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ORMATION POSITION APPLYING FOR LAST NAME FIRST NAME STREET ADDRESS CITY WHO COULD BE CONTACTED IF YOU CANNOT BE REACHED? SHIFT DAY NIGHT EVENING ROTATING MIDDLE INIT. STATE NAME RELATION SPECIFY TYPE OF WORKED DESIRED FULL TIME PART TIME DATE YOU CAN BEGIN WORK CIRCLE HIGHEST YEAR COMPLETED SCHOOL 1 2 3 ZIP CODE 4 NAME 5 6 7 CITY 8 9 10 STATE 11 12 1 2 3 TO COLLEGE SUPP/PRN ARE YOU WILLING TO WORK HOLIDAYS WEEKENDS YES NO YES NO Are you legally able to work.

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