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Ay re-apply. Available for Fulltime Partime Specify hours / days: Will you work weekends? Yes No Will you work any shift? Yes No Pay desired: $ per Please complete both sides of this form. Name Date (last) (first) (middle) Address (#) Phone No. ( (street) (city) ) (state) 2nd Phone No. ( Are you at least 18 years of age? Yes No Are you a US Citizen? Yes No (zip) ) If you are under 18, give birthdate If not, do you possess an Alie.

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