APPLICATION FOR EMPLOYMENTThis generic application is .provided by WorkSource Washington. This form complies with federal and state laws against discrimination;however, employers,using this form should check local ordininces. WorkSource Washington and Washington State Employment Securit,;are 1ot responsible for the mjsuse of information provided on this form. Provide all infonnation requested 6y printing in ihr br typing. Usithe 'TAB' key to move through the document.

GENERAL INFORMATION

POSITION

EDUCATION AND TRATNING

Position Or Type Or empryrnentEEGiEE' WillAccept:n Part-timeI rutt-limef] Temporary

shift:E oay

I swing

I Graveyardl-l Rotatinq

Are you able to perform the essential functions of the job you are applying for, with orwithout reasonable accommodationl f] yes f] No5arary ueslred

Date Available

Name (Last) (First) (Middle lnitial) Home Telephone()

ACrdress (Maiting Address) (city) (State) (zip) other Telephone()

E-Mail Address - .....-Are you legally entitled to worX in the U.S.? n Yes n ruo

High School Graduate Or General Education (GED) Test passed? [ yeslf no, list the highest grade completed

n No

College, Business School, Military (tV6st recent first)

Name and LocationDates

AttendedMonth/Year

Credits Earned

GraduateDegree& Year

Majoror Subject

Quarterly orSemester

Hours

Other(Specify)

From n YesENoTo

From D YesENoTo

From D YesnruoTo

From n YesE t'loTo

Ltcense, certificate or Registration Number Where lssued Expiration Date

License, Certificate or Registration Number Where lssued Expiration Date

uccupattonat License, Certificate or Registration Number Where lssued Expiration Date

Languages Read, Written or Spoken Fluenfly Other Than English

VETERAN INFORMATION

SPECIAL SKILLS nent skills and

EMS 10171 CC 7540-032 635ESD 1999 Rev.12l30l1i)

WORK EXPERIENCE Recent (lnclude work and

Employer TeteDhone Number ( From (Month/Year)

Job Title Number Employees SuPervised To (Month/Year)

IHours PerWeek

Last Salary

Supervisor

Reason For Leaving'' May We Contact Tnrs EmPloYer?-

Employer Telephone Number ( From (MonthlYear)

Job Title Number Employees Supervised To (Month/Year)

Hours PerWeek

Last Salary

Supervisor

f,rf

"V w" Contact This Employer? fl Yes n No

Reason For Leaving

EmployerFrom (Month/Year)

Job Title Number Employees Su PervisedTo (Month/Year)

Specifrc Outies (Maximum 1000 characters)Hours Per Week

Last Salary

Supervisor

*r*"Contu"t@Reason For Leaving

Employer Telephone Number ( ) From (Month/Year)

Job Title Number EmPloyees SuPervised To (Monthffear)

@racters)Hours Per Week

Last Salary

Supervisor

*.V *" contact rhis tqg9l".Ltr-Y"t nLReason For Leaving

I certify the information contained in this application is true, correct, and complete, I understand that, if employed' false

statements reported on this application may be considered sufficient cause for dismissal'

DateSignature of APPI

are ed;Cpportuni-ty emPloyers and

I nterviewer's Comments:

a"*irl"ry "iai

and services are available to persons with disabilities upon request,and training