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° PRE-EMPLOYMENT APPLICATION
C VeQ e. ice', o? Mo .k
d „3 ?osi.tLon App Led o f xa
' -. 9 x 5M
Jefferson County Ls an EquaL OppovtunLty Employer and encourages appLLce - ? '
tLons from aLL persons regardless of race, creed, color, sex, natLonal
orLgLn, maritaL status, age or physLcaL, sensory or mental. drsabLLLty un-
Tess based upon a bona fide occupational quaLificatLon. (State Law:
Chapter 49.60 RCN and N'AC 162).
IMPORTANT: Complete aLL sectLons. please use Lnk. Print name only.
_ 1. Name W :'? P r' ?? rust PS Kd
(Lases (mLd Le xx ?,
2. Address: ?/? / l/ S ti ?
street city (state) zip$, r.
y wr
3. Social Security No. S'?q-4q4 D t f ?
_ a e o 9Lrth a
?- !2, p
' (Age wLLL not be used to discriminate
-?? y.3- I
5. Home/Message phone;
6. Business phone:
sp, y,A
7. _
Education - Total years of pre-unlvers Lty SCFIOOI Lng:
CLrcLe year completed: 1 2 3 4 5 6 7 8 9 10 11 12 Z
8.
Have you passed the General Education Development (GED) Test Ln Lieu of s, ?z
f
HLgh School. Graduation: Yes NO.' Year
9. CoL L eges Attended Years From To
Degree
i
tr??t
10. REFERENCES: (Please do not list veLatLves)
Name Address Office/Home Phone `
1 ' lA `! k??-1 ' 4nn o r e- C
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2
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17. EMPLOYMENT HISTORY (begLnnLng with Latest empLoyment)
{ A. Company Name: (A r1 f"Lh t S C t 2 V\ C T 4 AT ar Phone: > t V
> Address: (?nf \ d
o\N w?GPU C 1 "\?iZ JCL - .H
Y orate
Zip
Job TLtLe: y 1S5^,5?m ? j Immediate Spvsr•..: I ?F u
P I Q '}
Dates EmpLoyed.ir ,q T ?a Salary S•35 ?r
FFro BegLnnLng FLnal Monthly ,
Specific Duties: r e n -?,^?r xr
ok N\
_ rooeeroooorreoroeoeeeoeoeo rrrerrr rr sero rr or re rr erro eo rr rre rorr•:` {
?5. re oe oereroe
..
B. Com7 pany Name_ S ?, (ham r" S? r f L o Phone
Z)OO n
t ? Address. a qty
Job TLtLe: ate ZLP
Immediate Spvsr. .:S r.N P rhU N
Dates EmpLoyed:F c1 tMM<r `b ToM S SaLar b a
-? Y n o
le&Lnntng Final Monthly a ??'
SpecifLc Duties: rt tit %, Vn {^ f ,
r
_ eoe'rreorerereerrreeereoe reore rrrr rroeeroeoroerorere roeoerrrreoreoeooe eereo ''?iy,.?y.` `"?rC=?'
C. Company Name • p y\ Q,
a Phone: CI?
Address: f n W ?:?
c? o
I-LTY
y, State ZLp e a t
Job TitLe:__ Immediate Spvsr.: P n r n(
Dates Employedl9l SaLarY_ r orgy j r
From t 1i ?\ Be ?nn,n" g FLnaL Monthly art `off;
SpecL'FLc Duties d
reeeerroee ororeoeoreier rrer eroo rorrreroereeor oerereeoreoror?oreseeeooerr• ?)
?.?
' D. Company Name= -hone F'y
\ r:
[ Address qy nit
t
t ate
Job TLtle: ZLP ?h ll
Immediate Spvsr• i
Dates Employed: SaLar
e From To y
Beginning FLn8 onth y
S ecLf'
r - p tc Duties: -
+
k '?, r.eoeoeerroeerereorerreerererroorroeorrrerereeeerreerreerr eoeer•rerrererero- .`??1 :t
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13. Do you have any'actLvLtLes, commitments or responsLbLLLtLes that may
prevent you from meeting work attendance requirements: Yes" !Jo_?L
CCO.M. •,nts :
14. Do you have any handicaps that may affect work performance which you
feel should be taken Lnto account Ln determining job placements:
Yes No X If yes, pLease expLaLn:
15. Do you have-any problems Ln becoming LawfuLLy employed Ln this country
because of visa or Lmmigration status: Yes No x
16. Can you provide proof of citLzenship, vLsa or aLLen regLstration
number after being hired: Yes_ No }
Comments: f
17.
x
Y
-
w
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19. PLEASE READ THE FOLLOWING AND SIGN BELOW:
1 certify that aLL statements above are true and to the best of my
knowledge. 1 understand that faLse statements shall be sufficient
cause for termLnation.
.M 51
Z)Lgna ur To f AppLLcant Date
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Have you had experience Ln the foLlowing:
(a) Carrying out varLng job sLtuatLons Yes X No
(b) Manual Labor Yes X No
(c) OutsLde Work Yes_ No
(d) Use of general hand tools Yes_ Y No
(e) Use and maintenance of power saws Yes No?<_
(f) DrLvLng truck Yes_ cX No
(g) Operating sma1.L equLpment Yes__2?_No
(h) Had others work under your LnstructLons Yes- No
(L) Working wLth others and the pubLLc Yes, No
Comments on the above:'
18, Have you een convLc a ov have you served Lme ?n a conrect?.ona
facLLLty within the past seven (7) years, for any crLme which mLght
have some bearLng on your quaLLfLeatLon and fitness to accept the
dutLnes and responsibLLLtLes of the posLtion for whLch you are apply
Lng? Yes No _X If yes, pLease gLve detaLLs
12. TaLents or Special. SkLLLs
it
X" r.. _!: :l v. .Ml if Y
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IIBSEfiVICE AGRM-E '^ f1.•rn.m (:, un'L'
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??riicipant Name: Soc. Sec. 9: S3q-CnL4-1071S Unit of Service: W fJ)C F%M DATE: 81?? I? k
Start Date : (pf30I$(, Review Late:
-r '11FS?a
Northwest Services Counc.l? 385-5572
? 1 1032 Lawrence Street
Fort Townsend, WA 98369
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Vc r) CrmJ 7>u61tc Works ?k?,O?uC-
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Workshops NSC
1•p 4?-2 SCG,D ?1
Failure to attend workshops and appointments can result in loss of hours .
work time. or
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I certify that I have participated in the development of the above Service
and understand its conditions and to comply with the content and objectives.
y Further, I understand that failure to comply may terminate this Agreement. I have
received a copy fo the forms checked b? ove.
Northwest Services Council Te n ??n
Private Industry Council 61 c_ (??o-L-S -
r Organization Organization Organization n
? F
rvice Provider SetvlEe Provider Service Provider
4 y FY: 1 iy' '?]< X
I have participated in the development of nw Employability Development Plan and have [? 1
received a copy.
h:.. atcr iC an?A r`1 c
ts .
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„ JF?_• - - PAGE T.10 _
CEJECTIVES & OUTCCEC-S HY CO!•iPE' NCY CAT._GCRY
Work Maturity Skills Obtain sa isfacto J (5)
rating on all work catu its
Occupational Skills Become proficient at all
taaks,on job description.
Pre-cDnployment Skills Complete all assignments
as requested.
Participate and cocpletc
jo'o search assignments.
Educational
Attached: 'Job Des. _ Memo of Agreement - WT Contract _ School Curriculum
Participant Personnel Policies VEP Curriculum
Other (specify) _ Handbook
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EMPLOYMENT PROGRAM JOB DESCRIPTION
JOB TITLE: Vegetation--Management WORK-SITE: Selected County
TXyr : 4Sq. t, 5'Y-010 Roads
HOST AGENCY: Jefferson County
Dept. Public Works
ADDRESS: Courthouse
Port Townsend, WA 98368
SUPERVISOR: William Arey
County Road Super.
PHONE NO.: 385-3505 or 385-0890
.? r
L `
T <.?y
NUMBER IN CREW: 8-10
WAGE: $3.35/hr, 40 hrs/wk
SCHEDULE: 7:00 AM to 3:30'PM
Monday thru,Friday
I. SUMMARY OF JOB
l A. GENERAL
U
f
se o
manual vegetation management techniques for the control
of
o
r
adside vegetation. Testing theories of'establishment of
plant communiti
a
es and v
lidity of non-use of herbicides..
Involving cutting
pullin
thi
i
,
g
nn
ng of noxious vegetation.
q II. PERFORMANCE REQUIREMENTS
A. OCCUPATIONAL JOB SKILLS
1. INITIALLY REQUIRED'
' Ability to take directions and criticism. Good eye-hand
coordination. Use of basic gardening tools i
2. WILL BE LEARNED
j l Skilled gardening techniques:-•:
Plant identification and
a ,
control methods.
s?
x
y.+ 4
G?
?Lr
?i
B. WORK MATURITY SKILLS
1. INTIALLY REQUIRED
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 effective coherant
suggestions for innovatipe treatment.
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???? ? ?NtY•il ? rl? s ? y? ! ?, 1 I 'r !G C r r ?r ?1+.?Y'? .
S'?*y? ? y 1 ? ? r' ? R
!?d4 ?:.,, ? p; r ? ? . ? ! ,?xl? yii L.lp?? 4?7•ypw , '? ,
i
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B. EDUCATIONAL SKILLS
1. Reading, writing, elementary math, reading roadmaps and
'estimation of footages. Identification of various plant ,
t apecies.
C. WORK MATURITY SISILLS
1. Ability to take supervision and critisism. Ability to x% `, °s•
117
tolerate a physically tedious task. -r??•.:
2. Work independently in recognizing and determining treatment
< for problem areas. Make effective, coherant suggestions
for innovative treatment.
A. MATERIAL PROVISION
No materials required.
B. EQUIPMENT PROVISIONS
Chain saws, hand saws, machete, provided by Department of
Public Works.
C. JOB SITE TRANSPORTATION NEEDED°
i Transportation to job site provided by Department of Public
y Works vehicle. Transportation to Hadlock Shop site not
?r provided.
D. CONTINGENCY PLANS ?5%
' With the exception o ?
high winds, this work may be performed ?.
xa in any weather. In high wind situations work in and around'
the Hadlock Shop will be accomplished.
E. ON-SITE TRAINING AN•O'1ORMAL TRAINING' k,.
Will be taught to!recognize desirable and undesirable-plant
* species; sight distance,.requirements for road approaches and ?"•
intersections and signs; contour control for potential t
erosion problems. Basic, practical landscaping. 9y,; 4rn
j ' F." ADDITIONAL PROVISIONS ?f
Heavy duty work clothes, boots and gloves. Rain'gear. ,3
Ad?
William Arey, up rvisor Date '
c ? ?I
WWI,
y y7
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7•"S?.
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Fa: t:_cipant Name: C,/q}' 14L
Unit Of ce:-rice: Y r-x
.ezvice r^oviaer
Northwest Services co.mc
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OBJECTIVES & OT=ar-. B Ca-IP=CY CA_EGORY !
?sz q >s CQf•iE `:Ci CA-r: CRY OBJEC IVcS GAIL! ACTUAL OLTIM CATS tF ?i s'
A t n r, {{ n
M
+ v ` -Work Maturity Skills Obtain satinfact.;:; (5)
r ' r JWFrating on all work maturit; `
skills. Occupational Skills Become proficient at all U, =k+ti'r
tasks on job description. Fj Pre-Dn,-loyz..ent Skills Complete all assignment.,
as requested.
Y.
Participate and com;:lete
job search assigar.,ents. „ °a "w r a
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r - e
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Attached: '.lob Des. Mew of Agreement _ WT Contract School Curriculum f??? x y
t.:`„ - -
Participant Personnel Policies _ VEP Curriculum
Other (specify) Handbook
r I certify that I have participated in the development of the above Service Agreement c
c 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
a Cs ;, received a copy fo`the forms checko above.
Northwest Services Council ?eFFerSOr? Cour k{
Private Industry Council '7"t,?,i;c Lt-NCI, -L.).
' - P{-
Organization Organization Organization
Service Provider S rvloe Pmv1der6i Service, Provider
I have participated in the development of my Employability Development Plan and have
received a copy.
AdWJ 4J
Glr o?rA ?? r A? Coordinator r • . 'ar C pant
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j EMPLOYMENT PROGRAM JOB DESCRIPTION eta ?, ?
6p,?
r JOB TITLE: Vegetation Management WORK SITE: Selected County
_00'r'yob Roads f
r t
p ' HOST AGENCY: Jefferson County NUMBER IN CREW: 8-10
e Dept. Public Works
ADDRESS: Courthouse WAGE: $3.35/hr, 40 hrs/wk 6a{h
Port Townsend, WA 98368
SUPERVISOR: William Arey SCHEDULE: 7:00 AM to 3:30 Ph! j a n
i County Road Super. Monday thru Friday
PHONE NO.: 385-3505 or 385-0890r
k -1? r+ f
"
4? r 1. SUMMARY OF JOB X13 ' fir
r S
I+ A. GENERAL ` i Use of manual vegetation management techniques for the-control
`
} of roadside-vegetation. Testing theories of establishment of
plant communities and validity of non-use of herbicides. j._
+
Involving cutting, pulling thinning of noxious vegetation.
wa 1 Ii. - PERFORMANCE REQUIREMENTS
A. OCCUPATIONAL JOB SKILLS
P 1. INITIALLY REQUIRED'
Ability to take directions and criticism. Good eye-hand
coordination. Use of basic gardening tools.
S 2: WILL BE LEARNED
s Skilled gardening techniques. Plant identification and
control methods."
B. WORK.MATURITY SKILLS
1. INTIALLY REQUIRED v
Ability to take supervision and criticism. :Ability to
r tolerate a physically tedious task.
2.. WILL BE LEARNED Work independently in recognizing and determining v
treatment for problem areas. Make effective coherant
l suggestions for innovative treatment. ? 11 i„ 1,
ij7 A. M1f ?.r _A + '
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B. EDUCATIONAL SKILLS
1. Reading, writing, elementary math, reading roadmaps and
estimation of footages. Identification of various plant
species.
C. WORK MATURITY SKILLS
1. Ability to take supervision and critisism. Ability to
tolerate a physically tedious task.
2. Work independently in recognizing and determining treatment
for problem areas. Make effective, coherant suggestions
for innovative treatment.
III. '
A. MATERIAL PROVISION
No materials required. "
B. EQUIPMENT PROVISIONS
Chain saws, hand saws, machete, provided by Department of
Public Works.
C. JOB SITE TRANSPORTATION NEEDED
Transportation to job site provided by Department 'of Public
Works vehicle.- Transportation to Hadlock Shop site not
provided:
D. CONTINGENCY PLANS
With the exception of high winds, this work may be performed
in any weather. In high wind situations work in and around
the Hadlock Shop will be accomplished.
E. ON-SITE TRAINING AND FORMAL TRAINING
Will be taught to recognize desirable and undesirable plant
species; sight distance requirements for road approaches and
intersections and signs; contour control for potential
erosion problems. Basic, practical landscaping.
F. ADDITIONAL PROVISIONS
Heavy duty work clothes, boots and gloves. Rain gear.
r r
!luc?v?uy /cam
William Arey, up rvisor
Date
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?jCPlftLC.71C?? art END DATE:
5?8/SC? 4
;''7 St Date : (o?? Review Late: -71y
r `„? Se vice Provider
I Northwest rerson 8
Services Dounc 1
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3?'9-5576 10J2 Lawrence S
Fort Townsend, W,1 9;tn
3$5-0890 `' ?k8uac, RntT?,
WA 1483(-_8
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-ne^ Actions Re aired cial Conditions SI
Failure to attend worksho s I'tive Services Provided
work time. P and appointments can result in loss oS
hour. or
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SEx\TCE i? ^h ' - -PAGE nJ0
.Y OHJECTNHS & O'JTCam By ccmPE?t 7Ci C:,:GORY
Work. Maturity Skills
Occupati,tnal Skills
Obtain satisfactor-j (5)
rating on all work maturit,
skills.
Become proficient at all
tasks on job descript:an.
Pre-Employnent Skills Complete all assirrments
as requested.
Participate and ccmpleto
job search assignments.
VT
Educational I ?i?A Vt/U? O
ro'
%51
3t ?
x F J
4y
S
Attached: Job Des. _ Memo of Agreement _ OJT Contract _ School Curriculum _ a ........
Participant Personnel Policies VEP Curriculum
Other (specify) Handbook Y
I certify that I have participated in.the development of the above Service Agreement,
and understand its conditions and agree to comply with the content and objectives.
Fluther, I understand, that failure to canply may terminate this Agreement. I have "'.
received a copy fo the forms checked above.
Northwest Services Council :3e f-Cersor? County ,tq4 ° `
_ Private Industry Council -Pobt:C-Wo acs Y
Organization Organization Organization
r ? ? 3 X ?? ?`?t? ti's r•
T {t ??, b f?5 4fj"
IL
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4 F Se ce eider Se ide Provider Service Provider
;I have participated in the development of my Employability Development Plan and have s}???lt??
received a copy. { a Y Ty
I A`rY
4 'i i nnn?C??.+tt-._TT a 1 G3Dant • >stvd ?a?5tid?,?,,d.? "1
? ? 1 ? - ? ' , • ? :? fir' ? ?3???t,.?
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WORK•SITE: Selected County
Roads y
NUMBER IN CREW:. B-10
WAGE: $3.35/hr, 40 hrs/wk t' .•"r i"
'
SCHEDULE: 7:00 AM to 3.30
PM
M
d
on
ay thru Friday SUMMARY OF JOB
A. GENERAL
Use of'manual vegetation management techniques for the control
of roadside vegetation. Testing theories of establishment of
plant communities and validity of non-use of herbicides..
Involving cutting, pulling thinning of noxious vegetation.
PERFORMANCE REQUIREMENTS "
A. OCCUPATIONAL JOB SKILLS
1. INITIALLY REQUIRED'
Ability to take directions and criticism. Good eye-hand
coordination. Use of basic gardening tools.
2. WILL BE LEARNED
Skilled gardening techniques: Plant identification and
control methods. -
B. WORK MATURITY SKILLS
1. INTIALLY REQUIRED
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 effective coherent
suggestions for innovative treatment.
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EMPLOYMENT PROGRAM! JOB DESCRIPTION
JOB TITLE: Vegetation Management
tX-. 4Sq. l00'1•-U10
VOST AGENCY: Jefferson County
Dept. Public Works
ADDRESS: Courthouse
Port Townsend, WA 98368
SUPERVISOR: William Arey
County Road Super.
PHONE NO,: 385-3505 or 385-0890
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B. EDUCATIONAL SKILLS K,
1. Reading ;"-writing, elementary math, reading roadmaps and
estimation of footages. Identification of various plant yz
species; +a
C. WORK MATURITY SKILLS air
1. Ability to take supervision and critisism. Ability to
tolerate a physically tedious task.f
2. Work independently in recognizing and determining treatment
for problem areas. Make effective, coherant suggestions
for innovative treatment. l u""
III. '
A. MATERIAL PROVISION
r No materials required.
B. EQUIPMENT PROVISIONS
Chain saws, 1,and saws, machete, provided by Department of
Public Works.
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C.
JOB SITE TRANSPORTATION NEEDED
Transportation to job site provided by Department of Public
r Works vehicle.; Transportation to Hadlock Shop site not
provided-.
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D.
CONTINGENCY PLANS
With the exception of high winds, this work may be performed
in any weather. In high wind situations work in and around
the Hadlock Shop will be accomplished.
E. ON-SITE TRAINING AND FORMAL TRAINING
Will be taught to recognize desirable and undesirable plant
species; sight distance requirements for road approaches and
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intersections and signs; contour control for po
, erosion problems. Basic, practical landscaping.
F. ADDITIONAL PROVISIONS
Heavy duty work clothes, boots and gloves. Rain gear.
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William Arey, up rvisor Date
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