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Last Name
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First Name
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Age
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Year of Birth
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City
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E-mail
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Where do you live(Major Intersection)
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Telephone Number
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Alternate Number
Are you currently working?
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Yes
No
If yes, how many hours?
Are you seeking Full-Time work?
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Yes
No
(Able to attend the Program and Employer Interviews between 9am and 3 pm daily)
Are you out of Full-Time school?
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Yes
No
(Able to attend the Program and Employer Interviews between 9am and 3 pm daily)
Where/how did you learn about the Program?
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What type of jobs are you seeking?
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First choice
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Second choice
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Third choice
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Optional Comments
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