Employment Application

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Peninsula College

Employment Application | Model


Applicant Information

Full Name: Scott Robin L Date:02/20/2017


Last First M.I.

Address: P.O Box 2633


Street Address Apartment/Unit #

Port Angeles WA 98362


City State ZIP Code

Phone: (360) 406-1776 Email: [email protected]

Date Available: Social Security No.: 572-11-6231 Desired Salary:$

Position Applied for:

YES NO YES NO
Are you a citizen of the United States? X If no, are you authorized to work in the U.S.? X

YES NO
Have you ever worked for this company? X If yes, when?

YES NO
Have you ever been convicted of a felony? X

If yes, explain:

Education
College: Peninsula College Address: 1502 East Lauridsen Blvd Port Angeles, WA 98362

YES NO
From: 9/15 To:12/17 Did you graduate? Degree:: 3.46 GPA

High
School: William Daylor Address: 6121 Orange Ave Sacto, CA 95823

YES NO
From: 9/85 To:6/88 Did you graduate? X Diploma:: 3.77 GPA

Other: Address:

YES NO
From: To: Did you graduate? Degree:

References

1
Please list three professional references.

Full Name: Sherry Sparrowk Relationship: Professor


Company: Peninsula College Phone: (360) 417-6375
Address: 1502 East Lauridsen Blvd Port Angeles, WA 98362

Full Name: Eve Wallis Relationship: Professor


Company: Peninsula College Phone: (360) 417-3328
Address: 1502 East Lauridsen Blvd Port Angeles, WA 98362

Full Name: Nicole Criel Relationship: Teachers Assistant


Company: Peninsula College Phone: (360) 461-8882
Address: 1502 East Lauridsen Blvd Port Angeles, WA 98362

Previous Employment

Company: Swains General Store Phone: 452-2357


Address: 601 East 1st St Supervisor: Don Droz

Job Title: Cashier Starting Salary:$ 9.00 Ending Salary:$ 13.75

Responsibilities: Help customers with Merchandise, Cashier, Clean, Sale hunting and fishing licenses

From: 4/2007 To: 7/2014 Reason for Leaving: Decided to go back to school

YES NO
May we contact your previous supervisor for a reference? X

Company: Fast Trax Phone: (785) 364-5373


Address: 111 Arizona Ave Holton KS 66436 Supervisor: Sandy

Job Title: Cashier/Assistant Manager Starting Salary:$ 5.50 Ending Salary:$ 7.50

Responsibilities: Cashier, Stock shelves, Count all money from prior days shift

From: 6/04 To: 4/07 Reason for Leaving: Moved out of state

YES NO
May we contact your previous supervisor for a reference? X

Company: Phone:
Address: Supervisor:

Job Title: Starting Salary:$ Ending Salary:$

Responsibilities:

2
From: To: Reason for Leaving:

YES NO
May we contact your previous supervisor for a reference?

Military Service

Branch: N/A From: To:

Rank at Discharge: Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature


I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or
interview may result in my release.

Signature: Date:

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