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To alert the employer and applicant of conditions that could negatively impact the health of customers or coworkers. This information may be used to determine fitness to perform job duties. This information will be handled in a confidential manner. It is essential that you answer all questions truthfully and completely. False or incomplete information may result in disqualification or termination if hired. Completed by Applicant/Employee (Type or Print in Ink) Section I Date:.

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