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Rov. 2/10 <br />t <br />': <br />c OM PLE IE S ELEG E.M ` Application for Employment o � <br />An Equal Opportunity Employer E M.D L O T M E N T S E R V 1(E S <br />Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and /or inter- <br />view process should notify a representative of Selectemp. THIS APPLICATION MUST BE COMPLETED BY THE PERSON APPLYING FOR EMPLOYMENT. <br />SOCIAL SECURITY NUMBER DATE <br />PLEASE PRINT F�: g r? d// <br />LAST NAME FIRST M I <br />HOME PHONE <br />E - �L <br />ADDRESS STR T CITY STAT ZIP <br />CELLPHONE PROVIDER <br />HAVE YOU APPLIED W9 BEEN ❑ Yes Where <br />HAVE YOU EVER <br />E -MAIL <br />EMPLOYED <br />BY SELECTEMP BEFORE? IR No When <br />BEEN TERMINATED <br />APPLIED FOP MINIMUM DATE AVAILABLE <br />G NCYCONTACT &PH N # <br />POSITION(S) <br />FRCMA JOB ❑ yes �No <br />N <br />AC EPTABLE WAGE: O START. <br />Oct -- <br />r s `filY^ ' ; r <br />1 4'm�2s�',Ys` ���'R. -r•Y <br />r <br />_ K c <br />18 OR OVER Ye [3 No <br />s <br />Piet CE cir= 8k &� 43 <br />NAME <br />CITWSTATE <br />DATES (OPTIONAL) <br />DEGREE <br />GRADUATE? <br />C <br />/ O� <br />' Y es 13 No <br />HIGH <br />SCHOOL/GED <br />sr 4 <br />COLLEGErrRADE <br />SCHOOL <br />ZCC <br />G t <br />L — ZO�� C'Zv <br />❑Yes [KNo <br />E�lE . L fNtt MNE '�* . •_ <br />, x a x a k r�xy3x1 <br />sza <br />�� m 4 <br />811`Ze;. `�8fiti<.h �Y. ti•..'� ix.tir:£. kt.: <br />i' F't?4�s•'v *.'_ :. <br />S�3sc,�a. <br />HOW WERE YOU REFERRED <br />TOSELECTEMP? <br />tr, AVAILABLE.FCR <br />15 Day C-Graveywd 4KFAldn <br />EVER CONVICTED OF A CRIME? <br />D <br />❑ Swing ❑ Weekend 4" Fu0 Time <br />❑ Yes iRlNo if yes, please list conviction & date. Also <br />please request a criminal history farm from the front desk. <br />REQUIRED, O OU VEA <br />SPORTATION <br />HOBBIES <br />IF <br />VALID DRIV LICENSE <br />C ELCAR ❑RIDE <br />YES []NO <br />❑BUS BIKE <br />INDUSTRIAL <br />APPLICANTS ONLY: Check equipment you currently have available. ❑ Welding Equipment ❑ Other (please list) <br />$Leather work boots L& Work gloves elg-Safety Glasses dR Rain Gear <br />fiZ Steel toe safety boots Hard Hat ❑ PulterApron ®,Tools <br />F <br />1. EMPLOYER STARTING DATE ENDING DATE PAY PHONE <br />Month I Year Month I Year / StaQiaa <br />( /�I JCJ 401At <br />W <br />Oc/! O <br />Q ADDRESS <br />�j <br />REASON FOR L AVING <br />�2/ <br />7 RVISOR'S NAME <br />MAY WE CONTACT? <br />Z <br />Y� d/`/�L <br />G /}/L ✓ <br />� Q e <br />�.YeS 13 No <br />)" <br />25 <br />C ST. ZIP <br />�� Sro 3 <br />JO DUTIES <br />�aa� �Cli S <br />- a <br />i a s �� liaC� c�E• <br />LL <br />JOB TI <br />2 EMPLOYER <br />START G DATE <br />DING DATE <br />PAY <br />PHONE <br />{ ) <br />Month <br />Year <br />Month <br />Year <br />Starting Final <br />lDAa <br />1 <br />70DRESS <br />R SON FOR LEAVWG <br />SUPERVISOR'S NAME <br />MAY WE CONTACT? <br />. <br />r ' <br />' / <br />Co Yes ❑ No <br />Cln; ST, ZIP <br />JOB oul > <br />JOB TITLE <br />3. EMPLOYER <br />STARTING DATE <br />ENDING DATE <br />PAY <br />PHONE <br />Month <br />Year <br />Month <br />Year <br />Starting I <br />Final <br />( ) <br />ADDRESS <br />REASON FOR LEAVING <br />SUPERVISOR'S NAME <br />MAY WE CONTACT? <br />❑ Yes ❑ No <br />CITY, ST, ZIP <br />JOB DUTIES <br />J08 TITLE <br />4. EMPLOYER <br />STARTING DATE <br />ENDING DATE <br />PAY_ <br />PHONE <br />Month I Year <br />Month Year <br />Starting Final <br />( ) <br />W <br />ADDRESS <br />REASON FOR LEAVING <br />SUPERVISOR'S NAME <br />MAY WE CONTACT? <br />Q. <br />❑ Yes ❑ No <br />z <br />CITY, ST, ZIP <br />JOB DUTIES <br />U) <br />J <br />JOB TITLE <br />Rov. 2/10 <br />