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Yes No
Yes No
Yes No
Name & Location of School Years Attended Did You Graduate? Subjects Studied
Grammar School Yes No
High School Yes No
College Yes No
Trade, Business or Coresspondence School Yes No
Subjects of special study or research
Work or special training/skills
US Military or Naval Service
Rank
Date
Month and Year
Name and Address of Employer Salary Position Reason for Leaving
Name Address Business Years Known

"I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.


I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.


This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."


e.g. m/dd/yyyy

To sign, please enter your full name.

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