
Employer Telephone Number ( ) -
From (Month/Year)
Address
Job Title Number Employees Supervised
To (Month/Year)
Specific Duties (Maximum 1000 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 1000 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 1000 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 1000 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.