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ER LAST NAME: MAILING ADDRESS - STREET & NUMBER FIRST NAME: CITY STATE ZIP CODE EMAIL ADDRESS TELEPHONE # (HOME) DATE AVAILABLE FOR WORK MINIMUM SALARY YOU WILL ACCEPT DESIRED LOCATION OF EMPLOYMENT: REFER TO LISTING OF COUNTY CODES AND ENTER IN THE BOXES BELOW THE APPROPRIATE CODE(S) OF COUNTIES WHERE YOU WILL ACCEPT EMPLOYMENT (IN PRIORITY ORDER). EXAMPLE: DAUPHIN COUNTY "22" 01 02 03 04 05 06 07 08 09 -ADAMS -ALLEGHENY -ARMSTRONG -BEAVER -BEDFORD -BERKS -BLAIR -BRADFORD -BUCKS 10.

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