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__________________ $_____________________ Final Salary/Wages $_____________________ $_____________________ $_____________________ May we contact this employer? Yes No Yes No Yes No Responsibilities Reason for Leaving I represent that the above information, and other information I may be required to provide, is complete and accurate and any misstatement or ommision may result in rejection of my application or termination of employment. I authorize LCE to conduct, at its discretion, f.

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