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Memorial Medical Center or affiliates. Applicant s Signature Date Attn: Applicant: S.S. # Position applied for: Applicant states he/she was employed by you as From to . Please complete the section below. All information will be held confidential. Orange Cross Personnel Date Position held at your Company: Dates of employment: From: To: Reason for leaving employment: Would you rehire: If no, why? Quality of work: Attendance: Quantity of work: Number of days absent in last year: An.
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