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N <br />C0 <br />W <br />Q <br />Z <br />H <br />U) <br />I= <br />LL <br />W <br />Q <br />Z <br />H <br />Q <br />J <br />ko <br />Application for Employment <br />Equal access to programs, services and employment is available to <br />view process should notify a representative of Selectemp. THIS API <br />D SELEGEMP <br />� . - - - - I <br />Flu.pc� pkOpportunity Employer E M D' L 0 Y M E N T S E R Y I( E S <br />edpbli&n l commodation to the application and /or inter - <br />ST BE COMPLETED BY THE PERSON APPLYING FOR EMPLOYMENT <br />SOCIAL SECURITY NUMBER DATE <br />PLEASE PRINT <br />LAST NAM ^ FIRST M I HOME PHON <br />ADDRESS STREET SE ZIP <br />u u I r v' ( 't4 <br />CELL PHONE RO DER <br />I - St �s 7� <br />,_,/ <br />HAVE YOU APPLIED WITH OR BE IJ Yes Where <br />HAVE YOU EVER <br />E- AIL <br />EMPLOYED BY SELECTEMP BEFORE? ❑ No When '5 au <br />BEEN TERMINATED <br />FROM A JOB? ❑ Yes ZNo <br />/%� <br />Y ►/ S21Z ( 4� <br />POSITION(S) APPLIED FOR: MINIMUM DATEAVAILABLE <br />EMERGENCY CONTACT BPHON <br />ACCEPTABLE WAGE: O START: <br />EDUCATION , � �. Y,,1;'?W ��;; 0 <br />x�Fr fi? ". � �. <br />� x <br />` <br />18 OR OVER Yes <br />x t+r v > <br />)iighest;grade,completed circle)), �� 6 , 7 ,,8t z9„ D R10�r 11 ? .,12 13, <br />�!- OF 41 <br />x14 ? 15, 16 X16± ?; <br />❑ No <br />NAME <br />CITY /STATE <br />DATES (OPTIONAL) <br />DEGREE <br />GRADUATE? <br />HIGH SCHOOUGED <br />04 <br />04 r C11 <br />444/JJ/ <br />ZY.. ❑ No <br />COLLEGE/TRADE SCHOOL ❑ Yes ❑ No <br />GENERAL`�INFORMATION s u•a� 4 �� cN arr. <br />, <br />HOW WERE YOU REFERRED AILABLE FOR EVER CONVICTED OF A CRIME? <br />TO SELECTEMP? < IrDay 06raveyard ❑ Fill -In I <br />t/l ' ❑ Yes L7 No If list 8 <br />C Swing ErWeekend Q-Full Time yes, please conviction date. Also, <br />Y t <br />please request a criminal history form from the front desk. <br />IF REQUIRED, DO YOU HAVE A TRANSPORTATION HOBBIES <br />VALID DRIVER'S LICENSE CAR <br />[]RIDE <br />YES ❑NO ❑BUS []BIKE <br />INDUSTRIAL APPLICANTS ONLY: Check equipment you currently have a ailable. ❑ Welding Equipment ❑ Other (please list) <br />❑ Leather work boots ❑ Work gloves ❑ Safety Glasses ❑ Rain Gear <br />❑ Steel toe safety boots ❑ Hard Hat ❑ Puller Apron ❑ Tools <br />FIVE YEARSSEMPLOYMENT '� <br />_: ». _.G.....:s ......,.......-, .,....,t....- .....•....- �:...+. ,t.- u....w...G. Y?5..� �hv- �.- w�.<:'�i4.r}'.+fk �E�i'1'.2�rl�L:..t��JC dTa". FSRa ;��.�'� '�dY�'.�`, �'�F,ar.:.Y�.^5..�".. `«uy <br />.rt = +`' <br />}M 1. EMPLOYER STARTING DATE ENDING DATE PAY PHONE <br />i Month Year Month Year Starting Final <br />l 'SDU. s J <br />s VC -e a .�vc .zvl d 13r <br />A DRESS <br />(A 1n Cam REASONFOR DLEAVING f / �j/�1A SUPERVISOR'S NAME/ n MAYV �JG' CONTACT? <br />iR) l� Yes ❑ No <br />/ �'C.. � A � <br />Y `. J Ji r V' t (��r at �`j <br />iE <br />2, CI T, ZIP JOB DUTIES / <br />wUVI r \Nl V I <br />If <br />N4 <br />JOB TITL _ / / <br />PTI <br />CZ S t SU rl A ht l1djr &. US E d 7 L bjs C�.0 1. enfH e 7- r <br />2. EMPLOYER <br />STARTING DATV <br />ENDING DAtt <br />PAY <br />PHONE <br />Month <br />Year <br />Month <br />Year <br />Start in <br />Final <br />�_ G <br />c5 <br />(-N' ADDRESS 1�) /► I( !1 <br />�- I <br />,X, <br />REASON FOR n LEAVING <br />�.,^ SU RVISOR'S NA1(N]/��/I MAY W ONTACT? <br />Yes ❑ No <br />V YI \ K <br />Y v�.. y 1 • • 1. W X. f t."� W <br />;? CITY, S ,ZIP q ` <br />Cr ( (J ( <br />JOB DUTIE r ,, <br />AIV r <br />1 <br />JOB TIT <br />Er <br />1 <br />S L& Gu y S o +H <br />". 3. EMPLOYER <br />c <br />STARTING DATE <br />ENDING DATE <br />PAY <br />1PHONE <br />Month <br />Year <br />Month <br />Year <br />Starting <br />'N ADDRESS <br />REASON FOR LEAVING SUPERVISOR'S NAME MAY WE CONTACT? <br />:7( <br />❑ Yes ❑ No <br />CITY, ST, ZIP <br />JOB DUTIES <br />*; <br />JOB TITLE <br />• <br />4. EMPLOYER <br />STARTING DATE <br />ENDING DATE <br />PAY PHONE <br />Starting <br />Month Year Month Year <br />N` <br />ADDRESS <br />REASON FOR LEAVING <br />SUPERVISOR'S NAME MAY WE CONTACT? <br />[:]Yes ❑ No <br />CITY, ST, ZIP <br />JOB DUTIES <br />JOB TITLE <br />1 <br />Rev. 2110 <br />