1. Give at least three, and preferably five, REFERENCES, including employers under whom you have worked recently and who have first-hand knowledge of your qualifications.

    Name Official Position Address & Phone Number
       
       
       
         
         

  2. Give reasons for applying for this position.
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    ________________________________________________________________________
    ________________________________________________________________________
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    ________________________________________________________________________
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  3. Are you able with or without reasonable accommodations to perform the functions of the job for which you are applying?  Yes ____   No ____

  4. Have you ever been convicted or adjudicated for a felony? Yes ____   No ____
I affirm that I have read this completed application and have not withheld any information or response to any question and that the information I have furnished is true and correct. I understand that any misrepresentation or omission of fact on my application or during the interview process, regardless of when such misrepresentation or omission is discovered, may result in the refusal of employment or, if employed, immediate termination from employment.

Signature of Applicant: _______________________________________

Date: _______________________

Revised: 12/2005