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An Equal Opportunity Employer Date: Name: ( ) Mailing Address: First (Legal) MI Nickname Address Physical Address: Last City State Zip City State Zip Address E-mail Address: Cell Phone: ( ) Home Phone: ( ) Departments and/or positions I am applying for, in order of preference: 1) 2) I am able to work: Days & Hours Available From Days Mon. Nights Tues. Weekends Wed. Thurs. Holidays Fri. Sat. Sun. To Start and end dates, as well as hours of work, are subj.

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