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)
Graber

(First)

(Middle Initial)

Carl

Address (Mailing Address)

(City)

1334 Welling Rd

(State)

(360) 730 - 0906

(Zip)

Bellingham

Other Telephone

98226

(360) 255 - 1441

E-Mail Address

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

carlgraber94@gmail .com

Home Telephone

Yes

No

POSITION
Position Or Type Of Employment Desired

Courtesy Clerk
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

Minimum wage

immediately

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

Dates
Attended
Month/Year

From
To
From
To
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

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

Food Worker Card

Whatcom Cty Health Dept

7/2016

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

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 Meridian Haggen

Address 2814 Meridian St. Bellingham

Telephone Number

(360) 671 - 3300

WA 98225

Job Title Courtesy Clerk

Specific Duties (Maximum 1000 characters)

Number Employees Supervised

Customer service, go backs, collect carts, collect baskets, face shelves, clean bathrooms

From (Month/Year)

2/23/15
To (Month/Year)

6/17/15
Hours Per Week

6
Last Salary

Trial work exp

Supervisor

Krissy Nevarez
Reason For Leaving

Trial work experience ended

Employer Appliance Depot

Address 802 Marine Dr. Bellingham

May We Contact This Employer?

Telephone Number

(360) 527 - 2646

WA 98225

Job Title Shop Assistant

Specific Duties (Maximum 1000 characters)

Number Employees Supervised

Appliance cleaning , customer service, recycling parts, organizing the shop

Yes

No

From (Month/Year)

9/22/14
To (Month/Year)

3/6/15
Hours Per Week

6.5
Last Salary

Trial Work exp.

Supervisor

Paul Wright
Trial work experience ended
Employer Sehome Haggen
Address 210 36th St. Bellingham WA 98225
Job Title Food Court Assistant
Reason For Leaving

May We Contact This Employer?

Telephone Number

(360) 647 - 4300

Number Employees Supervised

Yes

No

From (Month/Year)

11/18/13
To (Month/Year)

Specific Duties (Maximum 1000 characters)

5/16/14

Cleaned tables and chairs, filled condiments, swept, took out garbage, stocked drinks, and other
tasks as directed.

Hours Per Week

6.5
Last Salary

Trial Work exp.

Supervisor

Laurette Fowler
Trial work experience ended
Employer Bellingham High School Kitchen
Address 2020 Cornwall Ave. Bellingham WA 98225
Job Title Kitchen Assistant
Reason For Leaving

May We Contact This Employer?

Telephone Number

(360) 676 - 6470

Number Employees Supervised

Yes

No

From (Month/Year)

9/10/13
To (Month/Year)

Specific Duties (Maximum 1000 characters)

12/15/13

Restocked cereal, wrapped fruits and vegetables, wiped tables, poured condiments, packaged
cookies

Hours Per Week

6.5
Last Salary

Trial Work exp.

Supervisor

Bev Preston
Reason For Leaving

Trial work experience ended

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.