! We will be contacting you shortly! |
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