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Date of Application

________________

The Prudential Insurance Company of America

Please complete the following preliminary application.

All information will be treated as confidential to the extent possible and as required by law. Later in the process, you will be asked to provide detai

information regarding your background and The Company will verify your employment over the past ten years and educational history and reserves

right to investigate any of the facts provided by you.

I. Identification

ID #

NameFirst Middle

Last Suffix

Current residence

Address Apt. No. City or Town

Residence since

State Zip Code County mm/yyyy

Telephone number #1

Telephone number #2 Personal Email Address

Job position you are applying for?

Financial Professional Associate (FPA) Agency Recruiter (AR) Associate Managing Director (AMD)Experienced Financial Professional (EFP) Manager, Financial Services (MFS) Manager, Agency Training (MAT)Managing Director (MD) Operations & Controls Specialist (OCS) Director,Operations & Controls (DOC)Operations & Controls Consultant (OCC) Sr. Operations & Controls Specialist (Sr. OCS) Summer Agency Marketing Associate InFinancial Professional Associate (FPA) InternPrudential Marketing Assistant (Pru MA) Prudential Marketing Assistant (Part timeOperations & Controls Specialist (OCS) Part time

Are you currently employed by Prudential? YESNO

What is the highest level of education you have achieved?

Some high school Completed high school School or technical school courses beyond high schoSome college or university Completed college or university Some graduate schoolGraduate degree (including JD)Are you authorized to work in the US? YES NO

Jessica KernJessica Kern

12/22/201512/22/2015

32145863214586

[email protected]@outlook.com

01/011501/0115

19201920252252484484

JessicaJessica

KernKern

DowningtownDowningtown120 Christine Drive120 Christine Drive

Pennsylvania USAPennsylvania USA 1933519335

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Will you now or in the future require sponsorship for employment visa status (for example answer yes if you need H-1B visa or other nonimmigrant

sponsorship or if you have an adjustment based EAD and will need an employer letter of support in order to establish eligibility for AC 21 portability)?

YES NOWhat is your current employment status?

Currently a student Currently engaged in paid full time employmentCurrently engaged in paid part-time employment Not currently engaged in paid employment

Please select carefully the one source that INITIALLY stimulated your interest in a position with Prudential:

a. College Campus Recruiter b. Alumni Association c. Career/Job Faird. Career Information Seminar e. Educational Financial Workshop f. Referred by an organization or community group

affiliated with Prudentialg. Referred by a Prudential employee h. Referred by a business associate i. A letter you received in the mailj. A local print/radio advertisement k. Internet Advertising l. You walked into a Prudential Office

m. Other

Please provide the name of the source (i.e., Smith job fair, name of organization, Prudential employee or business associate, website, etc.)

Name:

I understand later in the application process, I will be required to sign an additional form pursuant to the Fair Credit Reporting Act

authorizing the Company to conduct an investigation into my background.

Signature of applicant

Dated at ______________ On

Town or City State Month Day Year

Additional Comments:

Nate M. SwartzNate M. Swartz



DowningtownDowningtown PennsylvaniaPennsylvania 1212 2222 20152015

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Name: Date:

Voluntary Self-Identification Form

The purpose of this voluntary form is to comply with government data collection, record keeping, reporting and other EEOrequirements. Providing information regarding ethnicity/race, gender, and veteran status is strictly voluntary. Your applicationwill not be adversely affected whether you respond, or decline to respond. All data records are kept in a confidential file and arenot part of your Application for Employment.

ETHNICITY/RACE GENDER

Are you Hispanic or Latino?

Yes No Male

FemaleIf NO, please check the onecategory that best applies to you:

WhiteBlack or African AmericanAsian

American Indian or

Alaskan Native

Native Hawaiian or otherPacific Islander

Two or more races

wish to disclose this informationI DO NOT

ETHNICITY/ RACE DEFINITIONS

HISPANIC or LATINO:A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.

WHITE:

(Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

BLACK or AFRICAN AMERICAN: (Not Hispanic or Latino) - A person having origins in any of the black racial groups of Africa.

ASIAN: (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent.(Includes Cambodia, China, Japan, India, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

AMERICAN INDIAN OR ALA SKAN NATIVE: (Not Hispanic or Latino) - A person having origins in any of the original peoples of North and SouthAmerica (including Central America), and who maintain tribal affiliation or community attachment.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam,Samoa, or other Pacific Islands.

TWO OR MORE RACES: (Not Hispanic or Latino) - All persons who identify with more than one of the above five races.

Ed. 1-09Self-ID

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Prudential is a Federal Government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act of1974, as amended (VEVRAA), which requires affirmative action to employ and advance in employment qualified

protected veterans at all levels of employment. The following invitation is made pursuant to VEVRAA and PrudentialsEqual Employment Opportunity and Affirmative Action Policy. Providing this information is voluntary and refusal to do

so will not subject you to any adverse treatment. Disclosure, though, will enable Prudential to better assess theeffectiveness of its affirmative action program. Please be assured that the information provided will be kept confidentialand disclosed or used only in ways consistent with the law. We appreciate your assistance in providing us with thisinformation.

_____________________________________________________________________________________________

INVITATION TO SELF-IDENTIFY

PLEASE ANSWER THE FOLLOWING QUESTIONS

Please indicate whether you identify as one or more of the following protected veteran categories by checking the appropriate box(es)

below.

Disabled Veteran: (i) a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but

for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of

Veterans Affairs; or (ii) a person who was discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran: any veteran during the three-year period beginning on the date of such veterans discharge or

release from active duty in the U.S. military, ground, naval, or air service. Please Enter Discharge or Release Date:__/__/____.

Armed Forces Service Medal Veteran: a veteran who, while serving on active duty in the U.S. military, ground, naval or air

service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant

to Executive Order 12985.

Active Duty Wartime or Campaign Badge Veteran: a veteran who served in the U.S. military, ground, naval or air service

during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered

by the Department of Defense. If you would like more information on campaigns or expeditions for which a campaign

badge has been authorized, please visit:http://www.opm.gov/policy-data-oversight/veterans-services/vet-guide/.

I am not a protected veteran.

I prefer not to answer.

In addition to our affirmative action obligations under VEVRAA, Prudential values all forms of military service. If you are not a

protected veteran, but would like to disclose your status as a member of the Armed Forces, you may do so below. Are you currently

serving, or have you served in the Armed Forces of the United States of America (including the Reserves and National Guard)?

Yes.

No.

I prefer not to answer.
http://www.opm.gov/policy-data-oversight/veterans-services/vet-guide/http://www.opm.gov/policy-data-oversight/veterans-services/vet-guide/http://www.opm.gov/policy-data-oversight/veterans-services/vet-guide/http://www.opm.gov/policy-data-oversight/veterans-services/vet-guide/

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Voluntary Self-Identification of DisabilityForm CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

Page 1 of 2

Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity toqualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us ifyou have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you willchoose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be usedagainst you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person maybecome disabled at any time, we are required to ask all of our employees to update their information every fiveyears. You may voluntarily self-identify as having a disability on this form without fear of any punishmentbecause you did not identify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition thatsubstantially limits a major life activity, or if you have a history or record of such an impairment or medicalcondition.

Disabilities include, but are not limited to:

Please check one of the boxes below:

YES, I HAVE A DISABILITY (or previously had a disability)

NO, I DONT HAVE A DISABILITY

I DONT WISH TO ANSWER

__________________________ __________________

Your Name Todays Date

Blindness Autism Bipolar disorder Post-traumatic stress disorder (PTSD)

Deafness Cerebral palsy Major depression Obsessive compulsive disorder

Cancer HIV/AIDS Multiple sclerosis (MS) Impairments requiring the use of a wheelchair

Diabetes

Epilepsy

Schizophrenia

Musculardystrophy

Missing limbs orpartially missing limbs

Intellectual disability (previously called mentalretardation)

Jessica KernJessica Kern 12/22/201512/22/2015

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Voluntary Self-Identification of DisabilityForm CC-305

OMB Control Number 1250-0005

Expires 1/31/2017

Page 2 of 2

Reasonable Accommodation Notice

Federal law requires employers to provide reasonable accommodation to qualified individualswith disabilities. Please tell us if you require a reasonable accommodation to apply for a job orto perform your job. Examples of reasonable accommodation include making a change to theapplication process or work procedures, providing documents in an alternate format, using asign language interpreter, or using specialized equipment.

___________________________

iSection 503 of the Rehabilitation Act of 1973, as amended. For more information about thisform or the equal employment obligations of Federal contractors, visit the U.S. Department ofLabors Office of Federal Contract Compliance Programs (OFCCP) website atwww.dol.gov/ofccp.

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 nopersons are required to respond to a collection of information unless such collection displays avalid OMB control number. This survey should take about 5 minutes to complete.
http://www.dol.gov/ofccphttp://www.dol.gov/ofccp

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If you need an accommodation to complete the application process, which may include anassessment, please call (973) 367-2714. If you need an accommodation to participate in anypost-application process, such as an interview, or to perform the essential functions of the job,please inform the assigned recruiter if and when you are contacted about your application.

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