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Origin. PERSONAL INFORMATION Date: Social Security #: Name: Last First Middle Address: Street City Home Telephone: State Other Phone: Zip Code Email: Referred By: Are you 18 years of age of older? Yes No EMPLOYMENT DESIRED Position Applied For: Type of employment desired: Date Available: Full-Time Part-Time Are you legally eligible for employment in this country? Languages: English Spanish French Temporary YES Salary Desired: Seasonal Educational Co-Op NO Other:.

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