WE ARE AN EQUAL OPPORTUNITY EMPLOYER

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran
status, or any other prohibited basis of discrimination, as provided under applicable local, state and federal law”. “Federal law
obligates us to provide a reasonable accommodation to the known disabilities of applicants and employees, unless to do so
would pose an undue hardship. Please feel free to let us know if you need an accommodation to complete the application
process or to perform any essential elements of the position sought.

I
Application For Employment
Please Print
Position Applied For: Date Of Application:
Checker June 5, 2018
How did you learn about us?
 Advertisement  Friend  Walk-in
 Employment Agency  Relative web search
 Other _____________________
Last Name First Name Middle Name Social Security Number
Koehler Kendra Ann 521-49-1179
Current Address Number Street City State Zip Code
108 E. Arapahoe St. PO Box 293 Fleming CO 80728

Telephone # (970 ) ____________

265-2289 any
Best time to reach: _________________ Answering machine  Y  N
Mobile/Beeper/Other Phone # ( 970 ) ________________
571-2085 any or leave voicemail
Best time to reach: _____________________
dajakeko@gmail.com
e-mail address _________________________ May we contact you at work? Y N
If Yes, work number and best time to call __________________________________ ___________a.m. or p.m.

If you are under 18 years of age, can you provide required proof of your eligibility to work? Y N

Have you ever filed an application with us before? Y N

If yes, give dates: ________________________________ Position applied for: __________________
Have you ever been employed with us before?  Y  N Give dates and position: _____________________

Are you legally eligible for employment in this country? Y N

Are you currently employed? Y N
May we contact your current employer? Y N
6 5 18
Date available for work: ___/___/___

Are you available to work:  Full-time  Part-time  Shift Work  Temporary

Are you available to work overtime if required? Y N
Comments: _____________________________________________________________
Are you currently on “lay-off” status and subject to recall? Y N

Can you travel if job requires it? Y N

92-124-8386
Driver’s license number if driving is an essential job function: #: ____________________ CO
State: _________

61908
Haxtun Hospital District
235 W. Fletcher Haxtun, Co.
Dietary aide/ Cook
970 774-6123
Preparing, cooking, and
8/2016 5/2018 serving food for staff, patients,
and residents. Cleaning,
stocking, maintaining logs of
temps, waste, chemical levels
and orders. Logging resident

Alice Holloway/Food Service Manager 10.41 hr food/liquid intake. Providing any and
all and keeping available any food
related items nursing staff requires
Please ask for patient care. Doing any prep work
for next day's meals. Keeping in
constant communication with other
11.63 hr cooks, dietary aids and nursing staff
concerning patient needs.

RE-1 Valley Schools 970 522-0792

310 Hagen Ave. Sterling, Co. 4/2012 8/2016

Cook

Kay Wernsman/Food Service Manager 8.00 hr

To find work closer to home

8.52 hr

Baja Tacos 970 522-5563

231 Broadway Sterling, Co. 3/2009 4/2012

Cook/Cashier

Jack Schneider/Owner
9.00 hr

Scheduling conflict
10.00 hr