Peninsula College

Employment Application | Model

Applicant Information
Full Name: Staley
Last

Tezara

First

M.I.

Date:

02/19/2016

2491 Lower Hoh Rd.

Address:

Street Address

Apartment/Unit #

Forks

WA

98331

City

State

ZIP Code

360-640-5169

Phone:

Date Available: Now

Email tezaradell@hotmail.com
Social Security No.: ***-**-****

Desired Salary: Negotiable

Position Applied for: Administrative Assistant / Bookkeeping

YES

NO

YES

Are you a citizen of the United States?

NO

If no, are you authorized to work in the U.S.?

YES

NO

Have you ever worked for this company?

If yes, when?
YES

NO

Have you ever been convicted of a felony?

If yes, explain:

Education
High School:

Forks High School

Address: 261 Spartan Ave, Forks, WA 98331

YES

From:

2006

To: 2009

College: Peninsula College

Diploma:: High School Diploma

Address: 1502 E Lauridsen Blvd, Port Angeles, WA 98362

YES

From:

2011

To: 2013

Other:

Peninsula College

2014

To: 2016

NO

Degree: Associate in Arts

Did you graduate?

Address: 1502 E Lauridsen Blvd, Port Angeles, WA 98362

YES

From:

NO

Did you graduate?

Did you graduate?

NO

Associate in Applied Science,

Administrative Office Systems,
Degree:Accounting Specialization

References
Please list three professional references.
Full Name: Glynda Schaad

Relationship: Instructor

Company:

Peninsula College

Phone:360-374-3223 ex.6451

Address:

481 S Forks Ave, Forks, WA 98331

Full Name: Sherry Sparrowk

Relationship: Instructor
Phone:360-417-6375

Company:

Peninsula College

Address:

1502 E Lauridsen Blvd, Port Angeles, WA 98362

Full Name: Claire Horejsi

Relationship: Previous Employer

Company:

Hoh Indian Tribe

Phone: 360-808-3952

Address:

33 Chalaat loop Forks, WA 98331

Previous Employment
Company:

Olympic Area Agency on Aging

Address:

481 5th Ave Forks, WA 98331

Job Title:

Independent Provider

Phone: 360-374-9496
Supervisor: Char Carte
Starting Salary:$ 10.03/hour

Ending Salary:$ 10.03/hour

Responsibilities: Assist client with in home needs, medical transportation

From:

July 2011

To: December 2012

Reason for Leaving: Client Relocated

YES

NO

May we contact your previous supervisor for a reference?

Company:

Hoh Indian Tribe

Phone: 360-808-3952

Address:

2261 Lower Hoh Rd, Forks, WA 98331

Job Title:

Childcare Provider

Supervisor: Claire Horejsi

Starting Salary:$16/hour

Ending Salary:$16/hour

Responsibilities: Provided residential in-home child care for three young children
From:

June 2010

To: December 2010

Reason for Leaving: Relocated

YES

NO

May we contact your previous supervisor for a reference?

Company:

Phone:

Address:

Supervisor:
Starting Salary:$

Job Title:
Responsibilities:
From:

To:

Reason for Leaving:

Ending Salary:$

YES

NO

May we contact your previous supervisor for a reference?

Military Service
Branch: Not Applicable

From:

Rank at Discharge:

To:

Type of Discharge:

If other than honorable, explain:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or
interview may result in my release.
Date: 02/19/2016

Signature: