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IIBS=CE AGREEIVENT Jefferson Co> r
y 'Participant Name: rnond- -(coclle?v
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Servi?a Provider
Northwest Sep-vices Coun
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:.1 ?Su p W Isar-? 385-5578 1002 Lawrence Street
Port Townsend, WA 98368
Ecd d4abrh-) - 395 bSgC) gQtp.0d), Cc?u ,{ c>n
•. d?'Alnc_r- , 12 20
Cooperating Agency Weekly Schedule Start Date s
JCrl-1sonCa1?d,-x 3)M kZU2S W15/87-W-1/k7
NX I 1 o I2C'.Sclts
Failure to attend workshops and appointments can result in loss of hours or
work time.
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OBJECTIVE., & OUTCOMES BY COMPETENCY CA'MORY
{xy s a r r r?
, * t COMPE-LENCY CATEGORY OBJECTIVES GAIN ACTUAL OUTCOME.' DA.? r?
+ ffi? r'
.? ht Work Maturity Skills[ Obtain satisfactory (5) {
n?Pw? rating on all work maturit
5?r ' skills.
r Occupational Skills Become proficient at all
tasks on job description.
Yv„5 r Yh? ?
Pre-Employment Skills Complete all assignments
,? r + ahv
as requested.
d '9 Participate and 'complete
job search assirrunants.
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y"ra Educational ?O?tAltnl?`?G
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Attached: Job. Des. Memo of Agreement OJT Contract School Curriculum
' Participant Personnel Policies VEP Curriculum
Other (specify) Handbook
,. Z certify that I have participated-in the development of the above Service Agreement
r•.. 1 and understand its conditions and agree to comply with the content and objectives.
Further, I understand that failure to comply may terminate this Agreement. I have
• '
"
received a copy fo the forms checked above. ,
F
Northwest Services Council
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Or zation Organization
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rv c vider Service Provider Service Provider • '?
{ I have participated in the development of my Employability Development Plan and hav_
rar ,:', received a copy.
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EMPLOYMENT PROGRAM
JOB DESCRIPTION
JOB TITLE: Vegetation Management WORK SITE: Selected
county road
rights of way
HOST AGENCY: JTPA PARTICIPANTS
Jefferson County TO BE EMPLOYED: 6
ADDRESS: P.O. Box 1220
WAGE: $3.35/hr. to be '
supplemented by
Jefferson County
amount of $1.50/hr.
SUPERVISOR: Far] Wells SCHEDULE: 7:00 a.m. - 3:30
Jefferson Co. Supervisor (or as mutually agreeable with
Supervisor) Monday - Friday
ALTERNATE SUPERVISOR: William Arey
PHONE NO.: 385-0890
I. SUMMARY OF JOB
A. GENERAL
U
the se of manual vegetation management techniques for
control of roadside
establishment eoftplant communities and
validity of non-use of herbicides. Involving
cutting, pulling, thinning of noxious vegetation.
Recognition of desirable species and critical areas
for control.
II. PERFORMANCE REQUIREMENTS
A. OCCUPATIONAL JOB SKILLS
1. INITIALLY REQUIRED
Ability to take directions and criticism.
Good eye-hand co-ordination. Use of basic
gardening tools.
2• WILL BE LEARNED
Skilled gardening techniques. Plant
identification and control methods.
B. WORK MATURITY SKILLS
1. INITIALLY REQUIRED
i Ability to take supervision and criticism.
Ability to tolerate a physically tedious task.
2• WILL BE LEARNED
Work independently in recognizing and
determining treatment: for problem areas. Make
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effective coherant suggestions for innovative 2n
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III. TRAINING PROVIDED l
A. ON-SITE TRAINING and FORMAL TRAINING
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Will be taught to recognize desirable and a
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undesirable plant species; sight distance
requirements for road approaches and intersections' t x+
and signs; contour control for potential erosion
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EQUIPMENT, TOOL or MACHINERY TRAINING 7
1
Basic gardening tools, some machete and chain saw
work. y
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Direct Supervisor Date k'>se??4 .
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r PRE-EMPLOYMENT APPLICATION
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fSrirSV. CreL,.1 / Sut ir;?Cr- Ilclo J
r. os on pA?p T-0 or .. 1
Jefferson County [s an Equal Opportunity Employer and eencourages appltca .
?t
*tons.from all persons e-egardLess of race, Cr, color, sex, national
eed
orLSLn, marital ststus, age or phystest. sensory or mental disability un-
` less based upon a bona fide occupat[onal qua(.ifieatlon. (State Law: „ -`
Chapter 49.60 RCM and HAC 762).
IMPORTANT: Complete all sections. PLease use [nk. Print name only.
8. Name:_ LYoni< MiCHAE-0 AL4AI
{last) ??--
2. Address: 1310 rsd v we, 2r
rn a --rm I.Ja . f7 S 3;2
s ree c ,
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APVIy%^q? s a• s P `
3. Soc[aL Security No. t ?? rPSF.rdl 4. Data of Birth ;,p4-. go, )967
_
?..• .. .. • ., .-(Ags aLll not be use o ?6cr m nt I L
ifome/Message phone; De.) ?3? - Lit,? N
'j G. OusLt?ess phonet `
rr r 7. EducatLon - Total yearn of pro-untvaratty schoottra s
V Ctrete year comptetodt 7 Z 8 4 8 6 7 m® 90'97 92
0. Wave you passed the Ceneral IEducat[on Davsto ¢E ?
1[ 4USh School CredustLon:. We No _ Ye?a+,?D Test Ln 1[w e
f
S. •Cotteges Attended Weam From To Degras
IMFOMNICES: Meass do not Ust PatattvasD swl
dame Addrmas PI-Don
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' 9. (nary rr1?llct,'1 110 ??sl' lnlle? /1el Chrn./:.dV lJ ?i7 -11189 t
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A. Company Name: Sc?,JhWes4ern
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Job Title: L
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A ••: 34-eve nc v,( 9
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Oo you„have any settvLtLes. cowAtm2nts or responstbLLLttes that may
prevent you from meeting work attendance"requtrementst Yes_llf-k--lVO_? x@
Comments:
r 1B. Do you have any handicaps that may affect work performance which
ou
y
feel should be taken into account Ln determLrnt g job placements:
a, Yes No ? If yes, please exptaLn: =
15. Do you have any probtems Ln becoming tawfutly employed Ln thts eountr
because of visa or immigration status: Yes No -
1 16. Can you provide proof of cittsenship, visa or alien resistrstton
number after being hired: Ves- V No ik
•
Comments:
• 17. Have you had experience Ln the fottowtnst
?/ Is) Cara-yin out oaring job sttwttons You V No
(b) Manual Labor Y
YS
v N
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(c) Outside Kork Yes- No `
(d)
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ns
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` Comments on the above: C I„K?0 {„ Alma
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eve you een eonv e e , or va you served - ma n a oorY`ac onarri
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or any crime slhteh tatght
have some bear-E
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Y 10. PLEASE READ THE FOLLM-ING AND 5 1GN BELOW:
1 c -*Lfy that att statements above are true and to the beat of any
u knowledge. 1 understand that fatse statements staLL be suffLeLent
k cause for termination.
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f PRE-EMPLOYMENT APPLICATION fY s
ositLon App Led For
{ Jefferson County Ls an Equal. OpportunLty Employer and encourages appLLca
tLons from aLL persons regardless of race, creed, color, sex, nationaL
origLn, marital status, age or physLcaL, sensory or mental dLsabLLLty un- r h
i Less based upon a bona fLde occupational quaLLfLcation. (State Law:
Chapter 49.60 RCN and WAC 162).
IMPORTANT: Complete aLL sectLons. PLease use Lnk. PrLnt name onLy. f
? i
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"?_ . ;
1 . Name: (Last) „".
firsst mLddLe `
r S ?:
33G + >
2. Address: ZO M"rFc?? S? 414dlo k WA
(street) city s ate u p r r
3. SociaL Security No.: z73;-u0 -7 4. Date of BLrth y'-/- (7 ti3
(Age wLLL not be used to discriminate
5. Home/Message phone: 3y,5"'7Y5/'l 6.- Business phone: M
4,
t 7. Education - TotaL years of pre-unLversity schooLLng: ysur.
CLrcLe year compLeted: 1 2 3 4 5 6 7 8 9 10 11 2, I \Sc.
B. Have you passed the General. Education Development (GED) Test Ln LLeu of
Yi HLgh School Graduat•Lon: Yes No Year
3 9. Co/?LLe es Attended years From To Degree
loe •n E I toe / ? . LAO 1Ib 3 -97
10. REFERENCES: (PLease do not LLst relatives)
4 Name Address OffLce/Home Phone Mtir, ??a r?
? d 0150M 261 t?U Anldwsoa L.k i2a C/,;..,, '73Z- y77D a
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D. Company Name: 'Phone:
Address:
City State Zip
Job TLtLe• lmmedLate Spvsr•
Dates Employed: SaLary:
From Ti BeginnLng FLna Month y
SpecLfLc Duties:
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Cic _ 'y
010 ?Form 100b
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EMPLOYMENT HISTORY (begLnnLng with Latest empLoyment)
A. Company Name::?'y +s%YJa U; 1.> Phone: 3SS-S! ?D
Address: e",I, . I-
___? .7TaTe Z. Lp
Job TLtle: (!IeAk lmmedLate Spvsr•.. C
Dates Employed: 3-XL 9-514, Salary: ?/Ol? ?/ 0O
From To Bey,LnnLng FLnaL Monthly
SpecLfLc Duties: fPv? ivtt??), e o __A a, I( h t?dtix e
• G • • • • . • • • . • • • ... • • • • ? • • • • • • • • • • • • • • • • • • • . • . • • • • • • • • • • • • • • • • • • • • • • . • • • • • •
B. Company Name P r-? Tn,v ??? _ +v (`,+ Phone:-3Y5-31
?c7
Address: ? Gfq 9Y 68
L ty State Zip
Job TLtLe:_ ?,? ry 811-11 Immediate Spvsr,
Dates Employed: _G_g5 9-Y5- SaLary: 75-6 7, S--
From To EegLnnLng FLnaL Monthly
Specific Duties:
•eve* ••a.••••••••..•.•.•.•....••••..•.•.•.••1.e.••.•.•••••••"•••••••..•••
C. Company Name: Phone:
Address:
city State ZLp
Job TLtLe: lmmedLate Spvsr.:
Dates Employed SaLary
From To BegLnncng FLna Month y
SpecLfLc Duties:
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Talents or SpecLaL SkLLLs
n.? P-r a ?d Do 'you have any activLtLes, commitments or responsLIoLLLtLes that m¢y
prevent you from me?etLng work attendance requLrements: Yes" !Jo ??
Comments:
Do you have any handLcaps that may affect work performance whLch you
f eeL should be taken Lnto account Ln determinLng job placements:
Yes No ?i If yes, please expLaLn:
Do you have any problems Ln becoming Lav%+uLLy employed Ln thLs country
because of vLsa or Lmmigration status: Yes No X
Can you provide proof of citizenship, visa or aLLen registration
number after being hired: Yes C _ No
Comments:
Have you had experience Ln the foLLowLng:
(a) Carrying out varing job situations Yes ')? No
(b) Manual Labor Yes Y, No
(c) Outside Work Yes K No
(d) Use of general hand tools Yes % No
(e) Use and maintenance of power.saws Yes?_ No
(f) Driving truck Yes No X
(g) Oper&tLng smal.L equipment Yes_,K
(h) Had others work under your Lnstructions Yes X No
(L) Working wLth others and the pubLLc Yeses No
Comments on the above:
Have you een convLc a or ave you served - Mme Ln a correc Bona
facLLLty,wLthin the past seven (7) years, for any crime which mLght
have some bearing 11,
on your quaLLfLcatLen and fitness to accept the
dutines and responsibLLLtLes of the position for which you are apply-
Ling? Yes No__y_ If yes, please gLve dataLLs
19. PLEASE READ THE FOLLOWING AND SIGN BELOW:
1 certify that aLL statements above are true and to the best of my
r
knowledge. 1 understand that false statements shaLL be suffLcLent
cause for termination.
f - Lgna ure o App Lcant Date
X ? :N
1 ' *?prm 700c
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4' t?
ry PRE-EMPLOYMENT APPLICATION
t
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ew
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Lierfs
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App Le
d For
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e
erson County Ls an Equal Opportunity Employer and encourages appLLca - : u+
YA tLons from aLL persons regardless of race, creed, coLor•, sex, natLonaL R" "x
!
" 0 Lgin, marital status, age or physLcaL, sensory or mental dLsabLLLty un-
Less based upon a bona fLde occupational quaLLfication. (State Law:
Chapter 49.60 RCW and WAC 162).
{5
_ IMPORTANT: Complete aLL sectLons. Please use Lnk. PrLnt name only.
1. Name : .S.A'"' >!f pA ( f;fc /lar?7
as Lrst -?mL dLe 'p, 4
2. Address: u043 6,+I< ?oa /j,p ??tLuc(lot.r
wlISN.
9
s36
s reet cLty s ate up
w 3. Social SecurLty No. 86 -641634. Date of BLrth 7- l 9- 6 g "
(Age WLLL not be used to dLscrLminate Fia?.
a
?, - S. Home/Message phone: 4/17-6. Business phone:
7. Education - Total years of pre-university schooLLng:
CLrcLe year compLeted: 1 2 3 4 5 6 7 8 9 10 77 h
r
z
.?` 8. Have you passed the General Education DeveLo ent (GED) Test Ln LLeu of
HL
h School G
d
tL
Y
¢g g
ra
ua
on:
es No Year,
9. Colleges Attended Years From To Degree g`
e'. F
my
i 10. REFERENCES: (Please do not LLst relatives)
Name Address Office/Home Phone
1.1_40WUr4 6',V1 aoX SL1d cN?Mlcum 7?d-4367
-
2. L
On /[t?? rPl? fOf?Cr?A. L'37?
ISK row
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3.1}?arV f/1naevlrer &Y 54>, cN/mPLUM ]
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4.Sakl 06ULs 1,)6 r*(.ud1."r LlS7 -d -Ark r'or e
t aru ??p
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5. r D[?rlc k Porf l ,d/o
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5 1 1. EMPLOYMENT HISTORY(begLnnLng with Latest employment) ; ?? •
t t A. Company Name:
Phone G/ ror
Aaaa-P
Address: Porl/Ld/o, r• sir°?° rti
W/?SH 9865
airy State Zip
Job TLtLe: Cart Nctndter fr
' Immediate Spvsr•..: /yn41on
Dates EmpLoyed:.li? - Se AIL Salary: `/• Sy Nom. dyoo
From To Qeft,LnnLng FLnaL Monthly
SpecifLc Duties:_C/PGrI C4r t
/ On oo/r Course r'x Some Broken
flirt' ctn•?.d G/C4h/nc1 V.0 T1..? yr/ujny rY:,++ge- , WfC?eut' 4 ,
,- ., eeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee _,, ?i a,f '.B. Company Name_Ap2 -7Phone: G/37-Axax-
Address:
_ ?jYf?Ut?/acJ wR N
9?s?s
City state ZL t
Job TLtLe: Cud' A' X, woo Immediate SPvsr.: ? p
D/Gk SC??/h1Q/ st
Dates EmpLoyed:June- Jv/y SaLary:?jr ( Orel 7co 7po ki <
From To BegLnning FLna Monthly
/ k?' t
? SpecifLc DutLes: Gut" r-1 re LyOOC1 0w?.u Se// { {
?JarfLud/a tnr .? 5,,?
?'' fee'eeoee•eeeeeeeeeeeeeeeeoeeeeeeeeoeeeeeeeeeeeeeeeeoeeeeeeeeeeeeeeeeeeee?e ?-7"? '.
IF
C. Company Name: Phone:
r
? Address:. •
CLry State Zip u`4 .1
Job TLtLe: ImmedLate Spvsr.: +
Dates Employed SaLar
r
From To BegLnnLng FLna onth y
M
Specific Duties: f _
i ? eseseeoeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee eexeeeeeeee
D. Company Name:' "Phone:
Address:
j CLty aLe Zt.p
y Job TLtle: Immediate Spvsr:,
j Dates Employed: Salary:
S e f From To 4
a Beginning FLnaL onth y
p cLLc Duties.
a ee se eeeeeemeeeeeeeeeeeeeeeeeeeeeeeeeeeeoeeeeeeeeeeeeeeeeeeoee ee eeeeeeeeeee
1
r ,
'Form 100b
, k
Y
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r ? ? 'r u
' N
?? Y: ?" ? Q?: - X12 J, ?" 1.., f '- .• ?.:
1?
12. TeLents or SpecLaL SkLLLs WOrk?ny (Ou1-Slde wiles 'my P1 c-44(4-
'.
,? Same /Y14G/410"cS /?rluiny car•ar rrucK. ?vn e3,ul?mu.t
13. Do you have any activLtLes, commitments or responsLbLLLtLes that may ' ;r=
prevent you from meetLng work attendance requirements: Yes" '?o 7g} tt
Comments:
14. Do you have any handicaps that may affect work performance which you '
ftiMt 5
feel should be taken Lnto account Ln determining job placements: ,
Yes If yes, please expLaLn: w
1
1
15.
Do you have any problems Ln becoming LawfuLLy employed in his country .
because of vLsa or Lmmigration status: Yes No
16. Can you provide proof of citizensh', visa or aLLen registratLon
number after being hired: Yes No
Comments:
17. Have you had experLence Ln the foLLowing: /
J
$ 6` (a) Carrying out varLnf; jo sLtuatLons Yes V No r
(b) Manual Labor Yes No
(c) Outside Work Yeses- No /
(d) Use of general hand too Ts Yes ? No
/
4
t rT_
e) Use and maintenance of ower saws Yes No
(
(f) Drivin
k Y
t
? N -
g
ruc
es
o
t' (g) Operating smell equipment Yes ?/ No
(h) Had others work under your LnstructLons s No
F1
(L) Worki
Lth oth
d th
blL
Y
N
ng w
ers an
e pu
es
o
e y.
i3 Comments on the above: !, i z `
33
18 Ha
b
L
" '
r . ve you
een conv
or
' you serve Mme Ln a conrec Bona
c a x=7 fr
facLLLty wLthin the past
seven ) years, for any crime which might
7
f
+ have some bearing on your aLLficatLon and fitness to accept the
m k
dutines and responsibLLL e
s of the position for which you are apply-
Lng? Yes No 1,1 If yes, please give detaLLs
19. ; PLEASE READ THE FOLLOWING AND SIGN BELOW:
+ 1 certify that all statements above are true and to the best of my ttt
knowledge. 1 understand that false statements shaLL be sufficient (.
cause for terminatLon.
r Lgnature o App Lcant ate
form 300c
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\®\® '` Mr. Scott M. Fink
210 Coman Hall
Pullman, WA 99163 v:•f•
- "4SFrcr c
March 20, 1987 N 'r ,ay,
Mr. Robert G. Nesbitt, P.E.
County Engineer Ft
Dept. of Public Works l
1820 Jefferson stw`;?ti
Port Townsend, WA 98368 ,.-
Dear Mr. Nesbitt
I am writing in regards to our conversation on March 1111, about FA i}
student technician employment this summer. We discussed in
t paticular the culvert inspection project. rv<
i#b?*'rt'>r3h
This project is of interest to `me because of my desire to develop t,
++ G skills in road management and utilize my education of soils,
?f fluids and geology. Also, while working for Port Angeles PUDj
last summer, I had extensive oppertunity to become familiar with
` map reading and locating installations. ?i
From this information and the enclosed resume I hope that I would
qualify for a position in your work this summer. I would like to ka,
J mention, if I did not during our discussuon, that my availability +a;.
would run from mid May to mid or end of August. Employment for the county and this project enthuses me very much so I would be
as,flexible as possible.
' I look foward to hearing from you soon.
y Sincerely,
-,?--
E Y j Scott M. Fink s
j civil engr. (WSU)
UNC:
! k t 9 ' t
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Scott M. Pink '
Current Address: t?-
r 210 Coman Hall Permanent Address:
I :Pullman, WA 99163 PO Box 817
(509) 335-1721 Port Townsend, WA 98368
385-6511
Objectives Seeking summer employment related to civil
engineering to enhance current education and
future career.
Education: Candidate for B.S. degree in Civil
Engineering, Washington State University
,
December 1988
Peninsula C.C., Port Angeles WA 1983-86
Mathematics:
Trigo- nometry, four quarters of Calculus
With Analytic Geometr
Dif
,- y,
ferential
Equations, and Probability and Statistics.
r i Computers:
Courses in Basic and FORTRAN lan A
s°
( guage
programming
Hngineering.
i
All e
ngineering-courses completed through
lst semester junior.
z-' Y
4
Mork Experience:
Engineering Technician:
Underground power inventory, As-Built
t mapping, drafting, and surveyors aide for
Port Angeles PUD.
Mcatcutter an3 man-3aement?
Ten years withSUnrise Meats in Port
Angeles !
? -
+ 'American soaiPfy of Civil Engineers
Port Angeles Fitness and Raquetball Club
-s
"
s Personal: Holder of a
private
license
Coman Hall Floor President
R.trerences: Available on request '
"
]SI".
{ ,
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77. ENFI.OYMENT HISTORY (begtmt with Latest employment)
A. Company Name: Q Phone: 42
J 7
Address: hl ' 1 ZJ l ;
CLty ¦ta e.. '
Oae*ae0se0e0*0eeeeeeeea ee OaesDeeeeeeeeaele0eeeeeeeee eee ee ee se eee 000 e0 0100 ?-.?''? '??
B. Company Name Phone: ;
Address:_?i w? A State
Li
Y p y
Job TMe: Immediate Spvar.:
Dates Emptoyed: Salary:
Spectfie DutLes;rom To eA m nR `.* na on t{
7 ?a0?*s?0*11/a/10a0weaeaaso0a 00000aso see see a 00080 0000 s e 00 s a a 1 s 0 e 00 a e 0 e 000.4
C. Company Names Phone: ?SY>
Address: y
E,
wp'
G&TY I ` state ZLP
t 47 Y
-
Job Tttte:
ImmedLate Spvsr.s ,
pp
d3
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Dates Employed
Salary
-
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Frain o es nn na Sionthl s
w
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f Specific Duties: 105,
i
000000600 so9*eeeee* aseaoesesseeseesesseseeeeeseessseo***@0a****eesseeseet '
,
'
O. Company Name i
Phone t ry
it t
?
E:
f Address.
r ,` s y state p
_9ob TLtte: Immediate Spvsr:
Dates Employed: Satary:
From To ®egdnn nZ Ins Mon 4
Specific Cuttes•
0-ovibooessoo so 000 *see***
y
Y, t f y _ ?1 ?J
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12. Talents or Spectsl Sktlls bail) d `Y??i
'
a U?1012YPQ ; w,
13. Do you have any ecttvtttes, comm'L4ments or responsibilities that a
prevent you from meetin
mark attendance re
uir
ment
Y
s' ' 'N `?-r T }
A?
z
P g
q
e
s:
e
o
:
x
fi Comments: ,
14. Do you have any handicaps that may sfFact;?work performance whlch you
feet shouLd ky taken Lnto account in detormLnLnZ job placementat
Vex No If yes. please explaln: t
?4r 1S. Do you have any problems Ln becomLng Lawfully employed Ln thLs count:
because of vta¦ or immigration status: Yes No fb
16. Can you provide proof of clUxen tp, vtss or Allan regtstratton
?
rK mber after betng hired: Vas No ( =
Comments: F
'17. Have you had experience Ln the followtrgt t '
r-
to) Carrytrig out vartnp. Sob attuattons Yes • No s '. .
(b) M
l L
b
X N
V -
onua
a
or
ex
o,
to) Outstde Mork Yes No
t
'
-
d) Use of generat
hand toots
des No
(e) Use and maintenan
of
ce
ppower saws
tf) lD
t
L
k Y
t
N
r
v
ruc
ng
es
o
) O
4
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tt
T
N
c
t?-Y
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pers
K
rvg ama
/qu
pm
n
es
o
i t ) "ad others work sander your gnstruc ons Vas X No ,.
r ti) WorkLing with others and the publLc Vss ?c QJo 4j
R Comments on the above: Z kAJ2 Some px42bPNfC 04l C/noll
{
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1 78. ave you een cont. a or have yyOU serve • me n a oonrac ons
facLLLt
within th
a
r
t
e
17)
fo
n
i
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h
l
ht
y
m,
e p
s
ven
yam
s
r a
y cr
me u
c
ea
g
Qmve, some bearLng on yyour Z:tLficatLon and fLtness to acce
t this
p
clotLnes and responatbLALt es of the posttton for u%tch yyoouu ars a
4
k
pp
y
anZ7 'Vex No,?_ Af Vas, pteaso (`tva detatts
- ? s
19. PLEASE READ THE FOL.LCM9ING AND SlQQ BELOW:
1 certify that ALL statements above are true and to the best of any
_ knowLedge. 1 understand that false statements shall be suffLeLent
cause for ' natL
y 7
lgna re pp can a e e5 ?
feral 1000 r s,'x
J , 1 1 f ? r F 1'
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PRE-EMPLOYMENT APPLICATION
4 ? ?C a '?`?r,E
Position Appli For 41
y5"'
Jefferson County is an Equal Opportunity Employer and encourages
<?1.', ;
applications from all persons regardless of race, creed, color, sex, ;r
national origin, marital status, age, or physical, sensory, or mental 4i` 1
disability unless based upon a bona fide occu ational
p qualification (State
Law: Chapter 49.60 RCT and WAC 162)
IMPORTANT: Complete all sections. Please use ink. Please PRINT.
1. Name:_ N6,4 A IV I<e y i /') .T.?f S'
(LAST) (First) (Middle) yxa'
2. Address: 133n 974 STi'CcT Ppr7-7oe_117
V end War4 . 9 36 Sf ? ?; ?`
.
(Street) (City)
(State, ZIP) .,
i?x+7`` i.
t 3. Social Security No.s33 - ?J2 -5
63 6 4. -
Date of Birth: s^O? - 6 7
?
4 (Age will not be used to discriminate) z^r°
¢ 5. Home/Message Phone:385 -/9GZ or38's o:2 u/ 5' Business Phone: /lo/7e_ "r
7. Education - Total years of pre-university schooling: ,
Circle year completed: 1 2 3 4 5 6 7 a 9 10 11 s3 "
r B H '
r,1 . ave you passed the General Education Develop lieu of
ment (GED) Test.in
e:!
1 t High School graduation? NO YES Year 'i
-
yp
X ?. oi /9N/fC .
a
4
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? 9. Colleges Attended 'Years From To Degree - •;?
? Fi SST sic ar /-? T SAO i<a?r G ('a„u?raia,'Ti? Go CL c 4 ?_ S'r?T- Tuh G ?
e ?
10. REFERENCES: (Please do not list relatives)
f 1. fZ:ci<" roc cfsoit 7 3 Z -elo ?o F
r
y
a 2. _7; p e 7W S 3 S -1 7 9 Z z
r, eu. .
,„
. 3./20/i90 e e P 3 8' S^ •. G/ [(/ $
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^ 12. Talents or Special Skills i?Terer)-eeC ,'/? i--7?G49iri[S• (r?C4
?
i v r Tl. ?r ? Jfa hd. S ?h?C ? zi
i< e r. I ?+
rF a 13. Do you have any activities, commitments, or responsibilities that may ' ' r*
' prevent you from meeting work attendance requirements? No - YES
l
,
' t3
Comments:_ X
:2u e Se A,56 r a earn it 5
c ,;
e "r ken ,'
( 14. Do you have any handicaps that may affect work performance which you
m}
feel should be taken into account in determining job placements?
r NO-2?._ YES
If yes, please explain.
lb. Do you have any problems becoming lawfully employed in this country i3s
because of visa or immigration status? NO OL YES '
Comments:
y.u
16. Can you provide proof of citizenship, visa, or alien registration
number after being hired?. YES oL NO
Comments: p
C.
17. Have you had experience in the following:
t (a) Carrying out varying job situations Yeses No
(b) Manual labor Yes Q(- No
n (c) Outside work
Yes•6-1_ No
(d) Use of general hand tools Yesp-1_ N
(e) Use and maintenance of power saws Yes oC No -
(f) Driving truck Yes Nom
(g) Operating small equipment Yes0_ No
(h) Had others work under your instruction Yes No?
Working with others and the public Yes 'No_ <
! Comments on the above:
18. Have you been convicted, or have you served time in a correctional
facility within the past seven (7) years, for any crime which might
have some bearing on your qualification and fitness to accept the
dutie and responsibilities of the position for which
ou are a
l
in
?
{ y
pp
y
g
NO_ YES
If yes, please give details.
19. PLEASE READ THE FOLLOWING AND SIGN BELOW:
I certify that all statements above are true and to the beat of my
knowledge. I understand that false statements shall be sufficient
: cause for termination.
16
Signature of Applicant Date
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Ilortllwest Services Council
.:' I't!'.t'I•I: ., r''• ;I UEEI. SUITE 1101 (P O. COY;o,Y)l nELLIh ,I?A':..:•a
WORK E%PENUNCE (W'X) TRAINING REFERRAL
DATE II T_ a?.? I {5 ?.
Lh:ar flout twency Site Supervisor,
This is to confine that "(' Fol. y1C? ti-?
(SSId: ,`j ?(? - ?1R - (p??1) r lino been certified as an eligible trainee for
tho' YJor•k FNperlenec (4JF]O cumimanent or the Youth 1-hployment and Training
Prorrarrl. lic/She hn. review::d the job information you subrnitted•And is
bn,ng ref'r:rrad for The poaitiun of Vegetation Management Crew_
After interviewing this young person, please contact Sue Wilson at
3A5-5578 to indicate your decision for accepting this young worker. A
meeting for bupervisoru_;•M resell to bo arranged once a start date in
set for the trainee. This meeting should include all persona who will
be invulved in the supervision or the trainee.
Sincerely,
Susan Wilson
(;oordinator
WiJ AGF.4Cy Jefferson County Public Works
COMICT Pidh: )N Earl Wells or Carter Breskin
ALll1iJ:1; Jefferson County Coutthouse, Port- Townsend
1'F:I,F]'NUiJI :?85-0890 (Call for an appointment)
WAGE $agas ilul,t<S i'Fa wEiK 40
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I AWO NCI rOnKS PRAIME Pl•1:a
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'VIII IC11Y I,;iI NII %VA swrn 1.OnKS, %VA 98.131
IS ',RN JT/ NMI)
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PRE-EMPLOYMENT APPLICATION
i
= ?
?/?
i
a
'? (L
o
r on App red r _ r:
zr .v.
Jefferson County Ls an Equal. Opportunity Employer and encourages appLLca
tLons from aLL persons
regardLess of race, creed, color, sex, natLonaL
origin, marLtaL status, age or physLcaL
j } t {' , sensory or mental disabLLLty un-
Less based upon a bona fLde occupationaL quaLLfLcation. (State Law:
Chapter 49.60 RCN' and WAC 162)
s
.
i IMPORTANT:-C
ompLete aLL sections. Please use Lnk. Print name only. j
7. Name:- 'C'k (c?
--
t
i
TmL dLe
_
_
2. Address:
??' ? = ?L??J?• JAS' ? ??J?aC?LJn
stre
t r D
r a Vr w ;
e
city s ate zlp „ ?d"i
4
3. SocLaL Security No.: c '` ?/2?/(ate)
4. Date of BLrth (:
_
(Age wLLL not be used to discriminate a4t'??
S
. Home/Message phone: 0??'"TS1 6
B
i
•
.
us
ness hone:
P ?
sr- 4?, /?
?
'
7. EducatLon - TotaL years of pre-unLversity schooling: -_
y?e+a,., ,
r1t
CLrcLe year completed: 7 2 3 4 5 6 7 8 9 70 77 72 l
8. Have you passed the General. EducatLon Development (GED) Test Ln Lieu of
HLgh School
Graduatio
Y F
f
n:
es No
Year
9
C
u"°1 r
.
oLCeges Attended Years
ege Attended r o t
m-/ y
l ?41,f? ral ?n?„r ! r
SCC?/qJ 7 '`aY
+
1
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,.
70. REFERENCES: (PLease do not LLst
L i"
re
atLves)
Name 3
,Address Office/Home Phone
2
L
.
?r?/tee. Alo-hl?te ?1 ecw)")b Q 9 4trll ri A
? fi t?_
FL 3
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EMPLOYMENT HISTORY (beginnLng wLth Latest employment) t
A. Company Name rA)RF
Phone:
Address: ?11-?: ??'G?n?lc^ill n.I? T.-vA1 P11 irl? Uc c?'
LLry state ZLp r +
Job TLtle:_r)5QTT ? ImmedLate Spvsr•..: !1 tiu
Dates EmpLoyed:L)h,C(?4? "IeSalary:-
From To~- Deginning Flnah Monthly
Specific Duties: lgr?. T Aa ,VC:1 7???1/c» , jjC1 t77r1
e e e e r w r e e e e r r e e e e e r e e e e e r e r e e r e r e e e 6 e e e e ............
r e r r r e r r e r e r e r e r e e r r r e ?l ?' ~
B. Company Name $• }? ???s( )?'Q 1 0of f) . Phone:
Address: 17-a I? L? P(7Xf- l"" CVllir' (A)l) Gq j
CLty State Zip
b
Job TLtLe:('tQf2l y d IC1?o?? _ImmedLate pvsr.: C Q, 4 5 y? r
Dates Employed: S c7 i- t'NcX SaLary:,
w
From To Beginning Final MonthLy
Specific Duties: ?nr? IXJ:ICII?Y?? I/?^:111? r•ht1??
9 s
•se'sseeeseeressssressseeesrsseeseeesseesseeesrsserrsreeessserreesssrreeees „cs '????•
C. Company Name: Phone:
\? 5b
Address:
a y State ZLp
Job TLtle: Immediate Spvsr.:
Dates Employed SaLary
From To BegLnnLng FLna Month y ti
SpecLfLc Duties:{? '
reesseesseesesses seseseeeseeessssereeeeeeseessseerreeeeersesses .: ti??f?.
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D. Company Name:' Phone: esessssosse
,+G a,
Address:
CLty ate Zip z.,
Job TLtLe: Immediate Spvsr:t
Dates Employed: SaLary:.
From To Beginning FLna Mon- thLy
Specific Duties:
see ess ss sr resersseeeeresssrersss••essrsreresrrreesrrrreeeerrsr er srreeserree rc
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12. TeLents or Special SkLL
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7 -7-1
IS l irV ?tI c11 F\ ?n':h t 2('. OL"l4??`
13. Du you have any activities, commitments or responsibLLLties that nay/
prevent you from meeting work attendance requirements: Yes' • No y
Comments:
14. Do you have any handicaps that may affect work performance which you
f eeL should be #aken into account in determining job placements:
Yes No L-*If yes, please expLaLn:
15. Do you have any problems in becoming LawfuLLy
beca
f
i employe. d jrf this country
use o
v
sa or immigration status: Yes No '
16. Can you provide proof of citizenshL visa or aLLen registration
number after being hired: Yes No
Comments:
17. Have you had experience in the following:
(a) Carrying out varLn o?sLtuations Yes I
J1
0 / No
?,(b) Manual Labor Yes
/
No
(c) Outside Work Yes No
(d) Use
f
l
t
t
o
genera
. hand
oo
s Yes V• No
(e) Use and mainten
f /
ance o
power?daws Yes
(f) Dri
i
t
k No
v
ng
ruc
Yes No ??
(g) Operating small equipment Yes VNo
(h) Had others work under your LnstructLons l?es ? 'No
(L) Working with others and the public Yes ?
No
Comments on the above: r
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r n/ %1
18. Have you een convLc a or have _you served - t
facLLity within the past seven (7)
r
f ime in a comet Lona
yea
s,
or any crime which might
have some bearing on your quaLLfication and fitness to accept the
dutLnes and responsibLLjhLes of the position for which you are apply-
Ln
7 Y
?V
g
es No
If yes, please gLve details
19. PLEASE READ THE FOLLOWING AND SIGN BELOW:
I certify that aLL statements above are true and to the best of my.'
knowled
e
1
d
t
nd tha
g
.
un
ers
a
t false statements shall be sufficLent
cause for ermination.
??;ln .
SLgna uure of AppLLcant Date
for+o1OUc
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