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: Final or current salary/wage: per Name and title of Supervisor: Telephone Number: Reason for Leaving: Is there any reason we cannot contact your current or former employer, or their representatives, or any current or former supervisor to obtain or verify references? No Yes (Please explain) PLEASE READ THE FOLLOWING CAREFULLY. BY SIGNING THIS APPLICATION, YOU ARE ACKNOWLEDGING AND ACCEPTING THE FOLLOWING: Except as I have specifically noted, I authorize you to contact any current or former.

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