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ri.,. <br />DUTIES PERFI .D <br />DATES I LAST SALARY FULL TIME C <br />TO PART TIME C <br />AME MAILING ADDRESS <br />--- DUTIES PERFOF <br />EMPLOYMENT DATES LASTSALARY FULL TIME <br />FROM TO PART TIME <br />EMPLOYER'S NAME MAILING ADD{ <br />POSITION HELD DUTIES PERFOI <br />EMPLOYMENT DATES LAST SALARY FULL TIME <br />FROM TO PART TIME <br />MAY WE CONTACT YOUR PRESENT EMPLOYER YES ❑ NO <br />)THER EXPERIENCE/SKILLS <br />FOR LEAVING <br />REASON FOR LEAVING <br />IF NO, PLEASE EXPLAIN <br />TELEPHONE NU. <br />ZIPCODE I TELEPHONE <br />IMMED. SUPERVI <br />ZIP <br />IMMED. SUPERVISOR <br />LIST ANY UNPAID WORK, VOLUNTEER EXPERIENCE, OR MILITARY DUTY NOT MENTIONED ABOVE THAT MAY RELATE TO THE POSITION <br />FOR WHICH YOU ARE APPLYING. INDICATE TYPE OF ACTIVITY, YOUR DUTIES, DATES INVOLVED, HOURS PER WEEK, AND NAME OF <br />YOUR SUPERVISOR. <br />LISTANY OTHER SKILLS OR EXPERIENCE WHICH RELATE TO THIS POSITION. I <br />REFERENCES <br />LIST THREE PERSONS WHO ARE NOT RELATED TO YOU AND WHO HAVE DEFINITE KNOWLEDGE OF YOUR QUALIFICATIONS AND FITNESS <br />FOR THE POSITION FOR WHICH YOU ARE APPLYING. DO NOT REPEAT NAMES OF SUPFRV I!.nAQ ARnVP <br />FULL NAME ADDRESS INCLUDING CITY, STATE, ZIP CODE GL'CIi:ESS OR OCCUPATION <br />•q �n .I �, ° t' ') r- `y.3 f SPClt'lq/y <br />Os <br />I HEREBY CERTIFY THAT ALL ANSWERS TO THE ABOVE QUESTIONS ARE TRUE AND 1 AGREE AND UNDERSTAND THAT ANY FALSE <br />STATEMENTS CONTAINED IN THIS APPLICATION MAY CAUSE- REJECTION OF THIS -':'PL!CATIVN OR TERMINATION OF EMPLOYMENT <br />WITHOUT NOTICE OR BENEFITS. J„ n <br />APPLICANT'S SIGNATURE^"+JC"• �t/r.` ,,,��.q.Z7<i I) I/ <br />rvnmiEHvIEWEH'i Ubt ONLY: ,�-��",,b,,+'Yy `� yes ovoi• &I" <br />69d (ilL �l�/7/:)!t+ilLt+tr' y,Y.L[./ LA?IL( U;B'L� — / • �� • <br />464X a/ �Q,r uzana !� lJ / �f /i/( t u t �X' c � l . �+►I>Kf./ <br />0 <br />�,a�necP e/u IoPJ cum,- �"' °'/`' <br />