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)
Rios-Loya

(First)

Address (Mailing Address)

(City)

(Middle Initial)

Mariana

211 N Washington St.

A
(State)

(360) 393 - 2465

(Zip)

Everson

Other Telephone

() -

98247
W

E-Mail Address

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

riosloyamariana@gmail.com

Home Telephone

Yes

No

POSITION
Position Or Type Of Employment Desired

Childcare Assistant
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

$ 9.47/hour

June 24, 2015

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)

Dates
Attended
Month/Year

Name and Location

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

Washington State Food Worker Card

Whatcom Co Health Dept

12-03-2015

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

N/A

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

can manage laundry facilities, industrial dishwashers and use janitorial supplies. I communicate
well with supervisors and co-workers. I know how to organize, front face and stock shelves. I am proficient with
computers. I know how to use Microsoft Word.

WORK EXPERIENCE (Most Recent First)

(Include voluntary work and military experience)

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

Employer Sunnyland Elementary Preschool

Address 2800 James Street Bellingham WA

Telephone Number

(360) 676 - 6446

Job Title Classroom Assistant

Specific Duties (Maximum 1000 characters)

Number Employees Supervised

Assisting classroom teacher with the following duties: helping students line up, supervise
students in the hall, monitor students in the classroom, supervise play time, sanitize tables,
supervise hand washing, assist with snack time, and supervise clean up.

From (Month/Year)

2/3/2015
To (Month/Year)

6/16/2015
Hours Per Week

4
Last Salary

Trial work
Supervisor

Jen Mallett
Reason For Leaving

Trial work experience ended

May We Contact This Employer?

Employer Northshore Veterinary Hospital

Address 1486 Electric Ave. Bllingham WA 98229

Telephone Number

(360) 738 - 6916

Job Title Kennel Assistant

Specific Duties (Maximum 1000 characters)

Number Employees Supervised

Clean exam rooms, clean kennels, stock supplies, complete laundry.

Yes

No

From (Month/Year)

9/2014
To (Month/Year)

1/2015
Hours Per Week

4.5
Last Salary

Trial work
Supervisor

Deirdre Kettlestrings
Trial work experience ended
Employer Barkley Village Haggen
Address 2900 Woburn Street, Bellingham WA 98226
Job Title Food Court Clerk
Reason For Leaving

May We Contact This Employer?

Telephone Number

(360) 676 - 5300

Number Employees Supervised

Yes

No

From (Month/Year)

2/2014
To (Month/Year)

Specific Duties (Maximum 1000 characters)

6/2014

Returning items to original shelves and general cleaning duties

Hours Per Week

5.5
Last Salary

Trial work
Supervisor

Kim Borg
Trial work experience ended
May We Contact This Employer?
Yes
From
(Month/Year)
Employer Sudden Valley Markets
Telephone Number (360) 734 - 7031
9/2013
Address 1945 Lake Whatcom Blvd. Bellingham WA 98226
To (Month/Year)
Job Title Shop Help/Stock
Number Employees Supervised 0
1/2014
Specific Duties (Maximum 1000 characters)
Store recovery, front facing shelves, stocking, light dusting, clean up.
Hours Per Week
4
Reason For Leaving

No

Last Salary

Trial work
Supervisor

Debbie
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.