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)

(First)

(Middle Initial)

Davenport Timothy
Address (Mailing Address)

(City)

2717 Superior St

B
(State)

(360) 920 - 1026

(Zip)

Bellingham

Other Telephone

98225

(360) 920 - 1026

E-Mail Address

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

timdavenport94@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

01/09/15

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
Sehome High School

Dates
Attended
Month/Year

From 2013
To 2015
From 2008
To 2013
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

diploma

Occupational License, Certificate or Registration

Number

Where Issued

Expiration Date

NA

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

NA

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

and punctuality, cleaning and organizing, social skills, animal and yard care

WORK EXPERIENCE (Most Recent First)

(Include voluntary work and military experience)

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

Employer
Address Meridian

Telephone Number

(360) 671 - 3300

Haggen 2814 Meridian Bellingham,WA

Courtesy Clerk
Number Employees Supervised 0

From (Month/Year)

09/2014

Job Title
Specific Duties (Maximum 1000 characters)

To (Month/Year)

Swept, go backs, collected carts,organized shelves

Hours Per Week

Current
6 Hours
Last Salary

Trial work exp

Supervisor

Dennis Yoon
Reason For Leaving

Trial work experience ended

May We Contact This Employer?

Employer Pediatric and Therapy Services

Address 348 W King Tut Rd Bellingham,WA

Telephone Number

(360) 398 - 2772

Job Title Farm Assistant

Specific Duties (Maximum 1000 characters)

Number Employees Supervised

Maintenance of barn & arena, cleaned goat & chicken coops, mowed the lawn, organized tools

Yes

No

From (Month/Year)

01/2014
To (Month/Year)

06/2014
Hours Per Week

7 Hours
Last Salary

Trial work exp

Supervisor

Susan McNutt
Work trial ended
Employer Value Village
Address 150 Bellis Fair Pkwy Bellingham,WA
Job Title Merchandise Associate
Reason For Leaving

May We Contact This Employer?

Telephone Number

(360) 733 - 2333

Number Employees Supervised

Yes

No

From (Month/Year)

09/2013
To (Month/Year)

Specific Duties (Maximum 1000 characters)

01/2014

Go backs, sorted items, vacuumed, cleaned mirrors & glass cases, front faced items.

Hours Per Week

4
Last Salary

Trial work exp

Supervisor

Laura
Reason For Leaving

Work trial ended

May We Contact This Employer?

Employer
Address

Telephone Number

Job Title
Specific Duties (Maximum 1000 characters)

Number Employees Supervised

() -

Yes

No

From (Month/Year)

To (Month/Year)

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________________

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.