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E }Fora <: D <br />S ELEGEMP <br />Application for Employment ENTER <br />dse,Onl N <br />T D <br />r EMPLOYMENT SERVICES <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 a 3 <br />LAST NAME FIRST M 1 HOME PHONE <br />-,?. / 'e D Sy/ -937- Igo <br />ADDRESS STREET CITY STATE ZIP CELL PHONE PROVIDER <br />S25 Qr0 xa /r✓A. OR 19 s7y3i sV / -E? ,2 _W 1 /< <br />HAVE YOU APPLIED WITH OR BEEN [7 Yes Where `' —! 7 ee! e HAVE YOU EVER E -MAIL c� / <br />EMPLOYED BY SELECTEMP BEFORE? ❑ No When �J �D /C — 9, O/o BEEN TERMINATED <br />POSITION(S) APPLIED FOR: MINIMUM DATE AVAILABLE FROM AJOB? ❑ Yes 'L7 No EMERGENCY CONTACT & PHONE # <br />N ACCEPTABLE WAGE: TO START: n <br />( ,�7a1�` Lnt J iaanrnr �r�i•.�ZrGL .�` 9 Sv ��� / 1Qly/ S�/ •- �s� -�� <br />EDUCATION s F" <br />> •-.ass i, ,., ,. z ...f,:: � 'c, � - l,l. i.�? i 18 OR OVER Yes ❑ No <br />lilghestg�ade;completed,(ci cle „ 6 ,,7^ : 8 � 9, 101 1a1 f 1 w 13� 14 ?. 15 16�� 16'14 <br />N�AAME CI /STATE DATES (OPTIONAL) DEGREE GRADUATE? <br />HIGH SCHOOUGED � y'�" / -/ 'f r.�� �a?�,�i ve JV' n rE]Yes [] No <br />COLLEGEFFRADE SCHOOL ❑ No <br />GENERALIN �� xs'$'" k �° �'� h�� <br />} x ;. <br />..:..i ;,��:.: `knroYr .._�.„_.i., wr ri*'_'?titi�.,.:.,:Y ,.a Fi ��., ��.:;:o�trrrtr'Y y� - �.,. ° . a '.�„•i°r�.u:- :i•��.'*t �:.� .zM+.�;,`� U'.��:`ti w. .tiv ��.n( ,$t +�F wr�� <br />HOW WERE YOU REFERRED AVAILABLE FOF3 EVER CONVICTED OF A CRIME? <br />u <br />TO SELECTEMP? Day Graveyard Fill -In <br />®'Weekend ffFullTime ❑ Yes 93 No If yes, please list conviction &cute. Alsn <br />please request a criminal history form from the front desk. <br />IF REQUIRED, DO YOU HAVE A TRANSPORTATION I, <br />� � QBBI S <br />VALID DRIVER'S LICENSE ®CAR ❑RIDE v /�i��^"�f ' yy„ ��� ��// � — - - -- - - - - - -- - <br />EffYES []NO ❑BUS ❑BIKE — <br />INDUSTRIAL APPLICANTS ON[ Y- C:herk r. tlipment YOU Currently ha �ve ya ailable. ❑ Welding Lquipmel <br />,._�/ I r1 . �� <br />eather work boots Work gloves � Safety Glasses ® Rain Gear t lJ <br />Ib steel toe safety boots ❑ Hard Hat ❑ Puller Apron Z'Tools <br />F � I d7' > rs /µ��, ii'. wK� n v, x.n"rT .'- ws"°'^.•"` -"C- (:y <br />FIVE YEARSEMI?LOYMENTtiISTOf7Y� ar ," <br />Q 1. EMPLOYER STARTING DATE ENDING DATE <br />Month Year Month Year TzX <br />w Si e 20 /U q Zo�G /d. <br />ZE <br />- ADDRESS REASON FOR LEAVING SUPEI <br />Z ='R+ / IPrayir ✓C/y G�v/ /�r>/o /s Gafl. A ri5 O /Scar) J(Yes L] No <br />N Ea <br />CITY, ST. ZIP JOB DUTIES - <br />�_ E . Off' 97ya <br />LL. 'N' JOB TITLE - <br />' / <br />2. EMPLOYER STARTING DATE ENDING DATE PAY PHONE <br />I1r,f� <br />(Z ; 'A.1 //r nS Month Year Month Year Starting <br />CIO :Z 20ib /0.70 l0 yU <br />N ADDRESS REASON FOR LEAVING SUPERVISOR'S NAME MAY WE CONTACT? <br />j ri Ha. Yes ❑ No <br />iTa <br />,, A : CITY, ST, ZIP JOB DUTIES <br />`�K, <br />.17 - is /�..- <br />I �'^' JOB TITLE <br />S Fr: rf T/Y/ `r'•►'+ ��G4/ ee �'cttr�rr.rs l'.c•! <br />h'•h 3. EMPLOYER STARTING DATE ENDING DATE PAY PIIONE <br />Month Year Month I Year Starting Final 1 16 - Ioo7 <br />dr. 00 <br />`N= CONTACT? <br />SUPERVISOR'S NAME MAY W <br />AUUKESS REASON FOR LEAVING E <br />EF / / J� E <br />1 X' C / vU' /F A! �f l� l d'[l �.,'C oi� frw....i �jrl+.G �X�"�!n SL/�a� J� L ' ❑ <br />�" r S !h/LHr� es No <br />T i CITY ST, ZIP JOB DUTIES A, <br />�YO R / S'JXCK <br />JOB TITL <br />;j. 4. EMPLOYER STARTING DATE ENDING DATE. PAY PHONE <br />Month Year Month Ycar Storting Final ( ) <br />N:r <br />W ADDRESS REASON I LEAVING SUPtKVISUK'S NAME MAY WE CONTAC lv <br />�Et <br />Q X ❑ Yes ❑ No <br />Z V <br />CITY, ST, ZIP JOB DUTIES <br />CA F <br />J '•'r; JOB TITLE <br />Rev. 2/10 <br />Rev. 2/10 <br />