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Hat to knowingly give false information or failing to disclose convictions may, in the event of employment, result in dismissal or disciplinary action. I confirm that to the best of my knowledge there are no medical reasons which would prevent me from undertaking the duties of the post. Signed: Date: Return to: The Practice Manager, Prices Mill Surgery, Newmarket Road , Nailsworth, Glos. GL6 0DQ Confidential Page 2 of 6 Rev 1 APPLICATION FOR EMPLOYMENT (Part 2) CURRENT OR MOST RECENT EMPLOY.

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