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TERED _ . , <br />E Use�on, Application for Employment EN SELKTEMP <br />. TED <br />r EMPLOYMENT SERVICES <br />Equal access to programs, services and employment is available to all persons. Those applicants requiring masnnahle accommodation to the application and /or inter - <br />view process should notify a representative of Selectemp. THIS APPLICATION MUST BE COMPLETED BY THE PERSON APPLYING FOR EMPLOYMENT. <br />N <br />N <br />9 <br />n � <br />Y <br />i <br />7 <br />Ii <br />W <br />SOCIAL GECURITY NUMBER <br />DATE <br />I <br />r PLEASE PRINT F 4 : , [•� <br />LA,'iT NAAMEE FIRST ` M I HOME PHONE <br />/l`/ S41- 933 <br />1` v <br />ADDRESS STREET CITY STATE ZIP <br />CELL PHONE PROVIDER <br />HAVE YOU APPLIED WITH OR BEEN ErYes Where D F ENE' HAVE YOU EVER <br />E -MAIL <br />EMPLUYLU BY SELEC I EMP BEFURE4 ❑ No When 0 D PEEN TERMINATED <br />POSITION(S) APPLIED FOR: MINIMUM DATE AVAILABLE FROM A JOB? ❑ Yes & No <br />ACCEPTABLE WAGE: TO STAR - P. <br />EMERGENCY eNTTACT & PPH E p <br />M (� <br />Y V t�,s auri <br />sLi I - Ia- -35ak <br />18 OR OVER yes ❑ No <br />#S <br />NAME CITY /STATE DATES (OPTIONAL) <br />DEGREE GRADUATE? <br />91-93 <br />F'Yes ❑ No <br />COLLEGE/TRADESCHOOL LHNE C mrnI/IN EIA GrJN v�O� - �oD� ❑ Yes ErNo <br />GENER INFORMATION' ti a fs d iF r X59 ai fi b g z c `" a Sys <br />AL d*, ,s'+,r ti: <br />3M1 �h.'.5 � '� .� K k 3 r., 3« � <br />. _...S ♦��S.J.��.. 'Me .t' C ...+' .rr" <br />I1UW WERE YUU REFERREU AILA13LE FOR f EVER CONVICTED OFACRIME? a <br />TO SELEG ILMP7 JDay <br />❑ Graveyard ❑ Fill -In <br />T I l /_ 0 G N In Swing 2- Weekend 'Full Time ❑ Yes O If yes, please list conviction & date. Also, <br />�1 V V V <br />please request a criminal history form from the Cunt desk. <br />IF REQUIRED, DO YOU HAVE A TRANSPORTATION L �f OBBIES <br />VALID DRIVER'S LICENSE ,aCAR []RIDE I'}�I�tNC�� fif�t�.�i \NC FtSHIN <br />E;�r ONO ❑BUS ❑RIKF - -A Q ?L CAMPI(v �, _..... <br />INDUSTRIAL APPLICANTS ONLY: Check equipment you currently have available. ❑ Welding Equipment ❑ Other (please list) <br />❑ Leather work boots ❑ Work gloves ]'Safety Glasses ❑ Rain Gear <br />jI-S teel toe safety boots ❑ I lard I lat ❑ Puller Aprun ❑ Tools <br />FIU_E YEARSEMPLOYMENT *HISTO.RY 2 <br />1. EMPLOYER STARTING DATE ENDING DATE. PAY PHONE <br />;Ml <br />rOJ Month Yvai Munth Year Starting Final ( ) <br />�(r - 7 56 -� noo <br />s Z" ,5 }�pNnE 1\'v� <br />,ka ADDRESS <br />REASON FOR LEAVING <br />SUPERVISOR'S NAME <br />MAY WE CONTACT? <br />F- <br />f <br />❑ Yes allo <br />E <br />c CITY. ST. ZIP <br />nRnI IT ` IC <br />E <br />S <br />w <br />N{ <br />,_ JOB TITLE_ <br />AN 5FIA -Z <br />r�pVT �.'R . S <br />2. EMPLOYER <br />STARTING DATE <br />ENDING DATE <br />PAY <br />PHONE <br />Month <br />Year <br />Zoo9 <br />Month <br />o <br />Year <br />1 - 2—e0c", <br />Starting <br />� .So <br />Final <br />»,Sb <br />GT o� Eve �� <br />rN" <br />( ) <br />sup 83- H°lloS <br />ADDRF, R <br />REASON FOR LEAVING RI IPERVIFOR'S NAME MAY WE CONTACT? <br />:e t <br />PWbrJX_L 1`CV ON Eres 0 N <br />CITY, ST, ZIP <br />JOB DUTIES FQL,_.OW <br />A 0 c, t.11. '2 C IS Oa <br />\.YPUZ eA FF - I P.EfV\0V WAV I&A - v (3\ILE 'F6)THS wa(�_.K <br />} JOB TITLE c <br />2A T 1 �L�M�V <br />N TtLH�FIf_ VL6 x 2EL,AT� S N�A�/`I L \F tIJ(� {�A LEI LO <br />3. EMPLOYER <br />r <br />STARTING DATE <br />ENDING DATE <br />PAY <br />IPHONE <br />Month <br />Year <br />Month <br />7 Year <br />Starting <br />0 c� <br />Final <br />lLt .00 <br />�r�6�v Lor�c,N <br />(5 I ) <br />-8t) I k <br />'t ADDRESS <br />S <br />REASON FOR LEAVING <br />SUPERVISOR'S NAME <br />MAY WE CONTACT? <br />z <br />X `� J 717 O`6V C, INWSTRt <br />T, <br />p (.� <br />l.U(`/\I�AN� sN VT � V W� <br />nn ^^ (/�� <br />1��L7 -CHO'c�lPv�ltti <br />O Yes No <br />sib CITY, ST, ZIP <br />JOB DUTIES <br />V � 0?- C l - 1 q 0 <br />P90V ?RRTS N SZ p, L t 120u SH OD t�AI F VIV LT Ot�S <br />JOB TITLE <br />t�R-O 11_ V Tl CJ� <br />1.El�PJ C`(LC�RN �2A D- C'T C3 FNl \c- <br />2 4. EMPLOYER <br />STARTING DATE ENDING DATE PAY IPHONE <br />Month Year Month Yuar Slartiny Final (Sl1 ( ) <br />2� 7 Zi s. o o ' 3- 2 y <br />AnnRFSS <br />REASON FOR LEAVING ° UPERVISOR'S NAME MAY WE CONTACT? <br />` <br />MnV-C - 0L_ji <br />BYus ❑Nu <br />en 7 <br />CITY, ST, ZIP <br />JOB DUTIES <br />y <br />4 tPr2L-0 0 ) - 7 W59 <br />JOB TITLE <br />Cv.S I-PaI kL r v noP Sw 6 p f A oN \A 0-NDL_lN <br />Rev. uru <br />