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 requested by printing in ink or typing. Use
the 'TAB' key to move through the document.
GENERAL INFORMATION
Name (Last)
Mejia
(First)
Address (Mailing Address)
(City)
(Middle Initial)
Vincent
1019 Harrison Avenue
I
(State)
(559) 493 - 0114
(Zip)
Sanger
Other Telephone
() -
93657
C
E-Mail Address
Are you legally entitled to work in the U.S.?
mejiavinny@gmail.com
Home Telephone
Yes
No
POSITION
Position Or Type Of Employment Desired
Management
Are you able to perform the essential functions of the job you are applying for, with or
without reasonable accommodation?
Yes
No
Will Accept:
Part-Time
Full-Time
Temporary
Salary Desired
Date Available
80,000/ year
12/09/2016
Shift:
Day
Swing
Graveyard
Rotating
EDUCATION AND TRAINING
High School Graduate Or General Education (GED) Test Passed?
If no, list the highest grade completed 11
Yes
No
College, Business School, Military (Most recent first)
Name and Location
Dates
Attended
Month/Year
From
To
From
To
From
To
From
To
Credits Earned
Quarterly or
Other
Semester
(Specify)
Hours
Graduate
Yes
No
Yes
No
Yes
No
Yes
No
Degree
& Year
Major
or Subject
Occupational License, Certificate or Registration
Number
Where Issued
Expiration Date
Occupational License, Certificate or Registration
Number
Where Issued
Expiration Date
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)
(Maximum 1000 characters) Organization,
Throwing large and small scale events, communication, management
WORK EXPERIENCE (Most Recent First)
(Include voluntary work and military experience)
EMS 10171 CC 7540-032 635
ESD 1999 Rev. 12/30/03
Employer Scott
Address
Okada
Job Title Teacher Assistant
Specific Duties (Maximum 1000 characters)
Telephone Number
(559) 493 - 0114
Number Employees Supervised
Aid the teacher in any way possible during their summer school class sessions.
From (Month/Year)
6/15
To (Month/Year)
7/15
Hours Per Week
20
Last Salary
$500
Supervisor
Scott Okada
Reason For Leaving
Temporary Employment
May We Contact This Employer?
Employer
Address
Telephone Number
() -
Job Title
Specific Duties (Maximum 1000 characters)
Number Employees Supervised
Yes
No
From (Month/Year)
To (Month/Year)
Hours Per Week
Last Salary
Supervisor
Reason For Leaving
Employer
Address
May We Contact This Employer?
Telephone Number
Job Title
Specific Duties (Maximum 1000 characters)
() -
Number Employees Supervised
Yes
No
From (Month/Year)
To (Month/Year)
Hours Per Week
Last Salary
Supervisor
Reason For Leaving
May We Contact This Employer?
Employer
Address
Telephone Number
Job Title
Specific Duties (Maximum 1000 characters)
Number Employees Supervised
() -
Yes
No
From (Month/Year)
To (Month/Year)
Hours Per Week
Last Salary
Supervisor
Reason For Leaving
May We Contact This Employer?
Yes
No
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.
Signature of Applicant_________________________________________________________ Date________________
Interviewers Comments:
WorkSource Washington and Washington State Employment Security are equal opportunity employers and providers of employment and training services.
Auxiliary aids and services are available to persons with disabilities upon request.
