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T and Housing Act will be provided as required by applicable law (Ref. Section 503 of the Rehabilitation Act of 1973) Position Applying For: SELECT POSITION---------------- Last Name First Name Middle Initial Social Security Number Street Address City/State Zip Code Phone Number If hired, can you provide evidence of legal eligibility to work in the US? Do you have a valid California Driver s License? Yes / No Yes / No DL# Any offer of employment is conditioned up.

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