Supervisor High School

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) (First) (Middle Home Telephone

Flansburg Scott Initial)

L (360) 753 -

7050

Address (Mailing Address) (City) (Stat (Zip) Other

1286 Bayloop s.w. Tumwater e) 98512 Telephone

WA (360) 556 -

3516

E-Mail Address Are you legally entitled to work in the

****************@*****.*** U.S.? Yes No

POSITION

Position Or Type Of Employment Desired Will Accept: Shift:

CDL Class B driver/ Part-Time Day

security/Forklift Full-Time Swing

Temporary Graveyard

Rotating

Are you able to perform the essential functions of the

job you are applying for, with or without reasonable

accommodation? Yes No

Salary Desired Date Available

$ 16/17/hr. now

EDUCATION AND TRAINING

High School Graduate Or General Education (GED) Test Passed? Yes No

If no, list the highest grade completed 12

College, Business School, Military (Most recent first)

Name and Location Dates Credits Earned Graduat Degree Major

Attended e & Year or Subject

Month/Year

Quarterl Other

y or (Specify)

Semester

Hours

Bates Tech. college From 9/74 45-50 Yes certifica fire

No te science/hydr

aulics

To 4/75 75

Ron Bailie School of From 9/72 40-45 Yes certifica journalism

Broadcast No te

To 73

From Yes

No

To

From Yes

No

To

Occupational License, Certificate Number Where Issued Expiration

or Registration Date

Occupational License, Certificate Number Where Issued Expiration

or Registration Date

Occupational License, Certificate Number Where Issued Expiration

or Registration Date

Languages Read, Written or Spoken Fluently Other Than English

VETERAN INFORMATION (Most recent)

Branch of Service Date of Entry Date of Discharge

Navy 9/69

4/72

SPECIAL SKILLS (List all pertinent skills and equipment that you can

operate)

(Maximum 300 characters) Forklift operator (electric /gas) / Class B cdl

(airbrakes) /Wa. st. Armed security lic.

WORK EXPERIENCE (Most Recent First) (Include voluntary work and military

experience)

Employer Garda cl. Telephone Number (206) 322 - From

8848 (Month/Year)

8/23/95

Address 1115 Zehnder st. Seattle,Wa.

Job Title driver/armed courier Number Employees Supervised To (Month/Year)

1 7/15/2010

Specific Duties (Maximum 350 characters)

protected/transported civil/federal valuables,operated various

armored vehicles/various classes crew captain in charge of

specified route

Hours Per Week

40+

Last Salary

$16.74/hr

Supervisor

Mike Hall

Reason For Leaving termination May We Contact This Employer?

Yes No

Employer Telephone Number (n/a) - From

Nabisco Brands Inc. (Month/Year)

9/1978

Address sumner, Wa.

Job Title forklift Number Employees Supervised To (Month/Year)

operator/shipping/ 0 6/1993

Specific Duties (Maximum 350 characters)

operated various forklifts,shipped / received /loaded

outgoing/incoming out of state trailers/operated various

manufacturing equipment

Hours Per Week

40

Last Salary

$15/hr

Supervisor

Dave Thomas

Reason For Leaving plant closure/termination May We Contact This Employer?

Yes No

Employer Telephone Number - From

(Month/Year)

Address

Job Title Number Employees Supervised To (Month/Year)

Specific Duties (Maximum 350 characters)

Hours Per Week

Last Salary

Supervisor

Reason For Leaving May We Contact This Employer?

Yes No

Employer Telephone Number - From

(Month/Year)

Address

Job Title Number Employees Supervised To (Month/Year)

Specific Duties (Maximum 350 characters)

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________________

Interviewer's 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.

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