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   First Name Middle Name Last Name
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   Zip City State
   Are you 18 years old? YES NO
   If “NO”, can you provide proof of your eligibility to work?
YES NO
   Can you, after employment, submit verification of your eligibility to work
   in the United States? (Proof of eligibility will be required if hired)
YES NO
   Employment desired
                                                                                 FULL-TIME ONLY
                                                              
PART-TIME ONLY
FULL TIME or PART-TIME
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