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M:__________ To:__________ Month/Year Month/Year Name and Address of Employer: Exact Title Of Position: Duties/Responsibilities: Name & Title of Your Supervisor: Reason for Leaving: Number Supervised:__________ 6. Certification of Applicant I certify that the foregoing information and answers are true, complete, and correct. I understand that any misrepresentation or omission of facts are cause for rejection of application and removal from the eligibility list for enrollment in the Fire Fight.

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