1. Peoria Unified School District #11
Work Based Learning
CTE/Professional Internship
Employment Application
DIRECTIONS: Read carefully and fill in ALL items. Incomplete or unsigned applications
will not be accepted.
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Last Name First Name Middle Initial
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Address City State Zip Code
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Home Phone Cell Phone E-mail
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Birth Date Date Available Starting Time
Work History
Begin with your current or most recent position. List each promotion as a separate job. Include paid and voluntary
positions. Be as accurate and complete as possible, especially in describing the duties of each position.
Current or Most Recent Position:
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Name of Employer/Company Job Title Dates of Employment (From - To)
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Employer’s Address City State Zip Code
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Name of Supervisor Hours Per Week Reason for Leaving
Description of Duties:
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Next Previous Position:
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Name of Employer/Company Job Title Dates of Employment (From - To)
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Employer’s Address City State Zip Code
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Name of Supervisor Hours Per Week Reason for Leaving
Description of Duties:
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Bell Emily A
7350 West Karen Lee Lane Peoria AZ 85382
N/A 623-707-9298 emilioannbell@gmail.com
07/09/1999 8/18/16 3:00
Angie Madsen Nannny 06/16-08/16
22612 North 73rd Drive Glendale AZ 85310
Angie Madsen 50 No longer needed.
I watched the two children and took care of their dog. I also helped with housework.
N/A

2. Education and Training
College:
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Name of College Dates Attended - Month/Year
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Address City State Zip Code
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Classes
High School:
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Name of High School Dates Attended - Month/Year
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Address City State Zip Code
Use this space to identify any career and technical education classes you have received a “C” or better
(i.e., Welding, Ag, Media, Culinary, Business Foundations, Life FACS, Drafting, Child Development, etc).
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List any relevant certificates and licenses (Food Handlers, CPR, etc.), or specialized classes you have taken
(i.e., Chemistry, Anatomy, Journalism, Photography, etc.)
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Please give any additional information you feel is pertinent that is not listed elsewhere. Do not leave it blank
.
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List Three References
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Reference #1: List name Address City State Zip Code Phone Number
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Reference #2: List name Address City State Zip Code Phone Number
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Reference #3: List name Address City State Zip Code Phone Number
Signature: By signing this application, you are certifying that the information is true and complete to the best of your
knowledge. Unsigned applications will not be considered.
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Signature Date
N/A
Centennial High School 08/13 08/16
14388 North 79th Avenue Peoria AZ 85381
Criminal Justice, Law Enforcement, Business Foundations.
Aim Chemistry, Aim Biology, Biology Applications Technology.
I am involved in National Honor Society, a member of Future Business Leaders of America, and apart of the Law club.
Angie Madsen 22612 North 73rd Drive Glendale AZ 85310 701-818-0048
Kim Johnson 14388 North 79th Avenue Peoria AZ 85381 623-412-4400
Micheal Gahan 14388 North 79th Avenue Peoria AZ 85381 623-412-4400