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<br />Application for Employment F�,�F,
<br />Equal access to programs, services and employment at
<br />view process should notify a representative of Selectemp.
<br />Zi lSELECTEMP
<br />Equal Opportunity mployer E M P L O Y M E N T S E R Y I (E S
<br />sonable accommodation to the application and /or inter -
<br />3E COMPLETED BY THE PERSON APPLYING FOR EMPLOYMENT.
<br />SOCIAI grr'11P1TV M11kA P � I
<br />DATE
<br />PLEASE PRINT
<br />i/
<br />7 /
<br />LAST NAME IRS M I
<br />✓. ���
<br />HOME PHONE
<br />C ILI'
<br />x // - _537
<br />A DRE S STREET CITY STATE ` ZIP
<br />CELL PHONE PROVIDER
<br />���,,,///
<br />HAVE YOU APPLIED WITH OR BEEN ?� Yes Where
<br />HAVE YOU EVER
<br />E -MAfL
<br />EMPLOYED BY SELECTEMP BEFORE ? /❑ No When 120-
<br />BEEN TERMINATED
<br />OM ® A JOB? E] ���,,,,,,/// Yes �No
<br />POSITION(S) APPLIED FOR: MINIMUM
<br />DATE AVAILABLE
<br />EMERGENCY CON TACT'S HONE\
<br />6 � G
<br />1 ,12 ACCEPTApLF
<br />O START:
<br />sell
<br />i
<br />s
<br />;EDUCATION
<br />y "
<br />18 OR OVER Yes No
<br />m_ = I
<br />Hi hesugrade;com leted cycle ;} . 6 �7 C1 „4
<br />NAME
<br />CITY /S ,TE
<br />DATES (OPTIONAL)
<br />DEGREE
<br />GRADUATE?
<br />e'
<br />❑Yes
<br />HIGH SCHOOUGED
<br />t
<br />_'�
<br />❑Yes ❑ No
<br />COLLEGE/TRADE SCHOOL
<br />GENERAL II+LFORMATION�.,y �.2 I MMUNE:- y ;� s,� a �
<br />O N, , r`� �',r "�"`t ?� t v , r r ' c �a - a+' a.-
<br />a '*?S,Tt”
<br />'°.4
<br />t 'Y ,X�
<br />.
<br />ns,V .�. ,....«4 �.=c mr.,, i.trt"r<r,, nv,!= .+.:�53,e..m. -...a 1 "tr'�r''" «.
<br />7
<br />�..h.r � - ;�
<br />HOW WERE YOU REFERRED AVAILABLE FOR
<br />EVER CONVICTED OF A CRIME?
<br />C; RIME?
<br />TO SELECTEMP? Day ❑ Graveyard [] Fill-in
<br />//-- ❑ Swing Weekend _Full Time
<br />C / .1
<br />❑Yes o If yes, please� nvic� date. Also,
<br />K i
<br />please r q a crimi is from the front desk.
<br />IF REQUIRED, DO YOU HAVE A T NSPORTATION HOBBIES
<br />V ID DRIVER'S LICENSE CAR []RIDE
<br />YES []NO ❑ BUS ❑ BIKE
<br />INDUSTRIAL APPLICANTS ONLY: Check equipment you currently have 0 _. We ll�pweat,_Q ( pleas e s e list)
<br />Leather work boots Work gloves ❑ Safety Glasses ❑ Rain Gear
<br />❑ Steel toe safety boots Hard Hat ❑ Puller Apron ❑ Tools
<br /><.:. ..'�'. �j' ° p ` t..eti;
<br />FIVE YEARS EMRLOYAAENT HISTORY � � � -V
<br />:.:� _ ... � _st s.bar ;� . .r,
<br />,,; � _.. ���
<br />rf 1. EMPLOYER ' STARTING DATE ENDING DATE PAY IPHONE
<br />M Month' Year Month Year Starting Final
<br />( )
<br />pi ,
<br />ADDRESS REASON FOR LEAVING / SUPERVISOR'S N ME MAY WE CONTACT?
<br />+#�� e - "Z.�1 Cc>.fC /r/t .✓`s'vt O,i :i/ o� // (/��T/`�f` V Ye ❑No
<br />i CITY, ST, ZIP yy�� �7 JOB DUTI S 11 //
<br />` �U �Vl'�- V f- / 1 cr �e ✓ t 4t- �: ,f' J r..! t 1/L s , .K r K. F/ r L
<br />IF
<br />JOB TITLE ' + — e
<br />$ 2. EMPLOYER
<br />STARTING DATE ENDING DATE PAY PHONE
<br />M Year _Month Year Starting Final ( )
<br />gg
<br />/
<br />13- /
<br />N-
<br />ADDRESS
<br />..Eq
<br />x mil- h
<br />REASON F 7 6)w VIN G SUPERVISOR'S NAME MAY WE CONTACT?
<br />❑ Yes tg_o
<br />l� � P
<br />o
<br />CITY, ST, ZIP /
<br />L
<br />JOB OUTIES
<br />JO TLE
<br />JO
<br />11 re-
<br />3. EMPLOYER
<br />STARTING DATE ENDING DATE PAY. PHONE
<br />ellks Cj /o c�
<br />_Month Year Month Year Starting Final
<br />e � 2 07 e) s /S
<br />W ADDRESS
<br />REASON FOR LEAVING SUPERVISOR'S NAME MAY WE CONTACT?
<br />I n
<br />k L... JHr 11N1 w r I es [j] No
<br />l!
<br />/1
<br />CITY, ST, ZIP' /
<br />JOB DUTIES /
<br />J�O/�j_TIITLE L. ,
<br />:fit# 4. EMPLOYER
<br />STARTING DATE
<br />ENDING DATE PAY
<br />PHONE
<br />Month
<br />Year
<br />Month
<br />Year Starting
<br />Final
<br />(�O
<br />`.N3 ADDRES
<br />X�I^h
<br />REASON FOR LEAVING SUPERVISOR'S NAME MAY WE CONTACT?
<br />Yes ❑ No
<br />711 x PGCi �t/ Y /j
<br />;d. CITY, ST, ZIP
<br />L V /v S5 /0�/
<br />JOB DUTIES
<br />Its %( -r- S',-.S -es r cS kir r .
<br />JOB TITL
<br />5� N�5
<br />Rev. 2/10
<br />
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