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APPLICATION FOR EMPLOYMENT This 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 ordinances. I understand that if employed false statements reported on this application may be considered sufficient cause for dismissal. Signature of Applicant Date Interviewer s Comments WorkSource Washington and Washington State Employment Security are equal opportunity employers and providers of employment and training services. WorkSource Washington and Washington State Employment Security are not responsible for the misuse of information provided on this form. Provide all information requested by printing in ink or typing. Use the TAB key to move through the document. GENERAL INFORMATION Name Last First Middle Initial Home Telephone Address Mailing Address City State Zip Other Telephone E-Mail Address - Are you legally entitled to work in the U.S. Yes No POSITION Position Or Type Of Employment Desired Are you able to perform the essential functions of the job you are applying for with or without reasonable accommodation Salary Desired Will Accept Part-Time Full-Time Temporary Shift Day Swing Graveyard Rotating Date Available EDUCATION AND TRAINING High School Graduate Or General Education GED Test Passed If no list the highest grade completed College Business School Military Most recent first Name and Location Dates Attended Month/Year Credits Earned Quarterly or Other Semester Specify Hours Graduate From Degree Year Major or Subject To Occupational License Certificate or Registration Number Where Issued Expiration Date Languages Read Written or Spoken Fluently Other Than English VETERAN INFORMATION Most recent Branch of Service Date of Entry Date of Discharge SPECIAL SKILLS List all pertinent skills and equipment that you can operate EMS 10171 CC 7540-032 635 ESD 1999 Rev. 12/30/03 Maximum 300 characters WORK EXPERIENCE Most Recent First Employer Include voluntary work and military experience Telephone Number Address Job Title Specific Duties Maximum 350 characters Number Employees Supervised Hours Per Week Last Salary Supervisor Reason For Leaving May We Contact This Employer I certify the information contained in this application is true correct and complete. WorkSource Washington and Washington State Employment Security are not responsible for the misuse of information provided on this form* Provide all information requested by printing in ink or typing. Use the TAB key to move through the document. GENERAL INFORMATION Name Last First Middle Initial Home Telephone Address Mailing Address City State Zip Other Telephone E-Mail Address - Are you legally entitled to work in the U*S* Yes No POSITION Position Or Type Of Employment Desired Are you able to perform the essential functions of the job you are applying for with or without reasonable accommodation Salary Desired Will Accept Part-Time Full-Time Temporary Shift Day Swing Graveyard Rotating Date Available EDUCATION AND TRAINING High School Graduate Or General Education GED Test Passed If no list the highest grade completed College Business School Military Most recent first Name and Location Dates Attended Month/Year Credits Earned Quarterly or Other Semester Specify Hours Graduate From Degree Year Major or Subject To Occupational License Certificate or Registration Number Where Issued Expiration Date Languages Read Written or Spoken Fluently Other Than English VETERAN INFORMATION Most recent Branch of Service Date of Entry Date of Discharge SPECIAL SKILLS List all pertinent skills and equipment that you can operate EMS 10171 CC 7540-032 635 ESD 1999 Rev* 12/30/03 Maximum 300 characters WORK EXPERIENCE Most Recent First Employer Include voluntary work and military experience Telephone Number Address Job Title Specific Duties Maximum 350 characters Number Employees Supervised Hours Per Week Last Salary Supervisor Reason For Leaving May We Contact This Employer I certify the information contained in this application is true correct and complete. .

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