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Employment Application
Address:

COMPANY OR EMPLOYER NAME:

River City Tattoo Co.

Position applying for:

Piercing Apprenticeship

EMPLOYEE INFORMATION
Name: Nelson Blair Last First Telephone: (507)-397-3853 Email: 14bnelson@nkstudents.com

Caitlan
Middle Alternate telephone:

N/A

573 6th Street North, Northwood, IA

If necessary for the job, I am able to: X Yes Work overtime? Yes Provide a valid Alaska Driver's License? If so, fill out the following: Issuing state: N/A Type: Endorsement(s):
Hazardous Material Tankers School Bus No

Are you able to perform the essential functions of the position with or without accommodations? Yes X No If necessary for the job are you older than: X 16 (Check one) 14 15
18 19 21

X No N/A
Passengers

I am legally eligible for employment in the U.S.? X Yes No Yes X No I am seeking a permanent position: I will be able to report to work Open days after being notified I am hired.

Tank with Hazardous Materials Double/Triple trailers Swing Rotating

Work the following shifts: (check all that apply)

X Any
Split

Day

X Night
Other:

Graveyard

EMPLOYMENT HISTORY
List most recent employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary following this section or on an extra sheet of paper if necessary. No more than 10 years history recommended. Fallgatter's Market 50459

Employer name and address:

Position title/duties, skills:

Checker, count lottery, help costumers

98 7th St N, Northwood, IA

Pay: $ 7.25 Per: Hour Employer name and address:

Start date: End date: 11/15/13 3/3/13 Reason for leaving: Job ended

Supervisor: Angie Senne Position title/duties, skills:

Telephone: (641) 324-1651 Start date: End date:

Reason for leaving: Pay: $ Per: Employer name and address:

Supervisor: Position title/duties, skills:

Telephone: Start date: End date:

Reason for leaving: Pay: $ Per: Employer name and address:

Supervisor: Position title/duties, skills:

Telephone: Start date: End date:

Reason for leaving: Pay: Per: $ Supervisor: Telephone:

Employment Application Page 1 of 2

Rev. 8/2010

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Summarize other employment related to this job:

EDUCATION
Institution name High school College/university Business/technical Additional Years completed Field of study Graduate or degree

Northwood-Kensett

General

Graduate

MILITARY
Are you a veteran? Duty/specialized training: Yes

X No

N/A

SKILLS & QUALIFICATIONS

Other qualifications such as special skills, abilities or honors that should be considered:

Good with people, needles don't bother me, good with sanitation Types of computers, software, and other equipment you are qualified to operate or repair: Any Professional licenses, certifications or registrations: N/A Additional skills, including supervision skills, other languages or information regarding the career/occupation you wish to bring to the employers attention: N/A Typing speed: 132 per minute

REFERENCES
List two personal references who are not relatives or former supervisors.

Anne Erickson
Name Name

184 Main Street, Northwood, IA

Address Address

(641)-374-8732
Telephone Telephone

Animal Ecologist
Occupation Occupation

Years known

Deb Faugstad 796 11th Street South, Northwood, IA (641)-374-9204

Teacher

5
Years known

CONTACT
In case of accident or illness, please contact: Name: Berdale Nelson Address: 573 6th Street North, Northwood, Ia Daytime phone: (507)-397-4586 Relationship: Father

INFORMATION TO THE APPLICANT

As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above.

Blair Nelson Signature of Applicant

2/6/14 Date

Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment. Developed at employer request by the Alaska Department of Labor & Workforce Development, Employment Security Division. Rev. 8/2010 Employment Application Page 2 of 2