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PRE-EMPLOYMENT APPLICATION
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PosLtLon AppLLed For
Jefferson County Ls an EquaL OpportunLty Employer and encourages appLLca -
tLons from aLL persons regardLess of race, creed, color, sex, natLonaL
orLgLn, marLtaL status, age or physLcaL, sensory or mental. dLsabLLLty un-
Less based upon a bona fLde occupatLonaL quaLLfLcatLon. (State Law:
Chapter 49.60 RCW and WAC 162).
IMPORTANT: CompLete aLL sectLons
1. Name:
2. Addre
PLease use Lnk. PrLnt name onLy.
3. Social SecurLty No.:?y?i7? 4. Date of BLrth O 0-/07 /`/y
(Age wLLL not be used to dLscrLmLnate)
5. Home/Message phone: 6. BusLness phone:
7. Education - TotaL years of pre-unLversLty schooLLng:
CLrcLe year compLeted: 1 2 3 4 5 6 7 8 9 10 11 12
8. Have you passed the General, Education DeveLopment (GED) Test Ln LLeu of
High School. GraduatLon: Yes No Year
9. Lieg'e/s Attended Years From To Degree
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10. REFERENCES: (PLease do not LLst reLatLves)
Name Address
1 /95-L-Au') N wAw, 10,E TY?Ei?
OffLce/Home Phone
3 SS -a 535
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