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PRE-EMPLOYMENT APPLICATION h
-HositLon App ied or
I TM'°
Jefferson County Ls an EquaL Opportunity Employer and encourages appLLca -
tions from aLL persons regardless of ra
d
ce, cree
, color, sex, national
origin, marLtaL status, age or physLcaL, sensory or mentaL dLsabLLLty un-
Less based upon a bona fide occupatLonaL quaLLficatLon. (State Law:
Chapter 49.60 RCN and WAC 162).
i
IMPORTANT: CompLete aLL sections. please use Lnk. PrLnt name only.
I
1. Name: ti? P ( ?n r' ?''i h v J PS b
(Lases ?rst mid Le
n
2. Address: /?DBG'?r/ %/1
35
.
street city s ate zip
3. SOcLaL SecurLty No.:_S?q-??= Sq?{ 4. Date of BLrth
' C?- C6
.
(Age wLLL not be used to dLscriminate
5. Home/Message phone: ?? 4 6• Business phone: .S O,)'A
e -
.
7. Education - TotaL years of pre-unLversity schooLLng:
CLrcLe year completed: 1 2 3 4 5 6 7 8 9 10 11 72
8. Have you passed the General Education De
veLopment (GED) Test Ln LLeu of
_
HLgh School GraduatLon: Yes No
Year
9. CoLLeges /Attended Years From To Degree
7?
4
10. REFERENCES: (PLease do not LLst reLatLves)
Name Address Office/Home Phone
ofe
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2. ?f -PfY?nh z'35 S? 3' US`3?0
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3? SIZy
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a. CL ?A? 1, R e G h a u 2,%C,- 'ASD'Z' 3 fi= Z
s.
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