Transitions LifeCare – EmailMeForm – Vol App

EmailMeForm – Vol App

 

<meta http-equiv="Content-Type" content="text/html; charset=utf-8" /><form id="emf-form" target="_self" enctype="multipart/form-data" method="post" action="http://www.emailmeform.com/builder/form/538j811e4gtLc7p">
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<font face="Verdana" size="2" color="#000000"><b style="font-size:20px;">Application for Volunteer Position</b><br /><label style="font-size:15px;">Transitions LifeCare does not discriminate in their selection of volunteers, hiring or employment on the basis of race, color, sex, disability, national origin, citizenship or on the basis of age with respect to persons 18 years or older. No question on this application is intended to secure information to be used for such discrimination. TL will hold you responsible for the accuracy of the statements you make on this application. Incomplete applications will not be considered. Applicants may attach an up-to-date resume to this application. Information requested on this application that is not included in the resume must be completed.<br /></label><br /></font>
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</tr><tr valign="top" ><td id="td_element_label_0" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Name</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_0" style=""><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_1" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Prefix</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_1" style=""><input id="element_1" name="element_1" value="" size="30"
class="validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_2" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>First</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_2" style=""><input id="element_2" name="element_2" value="" size="30"
class="validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_3" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Last</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_3" style=""><input id="element_3" name="element_3" value="" size="30"
class="validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_4" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Suffix</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_4" style=""><input id="element_4" name="element_4" value="" size="30"
class="validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_5" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Address</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_5" style=""><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_6" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Street Address</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_6" style=""><input id="element_6" name="element_6" value="" size="30"
class="validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_7" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Address Line 2</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_7" style=""><input id="element_7" name="element_7" value="" size="30"
class="validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_8" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>City</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_8" style=""><input id="element_8" name="element_8" value="" size="30"
class="validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_9" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>State / Province / Region</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_9" style=""><input id="element_9" name="element_9" value="" size="30"
class="validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_10" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Postal / Zip Code</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_10" style=""><input id="element_10" name="element_10" value="" size="30"
class="validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_11" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Country</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_11" style=""><input id="element_11" name="element_11" value="" size="30"
class="validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_12" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Years at current address</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_12" style=""><input id="element_12" name="element_12" value="" size="30"
class="validate[required]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_13" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Phone (home or cell)</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_13" style=""><table cellpadding='0' cellspacing='0' border='0'><tr><td style='padding-left:0px;'><input maxlength='3' style='width:30px;' value='' id='element_13_1' name='element_13[]' type='text' class='validate[required,custom[onlyNumber],length[3,3]]' /><br /><font face="Verdana" size="2" color="#000000">###</font></td><td style='padding-top:5px;padding-left:3px;' valign='top'><font face="Verdana" size="2" color="#000000">-</font></td><td style='padding-left:3px;'><input maxlength='3' style='width:30px;' value='' id='element_13_2' name='element_13[]' type='text' class='validate[required,custom[onlyNumber],length[3,3]]' /><br /><font face="Verdana" size="2" color="#000000">###</font></td><td style='padding-top:5px;padding-left:3px;' valign='top'><font face="Verdana" size="2" color="#000000">-</font></td><td style='padding-left:3px;'><input maxlength='4' style='width:40px;' value='' id='element_13_3' name='element_13[]' type='text' class='validate[required,custom[onlyNumber],length[4,4]]' /><br /><font face="Verdana" size="2" color="#000000">####</font></td></tr></table><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_14" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Phone (work or cell)</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_14" style=""><table cellpadding='0' cellspacing='0' border='0'><tr><td style='padding-left:0px;'><input maxlength='3' style='width:30px;' value='' id='element_14_1' name='element_14[]' type='text' class='validate[optional,custom[onlyNumber],length[3,3]]' /><br /><font face="Verdana" size="2" color="#000000">###</font></td><td style='padding-top:5px;padding-left:3px;' valign='top'><font face="Verdana" size="2" color="#000000">-</font></td><td style='padding-left:3px;'><input maxlength='3' style='width:30px;' value='' id='element_14_2' name='element_14[]' type='text' class='validate[optional,custom[onlyNumber],length[3,3]]' /><br /><font face="Verdana" size="2" color="#000000">###</font></td><td style='padding-top:5px;padding-left:3px;' valign='top'><font face="Verdana" size="2" color="#000000">-</font></td><td style='padding-left:3px;'><input maxlength='4' style='width:40px;' value='' id='element_14_3' name='element_14[]' type='text' class='validate[optional,custom[onlyNumber],length[4,4]]' /><br /><font face="Verdana" size="2" color="#000000">####</font></td></tr></table><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_15" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>May we call you at work?</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_15" style=""><div style="width:100%;padding-bottom:5px;"><input id="element_15_0" name="element_15" value="Yes" class="validate[optional]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;Yes&nbsp;</font></div><div style="width:100%;padding-bottom:5px;"><input id="element_15_1" name="element_15" value="No" class="validate[optional]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;No&nbsp;</font></div><div style="clear:both;"></div><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_16" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Email</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_16" style=""><input id="element_16" name="element_16"
class="validate[required,custom[email]]"
value="" size="30" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_17" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Are you 18 years or older?</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_17" style=""><div style="width:100%;padding-bottom:5px;"><input id="element_17_0" name="element_17" value="Yes" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;Yes&nbsp;</font></div><div style="width:100%;padding-bottom:5px;"><input id="element_17_1" name="element_17" value="No" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;No&nbsp;</font></div><div style="clear:both;"></div><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
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</tr><tr valign="top" ><td id="td_element_label_18" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>How did you learn about volunteer opportunities at Transitions LifeCare?</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_18" style=""><textarea id="element_18" name="element_18" cols="45" rows="1"
class="validate[required] "></textarea><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_19" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>What volunteer opportunities are you interested in?</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_19" style=""><textarea id="element_19" name="element_19" cols="45" rows="1"
class="validate[required] "></textarea><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_20" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Do you have skills or experience that support your interest in the above area(s)?</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_20" style=""><input id="element_20" name="element_20" value="" size="30"
class="validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_21" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>What days and times are you available to volunteer?</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_21" style=""><input id="element_21" name="element_21" value="" size="30"
class="validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_22" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Have you been impacted by a personal loss in the past 12 months?</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_22" style=""><div style="width:100%;padding-bottom:5px;"><input id="element_22_0" name="element_22" value="yes" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;yes&nbsp;</font></div><div style="width:100%;padding-bottom:5px;"><input id="element_22_1" name="element_22" value="no" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;no&nbsp;</font></div><div style="clear:both;"></div><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_23" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Educational data (check highest grade completed)</b></font>
<span style="color:red;"><small>*</small></span>
</td><td id="td_element_field_23" style=""><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_0" name="element_23" value="grade 1" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 1&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_1" name="element_23" value="grade 8" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 8&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_2" name="element_23" value="college 3" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;college 3&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_3" name="element_23" value="grade 2" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 2&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_4" name="element_23" value="grade 9" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 9&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_5" name="element_23" value="college 4" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;college 4&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_6" name="element_23" value="grade 3" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 3&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_7" name="element_23" value="grade 10" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 10&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_8" name="element_23" value="graduate 1" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;graduate 1&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_9" name="element_23" value="grade 4" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 4&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_10" name="element_23" value="grade 11" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 11&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_11" name="element_23" value="graduate 2" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;graduate 2&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_12" name="element_23" value="grade 5" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 5&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_13" name="element_23" value="grade 12" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 12&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_14" name="element_23" value="graduate 3" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;graduate 3&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_15" name="element_23" value="grade 6" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 6&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_16" name="element_23" value="college 1" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;college 1&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_17" name="element_23" value="graduate 4" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;graduate 4&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_18" name="element_23" value="grade 7" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;grade 7&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_23_19" name="element_23" value="college 2" class="validate[required]" type="radio" /><font face="Verdana" size="2" color="#000000">&nbsp;college 2&nbsp;</font></div><div style="clear:both;"></div><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_24" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Special skills (check all that apply)</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_24" style=""><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_0" name="element_24[]" value="computer"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;computer&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_1" name="element_24[]" value="music"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;music&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_2" name="element_24[]" value="art"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;art&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_3" name="element_24[]" value="massage therapy"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;massage therapy&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_4" name="element_24[]" value="writing"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;writing&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_5" name="element_24[]" value="administrative"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;administrative&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_6" name="element_24[]" value="pet therapy"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;pet therapy&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_7" name="element_24[]" value="fundraising"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;fundraising&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_8" name="element_24[]" value="public speaking"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;public speaking&nbsp;</font></div><div style="float:left;width:33%;padding-bottom:5px;"><input id="element_24_9" name="element_24[]" value="other"
class="validate[optional]" type="checkbox" /><font face="Verdana" size="2" color="#000000">&nbsp;other&nbsp;</font></div><div style="clear:both;"></div><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_25" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Please list languages you speak fluently</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_25" style=""><input id="element_25" name="element_25" value="" size="30"
class="validate[optional]" type="text" /><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_26" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Employment/volunteer history, most recent first</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_26" style=""><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_27" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Agency/Employer (include position and years of employment)</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_27" style=""><textarea id="element_27" name="element_27" cols="30" rows="5"
class="validate[optional] "></textarea><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_28" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Agency/Employer (include position and years of employment)</b></font>
<span style="color:red;"><small></small></span>
</td><td id="td_element_field_28" style=""><textarea id="element_28" name="element_28" cols="30" rows="5"
class="validate[optional] "></textarea><div style="padding-bottom:8px;color:#000000;"><small><font face="Verdana"></font></small></div>
</td>
</tr><tr valign="top" ><td id="td_element_label_29" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Agency/Employer (include position and years of employment)</b></font>
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</tr><tr valign="top" ><td id="td_element_label_30" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Community recommendations (reference forms will be sent to the names provided. Please provide either a mailing address or an email address for each reference.)</b></font>
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</tr><tr valign="top" ><td id="td_element_label_31" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Name, Mailing or Email address, Phone</b></font>
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</td><td id="td_element_field_31" style=""><textarea id="element_31" name="element_31" cols="30" rows="5"
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</tr><tr valign="top" ><td id="td_element_label_32" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Name, Mailing or Email address, Phone</b></font>
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</tr><tr valign="top" ><td id="td_element_label_33" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>Name, Mailing or Email address, Phone</b></font>
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</td><td id="td_element_field_33" style=""><textarea id="element_33" name="element_33" cols="30" rows="5"
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</td>
</tr><tr valign="top" ><td id="td_element_label_34" style="" align="left"><font face="Verdana" size="2" color="#000000"><b>I certify that the answers given herein are true and complete to the best of my knowledge (type name and date in box).</b></font>
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