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khcation for Empioym <br />qual access to programs, services and employmen <br />'view process should notify a representative of Sefec <br />SELECTEMP <br />n 1 o nity Employer EN➢L0yNENT SEKyI(ES <br />�T s: Those a s req ring reasonable acqgg@jjdjSj0o the application and/or inter= <br />P ftO FOR EMPLOYMENT. <br />SOCIAL SECURINNUMBER <br />� Z <br />P LEASE <br />DATE <br />ua �3 i3 <br />r - <br />, 19 , Zoto <br />LAST NAME FIRST M I <br />µms,, am ---� <br />HOME PHONE <br />s <br />a <br />ADDRESS STREET CITY n STATE ZIP <br />. <br />CELL PHONE PROVIDER <br />3 QO Qr l7 `i <br />E .VfHll <br />HAVE YOU APPLIED WITH.OR BEEN � Yes Where HAVE YOU EVER <br />EMPLOYED BY SELECTEMP BEFORE? El N rn,— <br />o When � t' 2-OID9 L,[) BEEN TERMINATED <br />N <br />POSITION(S) APPLIED FO f MINIMUM DATE AVAILABLE FROM AJOB ?❑ Yes No EMERGENCY CONTACT PHONE <br />ACCEPTABLE WAGE: TO START: <br />+� O 5 U Li - (00( <br />y <br />_ <br />t <br />,l. - pn +- ��•- 7 ,.�c -� �i.r ^_•. z ti - ZuZ"�E �»- ` 18 OR OVER ❑Yes No <br />r �I�i4' <br />,t 5e [ad e�carit @.. -.�. s�.: ��H?��r�r��•.�1Qf..�.7:1 , " _..�?t5���bz�1S't� -r. <br />- NAME CtTYlSTATE DATES (OPTIONAL) 7 DEGREE GRADUATE? <br />� <br />Z es ❑ No in <br />HIGH SCH000GED t,L � 10 <br />t <br />�, �"~ <br />CO SCHOOLL / ' J f ❑Yes ❑ No <br />' <br />VGF�y •'RIlJ�1,�f, - �yZ�� ,r•!?�+",��,"�9t{.- iet<ti+c 'r !i �.2 . ^`s`si Yid:•. s�. .,.� cV'•�.ar ?�.` \�"F� Batt ¢ J�K' 8!�,��✓' ^S}C.�� -'9=4 7 dd u�-- !Cg:..x:. . .�y <br />�> <br />?'4F1`:,�y �'�L ��F. 7; i.'�; e y'.; 2 . jS„�• <br />i F•t • 'S.= e: e :5:_:,. _ .'.`.'tie <br />'HOW WERE YOU REFERRED AVAILA LE FOR EVER CONVICTED CFA CRIME? <br />TO SELECTEMP? � ❑- Graveyard ❑ FiU -In. . <br />❑ <br />❑ Swing ❑ Weekend ❑Full Time Yes 210 If yes, please list conviction & date. Also, <br />7 please request a criminal history form from the front desk. <br />IF REQUIRED. DO YOU HAVE c ORTATION HOBBIES <br />T <br />E <br />VALID D gw R'S LICENSE <br />I []RICE RICE {{ _. t , , <br />❑XEs ❑NC ❑BUS []BIKE 1i�vNll /i <br />• E <br />r <br />INDUSTR> APPLICANTS ONLY: Check equipment you Currently have avail I . ❑ Wel ipment ❑ Other (please list) <br />eath work boots ork gloves afetq Glasses am ear <br />eel toe safety boots ❑ Hard Hat ❑ Puller Apron ols <br />: EVE EA�fi MPL 1Fi4 EM t fl Tid Y; s� °bt u ' � 7 � <br />` ` r _x <br />b'- .dr- "�_�xa"�s•.� �'•.YV.t.�C m.'.:.'d.R� >.�F.1* -Y <br />{ <br />1 EMPLOYER STARTING DATE ENDING DATE PAY PHONE <br />Year <br />Month Month Year Starting Final (� ) <br />�M1�2ti t7CUL (J3 1- 2oiU �} l Zo 1v 1 015z) oS0 ,7(It- 935 -S2o <br />w <br />Q ADDRESS <br />f , REA50 FOR LEAVING ^ SUPER(ISOR'SS N` MAY WE CONTACT? <br />of fl <br />Z <br />) a�rc�l V10 � t es . ❑ No <br />CITY, ST, ZIP <br />�. 2 <br />, <br />JOB DUTIES. l <br />f <br />!1 <br />1 JOB TITL ^� <br />l <br />2. EMPLOYER <br />STARTING DATE <br />ENDING DATE <br />PAY IPHONE <br />_ <br />emp <br />starting Final <br />11 1 5 SL( t- a -4a�5 <br />Mortlh Year Month Year <br />5- 09 Jo a`} <br />g ADDRESS <br />REASON FOR LEAVING - <br />SUPERVISOR'S NAME MAY WE CONTACT? <br />{� 0--OT ❑ No <br />CITY, ST, ZIP <br />JOB DUTIES <br />�rr,•cC <br />2 9 �io� <br />Df �c AR62awS s <br />_ _ <br />8 JOB TI _ <br />- <br />t�CK , <br />3. EMPLOYER <br />STARTING DATE ENDING DATE <br />PAY <br />PHONE <br />( ) <br />Mc <br />Year Month <br />Year <br />Staving Final <br />t° • ADDRESS <br />REASON FOR LEAVING SUPERVISOR'S NAME MAY WE CONTACT? <br />, L7 T ✓ es ❑ No <br />. <br />CIT S T, ZIP <br />JOB DUTIES - ... CY�`i ir' <br />2 <br />o. JOB TITLEJ <br />1 c.. Lc <br />M 4. EMPLOYER <br />4 <br />STA TING DATE <br />- ENDING DATE <br />. PAY <br />PHONE <br />( ) <br />Month <br />Year <br />Month <br />Year <br />Starting <br />Final <br />I <br />I <br />. <br />09 <br />W <br />i ADDRESS <br />REASON FOR LEAVING •: _ . SUP E VtSCR'S NAME -. MAY WE C�ACT1 <br />i1 i S C.i <br />J k t� I: L ��nal U d'7 s ❑ No <br />Z - <br />' CITY ST, ZIP - - <br />7 Y'? <br />JOB DUTIES - _ J <br />�l <br />WAG <br />JeL <br />Rev. 2110 <br />0 <br />r <br />