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)
Welch

(First)

(Middle Initial)

Jacob

Address (Mailing Address)

(City)

1489 Greenville Dr.

(State)

(360) 671 - 9587

(Zip)

Bellingham

Other Telephone

98226

(360) 820 - 1204

E-Mail Address

Are you legally entitled to work in the U.S.?

jacobwelch76@gmail.com

Home Telephone

Yes

No

POSITION
Position Or Type Of Employment Desired

Are you able to perform the essential functions of the job you are applying for, with or
without reasonable accommodation?
Yes
No

Will Accept:
Part-Time
Full-Time
Temporary

Salary Desired

Date Available

$9.50

Now

Shift:
Day
Swing
Graveyard
Rotating

EDUCATION AND TRAINING

High School Graduate Or General Education (GED) Test Passed?
If no, list the highest grade completed

Yes

No

College, Business School, Military (Most recent first)

Name and Location

Community Transitions
Squalicum High School,
Bellingham, WA

Dates
Attended
Month/Year

From 2012
To 2015
From 2008
To 2012
From
To
From
To

Credits Earned
Quarterly or
Other
Semester
(Specify)
Hours

Graduate

Yes
No

Yes
No

Yes
No

Yes
No

Degree
& Year

Major
or Subject

diploma

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

WA Food Worker Card

Health Department

4/8/16

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

Customer Service Certificate

Goodwill

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

Languages Read, Written or Spoken Fluently Other Than English

VETERAN INFORMATION (Most recent)

Branch of Service

Date of Entry

Date of Discharge

SPECIAL SKILLS (List all pertinent skills and equipment that you can operate)
(Maximum 1000 characters)

WORK EXPERIENCE (Most Recent First)

(Include voluntary work and military experience)

EMS 10171 CC 7540-032 635
ESD 1999 Rev. 12/30/03

Employer Golf and Country Club

Address 3729 Meridian St, Bellingham,

Telephone Number

(360) 733 - 3450

WA 98225

Job Title Server

Specific Duties (Maximum 1000 characters)

Number Employees Supervised

picking up dishes

From (Month/Year)

11/12/14
To (Month/Year)

Present
Hours Per Week

2hrs
Last Salary

Volunteer
Supervisor

Jordan Malarz
Reason For Leaving

May We Contact This Employer?

Employer Valley Market and Deli

Address 1945 Lake Whatcom, Bellingham,WA 98229

Telephone Number

(360) 734 - 7031

Job Title Stocker

Specific Duties (Maximum 1000 characters)

Number Employees Supervised

Stock food

Yes

No

From (Month/Year)

2/3/14
To (Month/Year)

Present
Hours Per Week

3hrs
Last Salary

$9.50
Supervisor

Debbie Elliot

Employer Sunnyland Elementary

Address 2800 James St
Job Title Teacher Assistant
Reason For Leaving

May We Contact This Employer?

Telephone Number

(360) 676 - 6446

Number Employees Supervised

Yes

No

From (Month/Year)

10/1/13
To (Month/Year)

Specific Duties (Maximum 1000 characters)

1/23/14

Help teachers with daily task

Hours Per Week

2
Last Salary

Volunteer
Supervisor

Christina Wasserman
Work trial ended
Employer Camp Firwood
Address 4605 Cable Street, Bellingham, WA 98229
Job Title Counselor in Training (C.I.T)
Reason For Leaving

May We Contact This Employer?

Telephone Number

(360) 733 - 6840

Number Employees Supervised

Yes

No

From (Month/Year)

6/17/12
To (Month/Year)

Specific Duties (Maximum 1000 characters)

8/31/12

assisted in leading small groups of children and build relationships with campers.
cleaned bathrooms,and performed kitchen duties such as washing dishes/wiping tables.

Hours Per Week

all day
Last Salary

Volunteer
Supervisor

Brayton Ruffcorn
Reason For Leaving

end of summer camp

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________________

Interviewers 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.