Washington State
Department of Services for the Blind

Your Name:

Social Security Number:

Date of Birth:

Mailing Address:

Home Telephone Number:

Work Telephone Number:

Position Desired:

Salary Desired:

In which geographical areas will you consider working? (List them.)

What types of employment will you accept? (Check all that apply.)

Day Shift

Swing Shift

Graveyard Shift

Rotating Shift

What type of work schedule will you accept? (Check all that apply.)

Full-Time

Part-Time

Temporary

Tandem (Shared)

Project

Seasonal

Intermittent (On-Call)

What language(s) do you speak? (List them.)

Have you ever been convicted of a crime?

Yes

No

Do you have keyboarding or computer skills?

Yes

No

How many words per minute can you type?

What software programs are you proficient in?

What is the highest level of education you have achieved?

(Check all that apply.)

Some primary education

(grade or elementary school)

Highest level completed

Some secondary education

(high school or GED preparation)

Highest level completed

High school graduate or GED certificate recipient

Some post-secondary education (college or university)

Highest level completed:

Some vocation/technical school education

Highest level completed:

2-year degree

Major(s):

4-year degree

Major(s):

Master’s degree

Major(s):

Doctoral degree

Major(s):

Other post high school training

Specify Type(s):

What is the history of your post-primary education? (E.g. high schools attended, colleges attended, etc.)

School Name and Location:

Month and Year Attended:

1.

From:

To:

2.

From:

To:

3.

From:

To:

4.

From:

To:

5.

From:

To:

6.

From:

To:

7.

From:

To:

8.

From:

To:

9.

From:

To:

10.

From:

To:

What is the history of your employment? (Start with your present or last position, then work backwards.)

1. Name of Present or Last Employer:

Address of Employer:

Telephone Number of Employer:

Your Title:

Months and Years Employed in this Position

From:

To:

Total Months Employed in this Position:

Average Hours Worked Per Week:

Last Salary (If volunteer, write “volunteer”):

Name of Immediate Supervisor:

Reason for Leaving:

Number of Employees Supervised:

Specific Duties:

2. Name of Previous Employer:

Address of Employer:

Telephone Number of Employer:

Your Title:

Months and Years Employed in this Position

From:

To:

Total Months Employed in this Position:

Average Hours Worked Per Week:

Last Salary (If volunteer, write “volunteer”):

Name of Immediate Supervisor:

Reason for Leaving:

Number of Employees Supervised:

Specific Duties:

3. Name of Previous Employer:

Address of Employer:

Telephone Number of Employer:

Your Title:

Months and Years Employed in this Position

From:

To:

Total Months Employed in this Position:

Average Hours Worked Per Week:

Last Salary (If volunteer, write “volunteer”):

Name of Immediate Supervisor:

Reason for Leaving:

Number of Employees Supervised:

Specific Duties:

4. Name of Previous Employer:

Address of Employer:

Telephone Number of Employer:

Your Title:

Months and Years Employed in this Position

From:

To:

Total Months Employed in this Position:

Average Hours Worked Per Week:

Last Salary (If volunteer, write “volunteer”):

Name of Immediate Supervisor:

Reason for Leaving:

Number of Employees Supervised:

Specific Duties:

5. Name of Previous Employer:

Address of Employer:

Telephone Number of Employer:

Your Title:

Months and Years Employed in this Position

From:

To:

Total Months Employed in this Position:

Average Hours Worked Per Week:

Last Salary (If volunteer, write “volunteer”):

Name of Immediate Supervisor:

Reason for Leaving:

Number of Employees Supervised:

Specific Duties:

Who are your personal references?

(References should be non-family members.  They could be former employers, professors, work associates, etc.)

1. Name of Reference:

Address of Reference:

Telephone Number of Reference:

Occupation of Reference:

Nature of Relationship:

2. Name of Reference:

Address of Reference:

Telephone Number of Reference:

Occupation of Reference:

Nature of Relationship:

3. Name of Reference:

Address of Reference:

Telephone Number of Reference:

Occupation of Reference:

Nature of Relationship: