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e„ 9 Noge `1 -1 - v I <br />'Oril <br />Application for Employment EGER <br />A MENT SEItYI(ESC <br />gQaaNtolthe <br />Equal access to programs, services and employment is available to all persons. Thos application and /or in <br />view process should notify a representative of Selectemp. THIS APPLICATION MUST BE COMPLETED BY THE PERSON APPLYING FOR EMPLOYMENT. <br />PLEASE PRINT DATE ZGt <br />66 <br />- - - - -- / bZ / <br />LAST NAME / FIRS M I <br />�Qn <br />HOME PHONE <br />- Vi <br />- <br />ADDRESS STREET CITY STATE ZIP <br />4s%26, U f ,,kc. W« Cve 11 D� q <br />CELL PHONE QQROVIDER <br /><9I- %_- 2 - 7S? A T 7". r <br />HAVE YOU APPLIED WITH OR BEEN ❑ Yes Where <br />HAVE YOU EVER <br />EIMAIL " <br />U) <br />EMPLOYED BY SELECTEMP BEFORE? NO When <br />BEEN TERMINATED <br />FROM A JOB? ❑Yes � No <br />- �� A V/ uV f)�•/.e J <br />POSITION(S) APPLIED FOR: MINIMUM <br />ACCEP ABLE WAGE: <br />�1ev ;�/L g n <br />DATE AVAILABLE <br />TO ST RT. <br />i3 t , <br />EM RGENCY CONTACT & HONE # <br />a` <br />M° ,°. <br />s-ti k-17 157 - Qs6`I <br />EDUCATION <br />a s wi a` x ." <br />' <br />Y .� 3 dv 7 <br />18 OR OVER Yes No <br />❑ <br />Highest f <br />rade completed{ clfcle ,., 6 �;7, 8, �9tf M - 10 ; ,,12r 13y <br />gf* <br />16 416 +, r <br />. 4 `` 15 ` c.' ..;;, <br />NAME <br />CITY /STA DATES (OPTIONAL) <br />DEGREE <br />GRADUATE? <br />F f 'eG5G W , W t l G ! <br />/ E <br />( (Ie65GA -� 1 /' '1 Q� D <br />Yec <br />/ s <br />Yes ❑ No <br />HIGH SCHOOUGED <br />COLLEGE/TRADE SCHOOL ()lAfve - f it OF Jen t D ,fA1W. ^ h�'fi9 /GS ❑ YesE5No <br />GENER r� s ; " ? yy z �a�rr 5 , <br />� } �tl �,.. J`v 3, <br />ci`.ti .�Y :.+C..; b2 F.` t TL�- fY #3:�.eS 1%" " * +i'4 <br />LJ �..3✓l7e*: <br />., .�a' >. Sf'S7:•:`�..X f.i.�w 5..'.#.. k+f'y, vY1GV, 3+n? < <br />HOW WERE YOU REFERRED AVAILABLE FOR EVER CONVICTED OF A CRIME? <br />TO SELE CTEAy2? Day Graveyard 0"F'ill -In <br />Time ❑ Yes No If yes, please list conviction & date. Also, <br />_L11<11 <br />quest a <br />please criminal history form from the front desk. <br />IF REQUIRED, DO YOU HAVE A T ANSPORTATION HOBBIES" <br />VA ID DRIVER'S LICENSE ���5 <br />CAR ❑RIDE <br />fj <br />YES []NO ❑BUS ❑BIKE - '6 ' U6(' 6 I <br />DUSTRIAL APPLICANTS ONLY: Check equipment you currently have available. ❑ Welding Equipment ❑ Other (please list) <br />❑ Leather work boots Work gloves ❑ Safety Glasses _,E!rRain Gear <br />❑ Steel toe safety boots 1 9 Hard Hat ❑ Puller Apron Tools <br />� "�' �/'Cc� �it� t •�". � an � {� F'3t 'tr 4r'.3� t xt'�t .r <br />..:..� w.. .�i <br />^M'i( 1. EMPLOYER STARTING DATE ENDING DATE PAY <br />PHONE <br />Month Year Month Year Starting ^ <br />`lo r I / <br />W <br />4 Fina <br />51 V� to IZ fo Fs '( <br />Z <br />T ' ADDRESS <br />c REASON FOR LEAVING S AME MAY W CONTACT? <br />W; l <br />Seus� i , Gi <br />(� YG�f`'e Son .CJ Yes ❑ No <br />E l P/ . LLB l nrr <br />l '- <br />-C CITY, ST; " <br />ZI JOB DUTIES �J 1� `L <br />':E. 5Fr.,� � G IL �GAr'K'r 1 5 `G,GI �•C„ -,) Qu�� /U�yGnt tf.XCK., <br />` JOB TITLE: I ( 1 I p <br />'T Y�I. oc_r . l`¢��er �t�C Sl /�G�'Sr �/tZi?j .$e "%�-(../ / <br />/1i/'[/1Z�7!`U <br />l <br />Z. EMPLOYER <br />"f <br />STARTING DATE <br />ENDING DATE <br />PAY IPHONE <br />Starting <br />Month Year Mo Year <br />S (C <br />Final <br />�6.`l0 <br />�e e•,e — vvtBrc.l s <br />t <br />�•i{O <br />• <br />jE ADDRESS <br />REASON FOR LEAVING <br />��Gl I <br />SUPERVISOR'S NAME MAY WE CONTACT? <br />T <br />kr <br />(l []Yes ❑ No <br />CITY, ST, ZIP <br />C v <br />JOB DUTIES <br />tty� <br />(.071G/ 0 z.e ri I' tth7.41 J.1 (t: $r ?9 �i✓ C V i J � <br />JOB TITLE t <br />' 3.EMPLOYER <br />.t <br />STARTING DATE <br />ENDING DATE <br />PAY <br />PHONE <br />A3 <br />. <br />( ) <br />Month " <br />Year <br />Month <br />Year <br />Starting <br />Final <br />I <br />i <br />ADDRESS <br />1E' <br />REASON FOR LEAVING SUPERVISOR'S NAME MAY WE CONTACT? <br />IT <br />[]Yes ❑ No <br />CITY, ST, ZIP <br />JOB DUTIES <br />JOB TITLE <br />t <br />4. EMPLOYER <br />M <br />STARTING DATE ENDING DATE PAY PHONE <br />Month Year <br />yk <br />, - 3't <br />Month Year Starting <br />J§ <br />sE ADDRESS <br />REASON FOR LEAVING SUPERVISOR'S NAME MAY WE CONTACT? <br />Q <br />aCp <br />" E] Yes ❑ No <br />Z <br />Pa <br />CITY, ST, ZIP <br />JOB DUTIES <br />U) <br />JOB TITLE <br />Rev. 2/10 <br />