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1. Employee name:

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2. Name of your organization:

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3. Name of person completing this form:

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5. Phone number of person completing this form:

Employee information

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6. Is this person currently employed at your organization?

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7. Employment start date:

Date

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8. Employment end date (if not currently employed):

Date

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9. Job title:

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10. Is this person eligible for rehire?

T