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. WorkSource Washington and Washington State Employment Security
are not responsible for the misuse of information provided on this form. Provide all information reuested by printing in ink or typing. !se
the "T#$" key to move through the document.
GENERAL INFORMATION
Name (Last)

(First)

(Middle Initial)

Home Telephone
% & '
Address (Mailing Address)

(City)

(tate)

(!ip)

Other Telephone
% & '
E"Mail Address

#re you legally entitled to work in the !.S.( )es *o
#OITION
#osition Or Type O$ Employment %esired

&ill A''ept(
Part'Time
+ull'Time
Temporary
hi$t(
,ay
Swing
-raveyard
.otating
#re you able to perform the essential functions of the /ob you are applying for, with or
without reasonable accommodation( )es *o
alary %esired

%ate A)aila*le

E%+CATION AN% TRAINING
High 'hool Grad,ate Or General Ed,'ation (GE%) Test #assed- .es No
0f no, list the highest grade completed
College/ 0,siness 'hool/ Military (Most re'ent $irst)
*ame and 1ocation
,ates
#ttended
2onth3)ear
4redits Earned
-raduate
,egree
5 )ear
2a/or
or Sub/ect
6uarterly or
Semester
7ours
8ther
%Specify&

+rom

)es
*o


To

+rom

)es
*o


To

+rom

)es
*o


To

+rom

)es
*o


To
O'',pational Li'ense/ Certi$i'ate or Registration

N,m*er

&here Iss,ed

E1piration %ate

O'',pational Li'ense/ Certi$i'ate or Registration

N,m*er

&here Iss,ed

E1piration %ate

O'',pational Li'ense/ Certi$i'ate or Registration

N,m*er

&here Iss,ed

E1piration %ate

Lang,ages Read/ &ritten or po2en Fl,ently Other Than English

3ETERAN INFORMATION (Most re'ent)
0ran'h o$ er)i'e

%ate o$ Entry

%ate o$ %is'harge

#ECIAL 4ILL (List all pertinent s2ills and e5,ipment that yo, 'an operate)
(Ma1im,m 6777 'hara'ters)
EMS 10171 CC 7540-032 635
ESD 1999 Rev. 12/30/03
&OR4 E8#ERIENCE (Most Re'ent First) (In'l,de )ol,ntary 9or2 and military e1perien'e)
Employer Telephone N,m*er % & ' From (Month:.ear)

Address
;o* Title N,m*er Employees ,per)ised To (Month:.ear)
pe'i$i' %,ties (Ma1im,m 6777 'hara'ters)

Ho,rs #er &ee2

Last alary

,per)isor

Reason For Lea)ing May &e Conta't This Employer- )es *o
Employer Telephone N,m*er % & ' From (Month:.ear)

Address
;o* Title N,m*er Employees ,per)ised To (Month:.ear)
pe'i$i' %,ties (Ma1im,m 6777 'hara'ters)

Ho,rs #er &ee2

Last alary

,per)isor

Reason For Lea)ing May &e Conta't This Employer- )es *o
Employer Telephone N,m*er % & ' From (Month:.ear)

Address
;o* Title N,m*er Employees ,per)ised To (Month:.ear)
pe'i$i' %,ties (Ma1im,m 6777 'hara'ters)

Ho,rs #er &ee2

Last alary

,per)isor

Reason For Lea)ing May &e Conta't This Employer- )es *o
Employer Telephone N,m*er % & ' From (Month:.ear)

Address
;o* Title N,m*er Employees ,per)ised To (Month:.ear)
pe'i$i' %,ties (Ma1im,m 6777 'hara'ters)

Ho,rs #er &ee2

Last alary

,per)isor

Reason For Lea)ing May &e Conta't This Employer- )es *o
I 'erti$y the in$ormation 'ontained in this appli'ation is tr,e/ 'orre't/ and 'omplete< I ,nderstand that/ i$ employed/ $alse
statements reported on this appli'ation may *e 'onsidered s,$$i'ient 'a,se $or dismissal<
ignat,re o$ Appli'ant========================================================= %ate================
0nterviewer9s 4omments:
&or2o,r'e &ashington and &ashington tate Employment e',rity are e5,al opport,nity employers and pro)iders o$ employment and training ser)i'es<
A,1iliary aids and ser)i'es are a)aila*le to persons 9ith disa*ilities ,pon re5,est<