Interview Screening Questionnaire

Last Name______First Name______MI______

Home Address ______

City______State______Zip Code ______E-mail Address ______

Home Phone ______Work Phone ______Cell Phone ______

Do You Have A High School Diploma or Equivalent? YESNO

How Were You Referred To Us? ResumeReferred By ______Other ______

Threshold Questions

Please read each of the four questions below and answer “yes” or “no”. When we say “you” in the questions below, we mean you personally and also any organizations that you owned or had a controlling ownership interest in or controlled as a principal manager. If the answer is “yes” to any of the questions, you are not eligible to qualify with Primerica.

  1. Have you EVER pled guilty or nolo contender (“no contest”) to, or have been found guilty of, FELONY crime?YES NO
  1. Have you, WITHIN THE LAST 10 YEARS, pled guilty or nolo contender (“no contest”) to, or have been found guilty of,

a MISDEMEANOR crime involving: (A) a financial industry law, rule or regulation; (B) lying/dishonesty, cheating or

fraud, money laundering or breach of trust; (C) burglary, or theft (in any form) of funds or securities of financial

instruments?YESNO

  1. Are you CURRENTLY expelled, suspended, barred or prevented by the order, judgment or decree of a civil court or a

regulatory or administrative agency from engaging in financial or professional services, or are you under investigation,

sentencing or order for alleged misconduct regarding financial services, lying/dishonesty, cheating or fraud, breach of trust,

theft in any form, burglary, sexual misconduct or indecency, violence or threats of violence, money laundering or drug

dealing/distribution?YESNO

  1. Are you NOW affiliated as an employee or independent contractor with any Primerica Company, or

are you, in any way, involved in or licensed for (A) marketing or promoting securities or investments, raising investment

funds, or planning, handling or advising on the investments of others, or (B) regulating or providing underwriting of

investigative services to Primerica?YESNO

Do you currently have a mortgage broker or similar license?...... YESNO

Do you currently have a securities license?...... YESNO

Do you currently have an insurance license?...... …...... YESNO

Have you ever held any of the above licenses?...... YESNO

Have you ever been denied a trade/professional license, or had a trade or professional license revoked, suspended or restricted?... YESNO

Character References

Name at least six local references, not related to you, who can comment on your professional work performance.

NameOccupationHome TelephoneWork TelephoneYears Known

1. ______

2. ______

3. ______

4. ______

  1. ______

6. ______

Identify Your Personality Type

Complete the following exercise. This will assist us in identifying which of our training programs would fit you best.

Read each row listed and rank each row from 1 to 4 with 1 being the personality that describes you the best.

Stability
Structure
Rules
Detail Oriented / Theory
Intelligence
Knowledge & Learning
Logical Consistency / Action
Competition
Excitement
Flexibility / Relationships
Harmony
Ethics
Counseling

YES NO

Are you currently earning what you’re worth?...... ….Y N

Does your job offer you a good chance for advancement?...... …Y N

Does your career challenge you?...... …Y N

Do you want to be doing your present job at retirement?...... …...Y N

Is your income sufficient to satisfy your goals and dreams?...... …Y N

Describe any specialized training or qualifications such as seminars, military, professional affiliations, certificates or awards.

______

If we offer you a position how soon would you be able to get started?

______

If we offer you a position, who other than yourself would be involved in the decision?

Spouse Parent Other______

Work Experience

Please note a resume DOES take place of completing the Work Experience section.

List each job held. Start with your present or last job. Include military experience, if applicable.

Present employer / May we contact? Y N
Self Employed? Y N / From / To / Work Performed
Address / Full Time / Part Time
City / State / Starting Income or Wage
Job Title / Final Income or Wage / Reason For Leaving
Supervisor’s Name / Title / Phone Number
Employer / May we contact? Y N
Self Employed? Y N / From / To / Work Performed
Address / Full Time / Part Time
City / State / Starting Income or Wage
Job Title / Final Income or Wage / Reason For Leaving
Supervisor’s Name / Title / Phone Number

Applicant Authorization and Consent for Release of Information

Statement of applicant:

  1. I hereby authorize the company to investigate the forgoing statements, references, and previous employers and I further authorize the release of such information without liability
  2. I certify that the forgoing information is correct and complete.
  3. I understand that any false statements in this screening questionnaire will be sufficient cause for discharge.
  4. I release the Company and its agents to the full extent permitted by law from any claims, damages, losses, liabilities, and expenses arising from retrieving and reporting of information

SignatureDate

We appreciate your interest in Primerica.

FOR INTERNAL USE ONLY !– In submitting this questionnaire, I certify that:

A review of this individual’s background and experience has been conducted and found to be satisfactory- pending CIB with Wisconsin Department of Justice.

Next Step: Overview Date:______or One on One Date:______Managers Name:______

Interviewer’s SignatureDate

3/2014