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W <br />Q <br />z <br />F- <br />LL <br />W <br />Q <br />z <br />U) <br />J <br />ENTERED <br />Application for Employme tCOMPLETED SELECT <br />An Equal Opportunity Employer E M P L O Y M E N T S E R Y I (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 />chnulrt nn8fv w re.nresentative of SeleclemD. THIS APPLICATION MUST BE COMPLETED BY THE PERSON APPLYING FOR EMPLOYMENT. <br />SOCIAL SECURITY NUMBER <br />DATE <br />PLEASE PRINT r r —L[— <br />LAST NAME FIRST I HOME PHONE <br />L,`f N�rl <br />ADDRESS � � J E � � � �.�orJ CI V L/v(V 1>,/ � ST , ZIP CELL PHONE � ^00 PROVIDER <br />HAVE YOU APPLIED WITH OR ® Yes Where <br />�7t <br />y HAVE YOU EVER <br />217 BEEN TERMINATED <br />E ) <br />`VlJ { �'J <br />EMPLOYED BY SELECTEMP BEFORE? ❑ No When 1 <br />M uwC <br />EMERGE CONTACT PHONE # \ <br />POSITION(S) APPLIED FOR: MINIMUM DATE AVAILABLE FROM A JOB? [] Yes ® No <br />ACCEPTABLE WAGE START <br />11" . <br />µ� •x 13 ' �= ' 15....�T6'_ t 1&Fr, ;`;;.-; <br />18 OR OVER Yes No <br />H ties e?oom a d circle .._�r� 6�. - .`1�:: 8r.. $., <br />Y9 <br />,x..10 > .1'_..1'f .,� _ <br />CITY /STATE DATES (OPTIONAL) <br />DEGREE GRADUATE? <br />iJ <br />® Yes ❑ NO <br />�ol�ilrr p �� /' [�✓ Clll � l�l' �- v ❑Ye s ®No <br />COLLEGFITRADE SCHOOL 1'v <br />'�.'•• tYS - `� `i. +: - :+,_ 4v�::. F �.„£fi'wdS(� 4 f 1 - J. E (y.: _.Sr. rt _ _.. , _�_ . <br />HOW WE RE YOU REFERRED <br />M AVAILABLE FOR EVER CONVICTED OF A CRIME? <br />®Day ®Graveyard ® Fill <br />TO SEL ECTEMP? <br />Weekend Full Time ❑ Yes ®No if yes, please fist conviction r date. Also, <br />l <br />please request a criminal history form from the front desk. <br />IF REQUIRED, DO YOU HAVEA TRANSPORTATION <br />VALID DRIVER'S LICENSE ®CAR ❑RIDE <br />HO`BIE ` ` ` <br />(_� `v���}t J <br />✓ 111 JJJ lN\ti '� `i" <br />®YES ONO RUBUS ®BIKE <br />INDUSTRIAL APPLICANTS ONLY_ Check equipment you currently have available. ❑ Welding Equipment ❑ Other (please list) <br />❑ Leather work boots ❑ Work gloves <br />❑ Hard Hat <br />❑ Safety Glasses ❑ Rain Gear <br />❑ Puller Apron n ❑Tools <br />❑ Steel toe safety boots <br />µ <br />FI�/� Y S EMLO�liV1Ek{ISTORY .: <br />, 1. EMPLOYER <br />STARTING DATE ENDING DATE PAY PHONE <br />Month Year Month ear Starti Final (� 7 ) j 2 <br />ADDRESSt <br />c . )u. ) �� <br />RY <br />SUPERVISOR'S NAME MAY WE CONTACT? <br />REASON FOR LEAVING _ (� (� �-t-� �J <br />wo 1 1yGtrul�/ CJ!��1 J tmP/ V o Kp ` , ` 1 ❑ Yes ❑ W <br />(, U7� <br />y CITY, ST, ZIP ^ ` ` ' a n { / <br />rEt Ur " `"l <br />I / -� <br />JOB DUTIES 1{- <br />I l a� <br />s <br />JOB TITLE <br />�p��t?iC2� <br />l V � <br />Uri I <br />2. EMPLOYER <br />STARTING DATE ENDING DATE PAY PHONE I 1 <br />Year Month Year Starting ( �) 7 <br />_ _ <br />( Oco �7� <br />Month <br />07' U�� �;71 <br />ADDR(ESSS \` <br />� � <br />REAtSyO�N FOR LEnAnVING `y SUPERVISOR'S NAME MAY WE CONTACT? <br />D ® Y� E3 No <br />`C.e � Q! ` lair --`� <br />a CITY, ST, ZIP <br />JOB DUTIES <br />L(, Lln�Oo., l a t, <br />- l <br />JOB TITLE - <br />- <br />y1 <br />�OI� LDr tW G 't W`v�v- O t'✓C�t <br />yn <br />3. EMPLOYER <br />STARTING DATE ENDING DATE PAY PHONE <br />Year Month Year Starting Final <br />Vt.�>c �1 <br />Month <br />©� 2c��v og ZQl(7 dr�o <oo <br />ADDRESS ` {y <br />/E�ASON FOR LE- niV1\I\N�G., SUPERVISOR' NAME MAY WE CONTACT? <br />®Yes ❑ No <br />0—� �\ <br />CITY, ST ZIP n �� � <br />JOB DUTIES r� �\ \ `}-r, `�.��y�'� r \ . " 9 6 <br />czj2z JOB TITLE <br />r �Gt <br />4. EMPLOYER <br />STARTING DATE ENDING DATE PAY PHONE <br />Month I Year Month Year Starting Final (q10 T '� <br />4co n 1 <br />�3 20o�t a t 050 '�:r o <br />N ' ADDRESS <br />REASON <br />I F'O�R�L�EAVING SUPE NAME MAY WE CONTACT? <br />r '7C� u✓a � � Y/l � l �-- (]'Yes [3 No <br />��� J + <br />! lU V t-el <br />CITY, s� Z IP -)-) <br />.:V 1p <br />JOB DUTIES <br />` <br />t'R mo� O D C (J C/V✓ / `Y t <br />JOB TITLE . <br />r . J�(Yt�it"JS� i 1 �"'A/ \� �� �• \' `"\ _ _ <br />Rev. 2rI0 <br />