JEFFCOM EMPLOYMENT APPLICATION
Dispatch Office Coordinator - Full Time
81 Elkins Road, Port Hadlock, Washington  98339
(360) 385-3831 x1
PLEASE TYPE OR PRINT IN INK
JeffCom is an equal opportunity employer. We do not discriminate, in violation of
law, on the basis of race, color, natural origin, religion, creed, sex, marital status,
age or disability as defined under the Americans with Disability Act.
Name:___________________________________________________			SSN:_______________________________
Last                              First                              MI
Address:__________________________________________________________________________________
Street Number                                             City                          State                 ZIP
Phone:  Home:  (          ) __________________________			Work:  (          ) _____________________
Electronic Mail_____________________________________________________________________________
EDUCATION AND TRAINING
Have you graduated from High School or passed the GED test?  Yes:__________  No:__________
	Name of School(s)	Major	When Attended	Degree
High School or GED
Undergraduate Studies
Graduate Studies
Business or Technical
Military Training
Other Job Related Training and/or Professional Licenses
NAME:                Last                                               First                                               Middle
		page 2
PREVIOUS RESIDENCES:  Addresses where you have lived for the past ten years.  Account for all
time with most recent address first.  Do not list your present address.
From	To	Address (Include City and State)
PREVIOUS NAMES and DATES OF BIRTH USED:  Include all aliases and maiden names
Have you been convicted of a crime?    Yes:    _________    No:  __________
If yes, please explain:________________________________________________________________________
__________________________________________________________________________________________
NAME:                Last                                               First                                               Middle
		page 3
EMPLOYMENT HISTORY
Beginning with your present or most recent employment, list your work experience history.  Be sure to
include any non-paid experience which is related to the job for which you are applying.  If additional space
is required, attach a separate sheet.  "SEE RESUME" WILL NOT BE ACCEPTED.
Employer Name:
Employed To/From:	Your Position:	Supervisor's Name:	Telephone:	May We Contact?
			(       )
Complete Address:
Describe Major Work Duties (attach a separate sheet if desired):
Reason for Leaving:  (If Applicable)
Base Salary (indicate if Hourly/Weekly/Monthly):
Start:	Final:
Employer Name:
Employed To/From:	Your Position:	Supervisor's Name:	Telephone:	May We Contact?
			(       )
Complete Address:
Describe Major Work Duties (attach a separate sheet if desired):
Reason for Leaving:  (If Applicable)
Base Salary (indicate if Hourly/Weekly/Monthly):
Start:	Final:
NAME:                Last                                               First                                               Middle
		page 4
Employer Name:
Employed To/From:	Your Position:	Supervisor's Name:	Telephone:	May We Contact?
			(       )
Complete Address:
Describe Major Work Duties (attach a separate sheet if desired):
Reason for Leaving:  (If Applicable)
Base Salary (indicate if Hourly/Weekly/Monthly):
Start:	Final:
Employer Name:
Employed To/From:	Your Position:	Supervisor's Name:	Telephone:	May We Contact?
			(       )
Complete Address:
Describe Major Work Duties (attach a separate sheet if desired):
Reason for Leaving:  (If Applicable)
Base Salary (indicate if Hourly/Weekly/Monthly):
Start:	Final:
NAME:                Last                                               First                                               Middle
		page 5
Have you ever been discharged or asked to resign from any position?  Yes:__________  No:__________
If yes, give complete details (date, place, reason, name and address of supervisor):
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PERSONAL REFERENCES:  List names and addresses of three reliable persons, other than
relatives or past employers, who know you well enough to give information about you.
Name:________________________________________________			Occupation:________________________
Address:_________________________________________________________________________________
Home Telephone Number:________________________________			How Long Known:___________________
Name:________________________________________________			Occupation:________________________
Address:_________________________________________________________________________________
Home Telephone Number:________________________________			How Long Known:___________________
Name:________________________________________________			Occupation:________________________
Address:_________________________________________________________________________________
Home Telephone Number:________________________________			How Long Known:___________________
Can you perform the essential functions of this job with or without reasonable accomodation?
(See Job Description)  Yes:__________  No:__________
Describe specialized equipment or software you have used, i.e., PC, spreadsheet, database, word
processing, 10 key calculator, data entry or other. (You may attach another page if you wish to elaborate.)
________________________________________________________________________________________
________________________________________________________________________________________
Typing Speed:__________ words per minute.  (If known.)
NAME:                Last                                               First                                               Middle
		page 6
	Authorization to Release Information
Print Name of Applicant:			Date:
I authorize any person, corporation, company, agency, or other entity, whose name and address I provide in
my application, or other materials I have provided to JeffCom, to release information.
	AUTHORIZATION
I, the above named applicant, the below signed, do hereby authorize the receiving person, corporation, company
or other entity to FULLY AND COMPLETELY DISCLOSE any and all facts regarding my employment, character,
work habits, skills, or other employment related information requested by JeffCom, or their agents, who bear
this authorization and to whom I have provided your name and address as a reference.
	RELEASE
In consideration for assisting me in my application for employment, I the above applicant, the below signed,
hereby RELEASE AND HOLD HARMLESS the reference recipient person, corporation, company, or other
entity receiving this release from any and all possible damages, direct or consequential, immediate or remote,
of all forms or types, that I may sustain or allege to sustain by virtue of the recipient person, corporation,
company, or other entity from complying with my request to fully and completely comply with the investigation,
inquirey or interests of this employer to whom I have made an application of employment and the bearer of
this Authorization.  I have given my consent to reproduce this release and such copy shall be considered to
be the original for all purposes whether such copy be by photo reproduction or an electronically transmitted
facsimile.  By my signature, I release any and all parties from any and all liability for any and all statements,
writings, conversations or communications of any form, with this Employer regarding any entry on this
application and other material I have provided.
If you decide to engage an investigative consumer reporting agency to report on my credit and personal
history, I authorize you to do so.  If a report is obtained, you must provide, at my request, the name and address
of the agency so I may obtain from them the nature and substance of the information contained in the report.
This is a legal document; read it carefully before signing.
Applicant's Signature:
Witness's Signature:		Witness's Address:
NAME:                Last                                               First                                               Middle
		page 7
CONSENT TO PROCUREMENT OF CONSUMER CREDIT REPORT
I understand that, as a condition of my consideration for employment with JeffCom, or as a condition of my
continued employment with JeffCom, JeffCom may obtain a consumer report that includes, but is not limited to,
my creditworthiness or similar characteristics, employment and education verifications, social security
verifications, criminal and civil history, personal interviews, DMV records, any other public records and any
other information bearing on my credit standing, credit capacity, character, general reputation, personal
characteristics and trustworthiness.
I hereby authorzie and sent to JeffCom procurement of such a report.  I understand that, pursuant to the
Federal Fair Credit Reporting Act, JeffCom will provide me with a copy of any such report if the information
contained in such a report is, in any way, to be used for making a decision regarding my fitness for
employment with JeffCom.  I further understand that such report will be made available to me prior to any such
decision being made, along with the name and address of the reporting agency that produced the report.
Signature of Applicant or Employee:			Date:
Printed Name of Applicant or Employee:
NAME:                Last                                               First                                               Middle
		page 8
Signed:_______________________________________________			Date:_____________________________
Applicant
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
BE SURE TO SIGN ALL DOCUMENTS IN THE SPACES PROVIDED!
BRING A COPY OF THIS COMPLETED APPLICATION WITH YOU TO YOUR INTERVIEW
		10/8/2007