{"id":5751,"date":"2022-06-20T00:22:34","date_gmt":"2022-06-20T00:22:34","guid":{"rendered":"https:\/\/n6z.673.myftpupload.com\/?page_id=5751"},"modified":"2022-06-20T00:22:34","modified_gmt":"2022-06-20T00:22:34","slug":"secure-application-for-employment","status":"publish","type":"page","link":"\/\/www.abcchristmas.com\/secure-application-for-employment\/","title":{"rendered":"Secure Application for Employment"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling fusion-animated\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-margin-bottom:120px;--awb-margin-bottom-medium:80px;--awb-margin-bottom-small:60px;--awb-flex-wrap:wrap;\" data-animationType=\"fadeInUp\" data-animationDuration=\"1.3\" data-animationOffset=\"top-into-view\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-center fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-blend:overlay;--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.536%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:1.92%;--awb-width-medium:40%;--awb-spacing-right-medium:3.84%;--awb-spacing-left-medium:4.8%;--awb-width-small:100%;--awb-spacing-right-small:1.92%;--awb-margin-bottom-small:15px;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-title-text fusion-title-size-two\" style=\"--awb-text-color:var(--awb-custom_color_1);--awb-margin-bottom:0px;--awb-font-size:37px;\"><div class=\"title-sep-container title-sep-container-left fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:var(--awb-color3);\"><\/div><\/div><span class=\"awb-title-spacer fusion-no-large-visibility fusion-no-medium-visibility fusion-no-small-visibility\"><\/span><h2 class=\"fusion-title-heading title-heading-left fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;text-transform:capitalize;--fontSize:37;line-height:1.35;\"><h5 style=\"text-align: center;\">It is the policy of this facility to provide equal opportunity to persons regardless of race, religion,<br \/>\nage, gender, disability or any other classification in accordance with federal, state and local<br \/>\nstatutes, regulations and ordinances.<\/h5><\/h2><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:var(--awb-color3);\"><\/div><\/div><\/div><div class=\"fusion-text fusion-text-1\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f5402-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/wp-json\/wp\/v2\/pages\/5751#wpcf7-f5402-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"5402\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.9.4\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f5402-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<table>\n\t<tbody>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>First Name <span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Middle, Last Name <span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Email <span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-email wpcf7-text wpcf7-validates-as-email\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Are You At Least 18 Years Old? <span class=\"wpcf7-form-control-wrap\" data-name=\"age\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"age\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Last 4-digits of Social Security Number <span class=\"wpcf7-form-control-wrap\" data-name=\"your-security\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"your-security\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Home Phone And Cell Phone<span class=\"wpcf7-form-control-wrap\" data-name=\"telephone-1\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telephone-1\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Present Address <span class=\"wpcf7-form-control-wrap\" data-name=\"present-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"present-address\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Present City <span class=\"wpcf7-form-control-wrap\" data-name=\"present-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"present-city\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Present ZIP Code <span class=\"wpcf7-form-control-wrap\" data-name=\"present-zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"present-zip\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Previous Address <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"previous-address\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Previous City <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-city\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"previous-city\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Previous ZIP Code <span class=\"wpcf7-form-control-wrap\" data-name=\"previous-zip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"previous-zip\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Current Open Position that you are applying: <span class=\"wpcf7-form-control-wrap\" data-name=\"openposition\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"openposition\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Type of Position:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"type-position\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Per Diem\" \/><span class=\"wpcf7-list-item-label\">Per Diem<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Full Time\" \/><span class=\"wpcf7-list-item-label\">Full Time<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Part Time\" \/><span class=\"wpcf7-list-item-label\">Part Time<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Pool\" \/><span class=\"wpcf7-list-item-label\">Pool<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"PRN\" \/><span class=\"wpcf7-list-item-label\">PRN<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Temporary\" \/><span class=\"wpcf7-list-item-label\">Temporary<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Shift:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"shift\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"shift[]\" value=\"Day\" \/><span class=\"wpcf7-list-item-label\">Day<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"shift[]\" value=\"Evening\" \/><span class=\"wpcf7-list-item-label\">Evening<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"shift[]\" value=\"Weekend\" \/><span class=\"wpcf7-list-item-label\">Weekend<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"shift[]\" value=\"Night\" \/><span class=\"wpcf7-list-item-label\">Night<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"shift[]\" value=\"Rotation\" \/><span class=\"wpcf7-list-item-label\">Rotation<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"shift[]\" value=\"Temporary\" \/><span class=\"wpcf7-list-item-label\">Temporary<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Salary Requirement <span class=\"wpcf7-form-control-wrap\" data-name=\"salary\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"salary\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Are you willing to travel? <span class=\"wpcf7-form-control-wrap\" data-name=\"travel\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"travel\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Are you willing to relocate? <span class=\"wpcf7-form-control-wrap\" data-name=\"relocate\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"relocate\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Do you have adequate way of transport to get to work<br \/>\non time each day and when called on short notice during normal working hours? <span class=\"wpcf7-form-control-wrap\" data-name=\"transportation\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"transportation\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>If overtime is required periodically,<br \/>\ndoes this pose a problem for you? <span class=\"wpcf7-form-control-wrap\" data-name=\"overtime\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"overtime\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Date Available<br \/>\nfor work? <span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"date\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Are You Legally Authorized to Work in the U.S.? <span class=\"wpcf7-form-control-wrap\" data-name=\"legally\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"legally\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Have you ever worked in this facility? <span class=\"wpcf7-form-control-wrap\" data-name=\"facility\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"facility\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>If yes, what facility? <span class=\"wpcf7-form-control-wrap\" data-name=\"ifyesfacility\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ifyesfacility\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Are you able to perform the essential, job related<br \/>\nfunctions of the position for which you are applying<br \/>\nwith or without reasonable accommodations? <span class=\"wpcf7-form-control-wrap\" data-name=\"accomodations\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"accomodations\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Describe any<br \/>\naccommodations necessary:<span class=\"wpcf7-form-control-wrap\" data-name=\"accom\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"accom\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Are you related to<br \/>\nanother facility employee?<span class=\"wpcf7-form-control-wrap\" data-name=\"related\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"related\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Are you currently excluded from participation in an<br \/>\nfederally funded healthcare program including Medicare<br \/>\nand Medicaid? Are you aware of any potential exclusion from federally funded health program? <span class=\"wpcf7-form-control-wrap\" data-name=\"excluded\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"excluded\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Are you presently charged with any<br \/>\nviolation of the law?<span class=\"wpcf7-form-control-wrap\" data-name=\"related\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"related\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>If yes, give date,<br \/>\nplace and nature of each such event:<span class=\"wpcf7-form-control-wrap\" data-name=\"ifyes\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ifyes\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<table>\n\t<body>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>How did you learn about this position?:<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"type-position\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"School\" \/><span class=\"wpcf7-list-item-label\">School<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Agency\" \/><span class=\"wpcf7-list-item-label\">Agency<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Ad\" \/><span class=\"wpcf7-list-item-label\">Ad<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Job Line\" \/><span class=\"wpcf7-list-item-label\">Job Line<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Internet\" \/><span class=\"wpcf7-list-item-label\">Internet<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Job listing\" \/><span class=\"wpcf7-list-item-label\">Job listing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"Current Employee\" \/><span class=\"wpcf7-list-item-label\">Current Employee<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"type-position[]\" value=\"State Employment\n         Commission\" \/><span class=\"wpcf7-list-item-label\">State Employment\n         Commission<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Other <span class=\"wpcf7-form-control-wrap\" data-name=\"others\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"others\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/body>\n<\/table>\n<h4><b> Professional Certifications <\/b>\n<\/h4>\n<table>\n\t<tbody>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Type: <span class=\"wpcf7-form-control-wrap\" data-name=\"type\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"type\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>State: <span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Date <span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"date\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Number <span class=\"wpcf7-form-control-wrap\" data-name=\"number\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"number\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Status<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cert-status\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cert-status[]\" value=\"Currently Certified\" \/><span class=\"wpcf7-list-item-label\">Currently Certified<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cert-status[]\" value=\"Eligible for Certification\" \/><span class=\"wpcf7-list-item-label\">Eligible for Certification<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Type: <span class=\"wpcf7-form-control-wrap\" data-name=\"type2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"type2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>State: <span class=\"wpcf7-form-control-wrap\" data-name=\"state2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Date <span class=\"wpcf7-form-control-wrap\" data-name=\"date2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"date2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Number <span class=\"wpcf7-form-control-wrap\" data-name=\"number2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"number2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Status<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cert-status2\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"cert-status2[]\" value=\"Currently Certified\" \/><span class=\"wpcf7-list-item-label\">Currently Certified<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"cert-status2[]\" value=\"Eligible for Certification\" \/><span class=\"wpcf7-list-item-label\">Eligible for Certification<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<h4><b> Language <\/b>\n<\/h4>\n<table>\n\t<tbody>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Language: <span class=\"wpcf7-form-control-wrap\" data-name=\"language\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"language\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<th>\n\t\t\t\t<p><b>Do you speak?<\/b><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"speakstatus\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"speakstatus\" value=\"Fair\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Fair<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"speakstatus\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"speakstatus\" value=\"Fluent\" \/><span class=\"wpcf7-list-item-label\">Fluent<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p><b>Do you read?<\/b><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"readstatus\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"readstatus\" value=\"Fair\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Fair<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"readstatus\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"readstatus\" value=\"Fluent\" \/><span class=\"wpcf7-list-item-label\">Fluent<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p><b>Do you write?<\/b><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"writestatus\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"writestatus\" value=\"Fair\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Fair<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"writestatus\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"writestatus\" value=\"Fluent\" \/><span class=\"wpcf7-list-item-label\">Fluent<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Language: <span class=\"wpcf7-form-control-wrap\" data-name=\"language2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"language2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<th>\n\t\t\t\t<p><b>Do you speak?<\/b><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"speakstatus1\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"speakstatus1\" value=\"Fair\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Fair<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"speakstatus1\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"speakstatus1\" value=\"Fluent\" \/><span class=\"wpcf7-list-item-label\">Fluent<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p><b>Do you read?<\/b><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"readstatus1\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"readstatus1\" value=\"Fair\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Fair<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"readstatus1\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"readstatus1\" value=\"Fluent\" \/><span class=\"wpcf7-list-item-label\">Fluent<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p><b>Do you write?<\/b><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"writestatus1\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"writestatus1\" value=\"Fair\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Fair<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"writestatus1\" value=\"Good\" \/><span class=\"wpcf7-list-item-label\">Good<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"writestatus1\" value=\"Fluent\" \/><span class=\"wpcf7-list-item-label\">Fluent<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<h4><b> Armed Services\/Volunteer Information <\/b>\n<\/h4>\n<table>\n\t<tbody>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Did you serve in the U.S. Armed Services? <span class=\"wpcf7-form-control-wrap\" data-name=\"serve\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"serve\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"serve\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>What branch? <span class=\"wpcf7-form-control-wrap\" data-name=\"branch\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"branch\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Have you volunteered your time or services? <span class=\"wpcf7-form-control-wrap\" data-name=\"volunteer\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"volunteer\" value=\"Yes\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"volunteer\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Where? <span class=\"wpcf7-form-control-wrap\" data-name=\"branch2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"branch2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Briefly describe duties and skills acquired through<br \/>\nmilitary or volunteer service (include dates): <span class=\"wpcf7-form-control-wrap\" data-name=\"duties\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"duties\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<h4><b> Educational History <\/b>\n<\/h4>\n<table>\n\t<tbody>\n\t\t<tr>\n\t\t\t<th>\n\t\t\t\t<p><b>Type of School<\/b>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p><b>Name of<br \/>\nSchool City, State<\/b>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p><b>Last Year Attended in<br \/>\nSchool<\/b>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p><b>Graduated\/GED?<\/b>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p><b>Degree<br \/>\nor Certificate<\/b>\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>High School\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"school\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"school\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"school\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"school\" value=\"9\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"school\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"school\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"school\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"graduated\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"graduated\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"grad\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"grad\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>College\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"school2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"school2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rschool2\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rschool2\" value=\"9\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool2\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool2\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rschool2\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"graduated2\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"graduated2\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"grad2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"grad2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>College\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"school3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"school3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rschool3\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rschool3\" value=\"9\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool3\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool3\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rschool3\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"graduated3\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"graduated3\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"grad3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"grad3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Graduate School\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"school4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"school4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rschool4\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rschool4\" value=\"9\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool4\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool4\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rschool4\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"graduated4\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"graduated4\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"grad4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"grad4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Other\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"school5\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"school5\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rschool5\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rschool5\" value=\"9\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool5\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool5\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rschool5\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"graduated5\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"graduated5\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>[text grad5<\/td>\n <\/tr>\n<tr>\n    <td>Other<\/td>\n    <td> [text school6]\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"rschool6\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"rschool6\" value=\"9\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">9<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool6\" value=\"10\" \/><span class=\"wpcf7-list-item-label\">10<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"rschool6\" value=\"11\" \/><span class=\"wpcf7-list-item-label\">11<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"rschool6\" value=\"12\" \/><span class=\"wpcf7-list-item-label\">12<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"graduated6\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"graduated6\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"grad6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"grad6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<h4><b> Clerical or other skills applicable to the position for which you are applying: <\/b>\n<\/h4>\n<table>\n\t<tbody>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wpm-status\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"wpm-status[]\" value=\"PBX\" \/><span class=\"wpcf7-list-item-label\">PBX<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Typing (WPM) <span class=\"wpcf7-form-control-wrap\" data-name=\"typing\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"typing\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wpm-status\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"wpm-status[]\" value=\"Proficient in Software:\" \/><span class=\"wpcf7-list-item-label\">Proficient in Software:<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Explanation <span class=\"wpcf7-form-control-wrap\" data-name=\"explanation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"explanation\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wpm-status\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"wpm-status[]\" value=\"Business machines and\/or equipment you can operate:\" \/><span class=\"wpcf7-list-item-label\">Business machines and\/or equipment you can operate:<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Explanation <span class=\"wpcf7-form-control-wrap\" data-name=\"bussmachine\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"bussmachine\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"wpm-status\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"wpm-status[]\" value=\"Other:\" \/><span class=\"wpcf7-list-item-label\">Other:<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Explanation <span class=\"wpcf7-form-control-wrap\" data-name=\"other\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<table>\n\t<tbody>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>List any professional licenses, registration or certification you possess (Include only the last 4 digits of your Driver's License, if applicable) Include Type, State Issued, Expiration Date and Number. Indicate if any licenses have been revoked, suspended or placed on probation.<br \/>\nAlso indicate if you are ineligible to become licensed or certified in your field. Please explain. <span class=\"wpcf7-form-control-wrap\" data-name=\"licenses\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"licenses\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<h4><b> Work History <\/b>\n<\/h4>\n<table>\n\t<body>\n\t\t<h5><b> Current or Most Recent <\/b>\n\t\t<\/h5>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>From (MM\/YYYY): <span class=\"wpcf7-form-control-wrap\" data-name=\"start_Date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start_Date\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>To (MM\/YYYY): <span class=\"wpcf7-form-control-wrap\" data-name=\"start_Date\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start_Date\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Company <span class=\"wpcf7-form-control-wrap\" data-name=\"company\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"company\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Phone No. <span class=\"wpcf7-form-control-wrap\" data-name=\"no\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"no\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Immediate Supervisor <span class=\"wpcf7-form-control-wrap\" data-name=\"supervisor\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"supervisor\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Salary ($): <span class=\"wpcf7-form-control-wrap\" data-name=\"salary\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"salary\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"add\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"add\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Name while employed <span class=\"wpcf7-form-control-wrap\" data-name=\"namewhile\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"namewhile\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>May we contact them? <span class=\"wpcf7-form-control-wrap\" data-name=\"contactthem\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"contactthem\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Job Title: <span class=\"wpcf7-form-control-wrap\" data-name=\"job_title\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"job_title\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Job Type <span class=\"wpcf7-form-control-wrap\" data-name=\"jobtype\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"jobtype\" value=\"PRN\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">PRN<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"jobtype\" value=\"Full time\" \/><span class=\"wpcf7-list-item-label\">Full time<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"jobtype\" value=\"Part time\" \/><span class=\"wpcf7-list-item-label\">Part time<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p># Hrs\/Week: <span class=\"wpcf7-form-control-wrap\" data-name=\"hours\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hours\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Reason For Leaving <span class=\"wpcf7-form-control-wrap\" data-name=\"leaving\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"leaving\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Nature of Duties <span class=\"wpcf7-form-control-wrap\" data-name=\"duties\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"duties\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/body>\n<\/table>\n<table>\n\t<tbody>\n\t\t<h5><b> 1st Previous <\/b>\n\t\t<\/h5>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>From (MM\/YYYY): <span class=\"wpcf7-form-control-wrap\" data-name=\"start_Date2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start_Date2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>To (MM\/YYYY): <span class=\"wpcf7-form-control-wrap\" data-name=\"start_Date2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start_Date2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Company <span class=\"wpcf7-form-control-wrap\" data-name=\"company2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"company2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Phone No. <span class=\"wpcf7-form-control-wrap\" data-name=\"no2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"no2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Immediate Supervisor <span class=\"wpcf7-form-control-wrap\" data-name=\"supervisor2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"supervisor2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Salary ($): <span class=\"wpcf7-form-control-wrap\" data-name=\"salary2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"salary2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"add2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"add2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Name while employed <span class=\"wpcf7-form-control-wrap\" data-name=\"namewhile2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"namewhile2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>May we contact them? <span class=\"wpcf7-form-control-wrap\" data-name=\"contactthem2\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"contactthem2\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Job Title: <span class=\"wpcf7-form-control-wrap\" data-name=\"job_title2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"job_title2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Job Type<span class=\"wpcf7-form-control-wrap\" data-name=\"jobtype2\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"jobtype2\" value=\"PRN\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">PRN<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"jobtype2\" value=\"Full time\" \/><span class=\"wpcf7-list-item-label\">Full time<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"jobtype2\" value=\"Part time\" \/><span class=\"wpcf7-list-item-label\">Part time<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p># Hrs\/Week: <span class=\"wpcf7-form-control-wrap\" data-name=\"hours2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hours2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Reason For Leaving <span class=\"wpcf7-form-control-wrap\" data-name=\"leaving2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"leaving2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Nature of Duties <span class=\"wpcf7-form-control-wrap\" data-name=\"duties2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"duties2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<table>\n\t<tbody>\n\t\t<h5><b> 2st Previous <\/b>\n\t\t<\/h5>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>From (MM\/YYYY): <span class=\"wpcf7-form-control-wrap\" data-name=\"start_Date3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start_Date3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>To (MM\/YYYY): <span class=\"wpcf7-form-control-wrap\" data-name=\"start_Date3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start_Date3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Company <span class=\"wpcf7-form-control-wrap\" data-name=\"company3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"company3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Phone No. <span class=\"wpcf7-form-control-wrap\" data-name=\"no3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"no3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Immediate Supervisor <span class=\"wpcf7-form-control-wrap\" data-name=\"supervisor3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"supervisor3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Salary ($): <span class=\"wpcf7-form-control-wrap\" data-name=\"salary3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"salary3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"add3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"add3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Name while employed <span class=\"wpcf7-form-control-wrap\" data-name=\"namewhile3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"namewhile3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>May we contact them? <span class=\"wpcf7-form-control-wrap\" data-name=\"contactthem3\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"contactthem3\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Job Title: <span class=\"wpcf7-form-control-wrap\" data-name=\"job_title3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"job_title3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Job Type <span class=\"wpcf7-form-control-wrap\" data-name=\"jobtype3\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"jobtype3\" value=\"PRN\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">PRN<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"jobtype3\" value=\"Full time\" \/><span class=\"wpcf7-list-item-label\">Full time<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"jobtype3\" value=\"Part time\" \/><span class=\"wpcf7-list-item-label\">Part time<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p># Hrs\/Week: <span class=\"wpcf7-form-control-wrap\" data-name=\"hours3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hours3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Reason For Leaving <span class=\"wpcf7-form-control-wrap\" data-name=\"leaving3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"leaving3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Nature of Duties <span class=\"wpcf7-form-control-wrap\" data-name=\"duties3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"duties3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<table>\n\t<tbody>\n\t\t<h5><b> 3rd Previous <\/b>\n\t\t<\/h5>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>From (MM\/YYYY): <span class=\"wpcf7-form-control-wrap\" data-name=\"start_Date4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start_Date4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>To (MM\/YYYY): <span class=\"wpcf7-form-control-wrap\" data-name=\"start_Date4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"start_Date4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Company <span class=\"wpcf7-form-control-wrap\" data-name=\"company4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"company4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Phone No. <span class=\"wpcf7-form-control-wrap\" data-name=\"no4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"no4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Immediate Supervisor <span class=\"wpcf7-form-control-wrap\" data-name=\"supervisor4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"supervisor4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Salary ($): <span class=\"wpcf7-form-control-wrap\" data-name=\"salary4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"salary4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Address: <span class=\"wpcf7-form-control-wrap\" data-name=\"add4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"add4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Name while employed <span class=\"wpcf7-form-control-wrap\" data-name=\"namewhile4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"namewhile4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>May we contact them? <span class=\"wpcf7-form-control-wrap\" data-name=\"contactthem4\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"contactthem4\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Job Title: <span class=\"wpcf7-form-control-wrap\" data-name=\"job_title4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"job_title4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Job Type <span class=\"wpcf7-form-control-wrap\" data-name=\"jobtype4\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"jobtype4\" value=\"PRN\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">PRN<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"jobtype4\" value=\"Full time\" \/><span class=\"wpcf7-list-item-label\">Full time<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"jobtype4\" value=\"Part time\" \/><span class=\"wpcf7-list-item-label\">Part time<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p># Hrs\/Week: <span class=\"wpcf7-form-control-wrap\" data-name=\"hours4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"hours4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Reason For Leaving <span class=\"wpcf7-form-control-wrap\" data-name=\"leaving4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"leaving4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Nature of Duties <span class=\"wpcf7-form-control-wrap\" data-name=\"duties4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"duties4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<table>\n\t<tbody>\n\t\t<h4><b> Professional References (Other than Relatives) Give references who have good knowledge of your work. <\/b>\n\t\t<\/h4>\n\t\t<tr>\n\t\t\t<th>\n\t\t\t\t<p>Name\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p>Position\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p>Address (Include City\/State)\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p>Phone - Work\/Home\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t\t<th>\n\t\t\t\t<p>Number of Years known\n\t\t\t\t<\/p>\n\t\t\t<\/th>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"name_pos\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"name_pos\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"position\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"position\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"phone-work\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"phone-work\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"years\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"years\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"name_pos2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"name_pos2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"position2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"position2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"phone-work2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"phone-work2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"years2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"years2\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"name_pos3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"name_pos3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"position3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"position3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"phone-work3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"phone-work3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"years3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"years3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"name_pos4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"name_pos4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"position4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"position4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"address4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"address4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"phone-work4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"phone-work4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"years4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"years4\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t<\/tbody>\n<\/table>\n<p>Please Review and Acknowledge That You Understand The Following.<br \/>\nIn making application for employment:<br \/>\n* I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.<br \/>\n* I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such a report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.\n<\/p>\n<p>I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES.<br \/>\n* I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis or blood test, when requested to do so, may result in termination of my employment.<br \/>\n* Compliance with this facility's Substance Abuse Policy is a condition of employment. This hospital requires that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test\/screen for alcohol and drugs in accordance with hospital policy. Continued employment is also contingent upon compliance with the hospital's Alcohol and Drug Abuse Policy.<br \/>\n*I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.<br \/>\nRelease:<br \/>\nI hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar\/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.\n<\/p>\n<p>I agree that I will settle any and all claims, disputes or controversies arising out of or relating to my application for employment, employment or termination of employment with the employer exclusively by final and binding arbitration and before a neutral Arbitrator and in accordance with the rules and procedures for employment disputes adopted by the employer. Such claims shall include those that could be brought in a court of law under any applicable federal, state or local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Family and Medical Leave Act, state civil rights acts, the law of contract and the law of tort.\n<\/p>\n<table>\n\t<body>\n\t\t<td>\n\t\t\t<p>I have read and understand these conditions of employment.<span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-979\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-979[]\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>Applicant's full name <span class=\"wpcf7-form-control-wrap\" data-name=\"namefull\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"namefull\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p>Date prepared <span class=\"wpcf7-form-control-wrap\" data-name=\"dateprepared\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dateprepared\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/td>\n\t<\/body>\n<\/table>\n<h4><b>Acknowledgement and Authorization<\/b>\n<\/h4>\n<table>\n\t<body>\n\t\t<h5><b> In considering your application for employment, the facility may conduct a detailed and thorough investigation, which may include but is not limited to criminal record check, interviews, or inquiries of prior employers, coworkers, acquaintances, relatives, or friends. <\/b>\n\t\t<\/h5>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Last Name <span class=\"wpcf7-form-control-wrap\" data-name=\"lastname6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"lastname6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>First <span class=\"wpcf7-form-control-wrap\" data-name=\"firstname6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"firstname6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Last 4 Digits of Social Security Number <span class=\"wpcf7-form-control-wrap\" data-name=\"lastSSN\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"lastSSN\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Maiden And\/Or Other Name(s) Used <span class=\"wpcf7-form-control-wrap\" data-name=\"maidenName\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"maidenName\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>Last 4 Digits of Driver's License<span class=\"wpcf7-form-control-wrap\" data-name=\"digitsDriverLicense\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"digitsDriverLicense\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Sex <span class=\"wpcf7-form-control-wrap\" data-name=\"sex6\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"sex6\"><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Current Address(street) <span class=\"wpcf7-form-control-wrap\" data-name=\"currentAddress6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"currentAddress6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>State <span class=\"wpcf7-form-control-wrap\" data-name=\"state6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>City <span class=\"wpcf7-form-control-wrap\" data-name=\"city6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"city6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>State <span class=\"wpcf7-form-control-wrap\" data-name=\"state6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"state6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Zip <span class=\"wpcf7-form-control-wrap\" data-name=\"zip6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zip6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>County <span class=\"wpcf7-form-control-wrap\" data-name=\"county6\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"county6\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td>\n\t\t\t\t<p>I understand that by checking the following box and typing my name into the name field above, this document is as valid as if I have signed it. <span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox-979\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"checkbox-979[]\" value=\"I agree\" \/><span class=\"wpcf7-list-item-label\">I agree<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t\t<td>\n\t\t\t\t<p>Applicant's full name <span class=\"wpcf7-form-control-wrap\" data-name=\"namefull3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"namefull3\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<h4><b>Application Addendum<\/b>\n\t\t<\/h4>\n\t\t<table>\n\t\t\t<body>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>\n\t\t\t\t\t\t<p>1. Have you ever been convicted of a crime, had adjudication of a crime withheld, or pled nolo contendere to a crime? <span class=\"wpcf7-form-control-wrap\" data-name=\"yesno\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"yesno\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/td>\n\t\t\t\t\t<td>\n\t\t\t\t\t\t<p>If yes, please state the circumstances with regard to each.<span class=\"wpcf7-form-control-wrap\" data-name=\"circumstances\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"circumstances\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/td>\n\t\t\t\t<\/tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>\n\t\t\t\t\t\t<p>2. Have you been arrested for any crime that had not been adjudicated?<span class=\"wpcf7-form-control-wrap\" data-name=\"yesno2\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"yesno2\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/td>\n\t\t\t\t\t<td>\n\t\t\t\t\t\t<p>If yes, please state the circumstances and current status of each arrest. <span class=\"wpcf7-form-control-wrap\" data-name=\"circumstances2\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"circumstances2\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/td>\n\t\t\t\t<\/tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>\n\t\t\t\t\t\t<p>3. Have you ever committed a crime for which you were not arrested or convicted? <span class=\"wpcf7-form-control-wrap\" data-name=\"yesno3\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"yesno3\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/td>\n\t\t\t\t\t<td>\n\t\t\t\t\t\t<p>If yes, please state the circumstances.<span class=\"wpcf7-form-control-wrap\" data-name=\"circumstances3\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"circumstances3\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/td>\n\t\t\t\t<\/tr>\n\t\t\t\t<tr>\n\t\t\t\t\t<td>\n\t\t\t\t\t\t<p>4. Have you ever been a defendant in a civil action for intentional tort? Intentional tort commonly refers to examples, such as assault, battery, and false imprisonment:<span class=\"wpcf7-form-control-wrap\" data-name=\"yesno4\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"yesno4\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/td>\n\t\t\t\t\t<td>\n\t\t\t\t\t\t<p>If yes, please state the circumstances.<span class=\"wpcf7-form-control-wrap\" data-name=\"circumstances4\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"circumstances4\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/td>\n\t\t\t\t<\/tr>\n\t\t\t<\/body>\n\t\t<\/table>\n\t\t<p><label> Your message (optional)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-message\"><textarea cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"your-message\"><\/textarea><\/span> <\/label>\n\t\t<\/p>\n\t\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t\t<\/p>\n\t<\/body>\n<\/table><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-size:1px;--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<\/form>\n<\/div>\n\n<\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","footnotes":""},"_links":{"self":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/5751"}],"collection":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/comments?post=5751"}],"version-history":[{"count":1,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/5751\/revisions"}],"predecessor-version":[{"id":5752,"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/pages\/5751\/revisions\/5752"}],"wp:attachment":[{"href":"\/\/www.abcchristmas.com\/wp-json\/wp\/v2\/media?parent=5751"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}