InterWest Job Application

Education
High School:*
Address:
Street Address City State ZIP Code
From/To:*
Did you graduate?*
- Yes
- No
Degree:
College
College Institution:
Address:
Street Address City State / Province / Region ZIP / Postal Code
From/To:
Did you graduate?
- Yes
- No
Degree:
Other
Other:
Address:
Street Address City State / Province / Region ZIP / Postal Code
From/To:
Did you graduate?
- Yes
- No
Degree:

References - Please list three
Name:*
First Last
Relationship:*
Company:*
Phone:*
Address:
Street Address City State ZIP Code
Name:*
First Last
Relationship:
Company:*
Phone:*
Address:
Street Address City State ZIP Code
Name:*
First Last
Relationship:*
Company:*
Phone:*
Address:
Street Address City State ZIP Code

Employment Experience
Directions: Begin with your present or last job. Account for all periods of time, including military experience, and period of unemployment and the nature of your activities. Since we will make every effort to contact previous employers, the correct telephone numbers are appreciated. THE FOLLOWING MUST BE COMPLETED IN DETAIL – RESUMES ARE NOT ACCEPTED IN LIEU OF THIS INFORMATION
Company:*
Phone:*
Address:
Street Address City State ZIP Code
Supervisor:*
Job Title:*
Responsibilities:*
From/To:*
Reason for Leaving:*
May we contact your previous supervisor for a reference?*
- Yes
- No
Company:*
Phone:*
Address:
Street Address City State / Province / Region ZIP / Postal Code
Supervisor:*
Job Title:*
Responsibilities:*
From/To:*
Reason for Leaving:*
May we contact your previous supervisor for a reference?*
- Yes
- No
Company:*
Phone:*
Address:
Street Address City State ZIP Code
Supervisor:*
Job Title:*
Responsibilities:*
From/To:*
Reason for Leaving:*
May we contact your previous supervisor for a reference?*
- Yes
- No

Disclaimer and Signature
DIRECTIONS: PLEASE READ THE FOLLOWING CAREFULLY AND INITIAL BEFORE SIGNING THE APPLICATION FORM
Consent*
I hereby certify that I have personally completed this application and that the answers given by me to the foregoing questions and statements are true and complete and that no material fact has been omitted. I understand that any false statements appearing on this or any other employment form will be sufficient reason to end further consideration of the application and not hire me; if discovered after my employment, such false statement will be sufficient reason for dismissal from the services of InterWest Insurance Services, LLC regardless of the time that has elapsed before discovery.
Initials
Consent*
I authorize InterWest Insurance Services, LLC or its designated agents to contact my references and to investigate my past employment, credit history, education credentials, Department of Motor Vehicles driving record, and other employment-related activities, without giving me prior notice of such disclosure. I agree to cooperate in such investigations and release those parties supplying such information to InterWest Insurance Services, LLC from all liability or responsibility with respect to information supplied to InterWest Insurance Services, LLC
Initials
Consent*
I request, authorize and consent to the procurement of an Investigative Consumer Report and understand that it may contain information about my background, mode of living, character, personal characteristics and general reputation. This authorization in original or copy format shall be valid for one year from the date indicated next to my signature below. According to the Fair Credit Reporting Act, I will be notified if employment is denied because of information obtained from a Consumer Reporting Agency. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided.
Initials
Consent*
I understand that filling this application in no way assures me a position with InterWest Insurance Services, LLC, and that this application is not, and is not intended to be, a contract of employment. I understand that if employed, my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, and at the option of either InterWest Insurance Services, LLC or myself. I further understand that no one other than the President of InterWest Insurance Services, LLC has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.
Initials
Consent*
If employed by InterWest Insurance Services, LLC, I agree to abide by the rules, policies and procedures of InterWest Insurance Services, LLC and subsequent rules, policies and procedures that may become effective after employment. I understand that my initial and continued employment may be contingent upon the successful completion of a medical examination, and such examination may include drug and alcohol screening. I understand that InterWest Insurance Services, LLC believes strongly in a drug-free work environment and agree to abide by the drug and alcohol policies of InterWest Insurance Services, Inc. during the time of my employment.
Initials
Date
MM slash DD slash YYYY

Step 1 of 8

Application Information

Special Skills and Training

Education

College

Other

References - Please list three

Employment Experience

Military Service

Disclaimer and Signature