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f • C = - <br />r <br />y <br />Application for Employment 4EN PEo <br />ni <br />Equal access to programs, services and employment is available to all pe rsons. nose applicants regilrutg-tc <br />view process should notify a representative of Selectemp. THIS APPLICATION MUST BE COMPLETED BY <br />N <br />9 <br />W <br />a <br />z <br />LL <br />W <br />a <br />2 - <br />H <br />t <br />SELMEMP <br />EMPLOYMEN7 SERYI(ES <br />odation to the application and /or nter- <br />PERSON APPLYING FOR EMPLOYMENT <br />SOCIAL SECURITY NUMBER <br />PLEASE <br />DATE <br />���� <br />PRINT <br /># 1 <br />/ r f <br />LAST NAM M I <br />HOME PHONE <br />IS <br />A RESS i6T E� CITY STATE ZIP <br />0Y1 � ti p(Z �c�� <br />CELL PHONE ROVIDER <br />Li ' <br />HAVE YOU APPLIED WITH CR BEEN es Where_ HAVE YOU EVER HAVE <br />I <br />^ ^ <br />�� 11 <br />' EMPLOYED BY SELECTEMP BEFORE? ❑ No When 5;� BEEN TERMINATED <br />I «✓) S J�.l \(Q 4 M;i,( L r <br />POSITION(S)APP ED FOR: MINIMUM DATE AVAILABLE FROMAJOB? ❑Yes No <br />r / ACCEPTABLE WAGE: O START: <br />EMERGENCY CONTACT & PHONE # <br />EDUCAT � as <br />10 k <br />xJ. <br />it hest r�d�•:com'leted'cJrcle} S FT °t8 9r 1.6.? 11K ,�12:13x,14�:1'S <br />teORO es ❑ <br />VER No <br />' NAME - CITYISTATE <br />DATES (OPTIONAL) DEGREE <br />GRADUATE? <br />❑ yes [aNO <br />HIGH SCHOOUGED <br />COLLEGEi TRADE SCH60L <br />4 ❑ Yes ❑ No <br />GENER1�LatNFO.�NTATION �u "? a z, fi�,t� s.� <br />� �`: � <br />�: 'u�. �" t �'4 <br />�:: r1 �3�:.u ...1_���c%:- ,'�9i'a.�- 4?-F\ ,��..:'Q'J_•��d,l� i'LCn y �... r52 t' P,Y'� <br />� t4 tLIHvS <br />- HOW WERE YOU REFERRED <br />TO SELECTEMP? <br />AVA BLEF0R <br />T Da raveyard E3 Fill -In <br />EVERCONVICTEDOFACRIME? <br />- <br />�Q ^ <br />X- <br />wing ❑:NBekend ❑ Full Time <br />[_�"/ <br />❑ Yes No It yes, please list conviction & date. Also, <br />V � V 1 ' i <br />please request a criminal history form from the front desk. <br />IF REQUIRED, DO YOU HAVE A <br />TRA09ORTATION <br />HOBBIES <br />VALID IVER'S LICENSE <br />AR ❑RIDE <br />M-fE ❑NO <br />❑BUS []BIKE <br />INDUST LAPPLICANTS ONLY: heck ea '� ent you Currently have av ble. ❑ WT mg Equipment C] Other (please list) <br />er work boots ffWork gloves p Safety Glasses Rgiw Gear <br />feel toe safety boots ❑ Hard Hat ❑ Puller Apron Iools <br />, f .. .. �„ �. ^✓ldi .. - .Fs��� •%C CD .�[(� f .J 't 4 ..nG tyFSiTMCa'Sri• Ifh y ..... <br />} <br />� <br />Wow <br />.. <br />T'RUSJI "f�'m ?,YZ <br />t. EMPLOYER <br />STARTING DATE <br />ENDING DATE <br />PAY <br />PHONE <br />Month I Year <br />_ 200 <br />�Month <br />Year <br />� <br />Starting <br />la- <br />Final <br />I o '7S 3 6 <br />m ASS <br />(' � k ) <br />ADDRESS <br />RFON FO EAVING <br />`3c�tv� <br />SUPERVISOR'S At�M <br />MAY WE CONTACT? <br />R <br />f: <br />i_nd o i �_ <br />`/'t al i s <br />❑ No <br />CG; CITY, ST, ZtR. <br />/ OIL <br />--�� <br />JOB DUTIE yl �c -0 GV <br />`,7:5 , �, <br />M. JOB JITLE n <br />Nei <br />- - /}ii <br />yer <br />2. EMPLOYER <br />STARTING DATE <br />ENDING DATE <br />PAY <br />PHONE <br />Month <br />Year <br />Month <br />Year <br />Starting <br />ADDRESS <br />REASON FGR LEAVING <br />SUPERVISOR'S NAME <br />MAY WE CONTACT? <br />❑ Yes ❑ No <br />CITY. ST ZIP <br />JOB DUTIES <br />n ` JOB TITLE <br />3. EMPLOYER <br />STARTING DATE ENDING DATE PAY IPHONE <br />Month Year Month Year Staving Final ( ) <br />rr <br />- <br />'NE <br />ADDRESS <br />REASON FOR LEAVING SUPERVISOR'S NAME MAY CONTACT? <br />❑Yes No <br />CITY, ST, ZIP <br />JOB DUTIES <br />h. <br />JOB TITLE <br />4. EMPLOYER <br />STARTING DATE ENDING DATE PAY PHONE <br />Month Year Month Year Starting Final ( ) <br />aq <br />ADDRESS .. <br />REASON FOR LEAVING SUPERVISOR'S NAME MAY WE CONTACT? <br />. <br />[:]Yes ❑ No <br />' CITY, ST, ZIP <br />r <br />JOB DUTIES <br />JOB TITLE <br />' <br />'A l <br />Re, VIO <br />