{"id":12,"date":"2026-07-16T04:38:59","date_gmt":"2026-07-16T04:38:59","guid":{"rendered":"https:\/\/privatecareathome.com\/forms\/?page_id=12"},"modified":"2026-07-16T06:45:45","modified_gmt":"2026-07-16T06:45:45","slug":"career","status":"publish","type":"page","link":"https:\/\/privatecareathome.com\/forms\/career\/","title":{"rendered":"career"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"12\" class=\"elementor elementor-12\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e2d7436 e-con e-atomic-element e-flexbox-base e-d52f46e \" data-id=\"e2d7436\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"e2d7436\">\n    <div class=\"elementor-element elementor-element-5e76863 e-con e-atomic-element e-flexbox-base e-7b9b73d \" data-id=\"5e76863\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"5e76863\">\n    \t\t<div class=\"elementor-element elementor-element-1c55fc7 elementor-widget elementor-widget-image\" data-id=\"1c55fc7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"1024\" height=\"295\" src=\"https:\/\/privatecareathome.com\/forms\/wp-content\/uploads\/2026\/07\/Private_Care_at_home_logo-01-1024x295.png\" class=\"attachment-large size-large wp-image-48\" alt=\"\" srcset=\"https:\/\/privatecareathome.com\/forms\/wp-content\/uploads\/2026\/07\/Private_Care_at_home_logo-01-1024x295.png 1024w, https:\/\/privatecareathome.com\/forms\/wp-content\/uploads\/2026\/07\/Private_Care_at_home_logo-01-300x86.png 300w, https:\/\/privatecareathome.com\/forms\/wp-content\/uploads\/2026\/07\/Private_Care_at_home_logo-01-768x221.png 768w, https:\/\/privatecareathome.com\/forms\/wp-content\/uploads\/2026\/07\/Private_Care_at_home_logo-01-1536x442.png 1536w, https:\/\/privatecareathome.com\/forms\/wp-content\/uploads\/2026\/07\/Private_Care_at_home_logo-01-2048x590.png 2048w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\n<\/div>\n<div class=\"elementor-element elementor-element-fe833cc e-con e-atomic-element e-flexbox-base e-9aa0661 \" data-id=\"fe833cc\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"fe833cc\">\n    \t\t<div class=\"elementor-element elementor-element-a7e7df5 elementor-icon-list--layout-inline elementor-align-center elementor-widget__width-initial elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"a7e7df5\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items elementor-inline-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/privatecareathome.com\/index.php\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Home<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/privatecareathome.com\/index.php#about\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">About<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/privatecareathome.com\/services.php\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Services<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/privatecareathome.com\/mission.php\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Mission &amp; Values<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item elementor-inline-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/privatecareathome.com\/contact.php\">\n\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">Contact Us<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\n<\/div>\n<div class=\"elementor-element elementor-element-38f6350 e-con e-atomic-element e-flexbox-base e-ad5924d \" data-id=\"38f6350\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"38f6350\">\n    \t\t<div class=\"elementor-element elementor-element-aa24ef9 elementor-widget elementor-widget-button\" data-id=\"aa24ef9\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/privatecareathome.com\/contact.php\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Book an Appointment<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\n<\/div>\n\n<\/div>\n<div class=\"elementor-element elementor-element-3575bf4 e-con e-atomic-element e-flexbox-base e-3575bf4-b91ead0 \" data-id=\"3575bf4\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"3575bf4\">\n    <div class=\"elementor-element elementor-element-721ac42 e-con e-atomic-element e-flexbox-base e-721ac42-24e9d85 \" data-id=\"721ac42\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"721ac42\">\n    \n<\/div>\n<div class=\"elementor-element elementor-element-df347dc e-con e-atomic-element e-flexbox-base e-df347dc-3a668e5 \" data-id=\"df347dc\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"df347dc\">\n    \t\t<div class=\"elementor-element elementor-element-92a0767 elementor-widget elementor-widget-shortcode\" data-id=\"92a0767\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-10 forminator-design--material  forminator_ajax draft-enabled\" data-forminator-render=\"0\" data-form=\"forminator-module-10\" data-uid=\"6a594eb7394bc\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-10\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-10 forminator-design--material  forminator_ajax draft-enabled\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"10\"\r\n\t\t\t\tenctype=\"multipart\/form-data\" data-color-option=\"theme\" data-design=\"material\" data-grid=\"open\" style=\"display: none;\"\r\n\t\t\t\tdata-uid=\"6a594eb7394bc\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div role=\"tablist\" class=\"forminator-pagination-steps\" aria-label=\"Pagination\"><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-10--page-0\"\r\n\t\t\t\tclass=\"forminator-pagination forminator-pagination-start\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-10--page-0-label\"\r\n\t\t\t\tdata-step=\"0\"\r\n\t\t\t\tdata-label=\"Finish\"\r\n\t\t\t\tdata-actual-label=\"Page 1\"\r\n\t\t\t\tdata-name=\"page-break-5\"\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-10__field--name-1_6a594eb7394bc\" id=\"forminator-field-10__field--name-1_6a594eb7394bc-label\" class=\"forminator-label\">Prefix<\/label><select name=\"name-1-prefix\" id=\"forminator-field-10__field--name-1_6a594eb7394bc\" class=\"forminator-select2\" data-multi=\"1\" autocomplete=\"honorific-prefix\" aria-labelledby=\"forminator-field-10__field--name-1_6a594eb7394bc-label\" data-default-value=\"\"><option value=\"Mr\" >Mr.<\/option><option value=\"Mrs\" >Mrs.<\/option><option value=\"Ms\" >Ms.<\/option><option value=\"Mx\" >Mx.<\/option><option value=\"Miss\" >Miss<\/option><option value=\"Dr\" >Dr.<\/option><option value=\"Prof\" >Prof.<\/option><\/select><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_6a594eb7394bc\" id=\"forminator-field-first-name-1_6a594eb7394bc-label\" class=\"forminator-label\">First Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"\" id=\"forminator-field-first-name-1_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-middle-name-1_6a594eb7394bc\" id=\"forminator-field-middle-name-1_6a594eb7394bc-label\" class=\"forminator-label\">Middle Name<\/label><input type=\"text\" name=\"name-1-middle-name\" placeholder=\"\" id=\"forminator-field-middle-name-1_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"additional-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_6a594eb7394bc\" id=\"forminator-field-last-name-1_6a594eb7394bc-label\" class=\"forminator-label\">Last Name <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"\" id=\"forminator-field-last-name-1_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_6a594eb7394bc\" id=\"forminator-field-phone-1_6a594eb7394bc-label\" class=\"forminator-label\">Phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_6a594eb7394bc\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_6a594eb7394bc\" id=\"forminator-field-email-1_6a594eb7394bc-label\" class=\"forminator-label\">Email Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_6a594eb7394bc\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" autocomplete=\"email\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_6a594eb7394bc\" id=\"forminator-field-address-1-street_address_6a594eb7394bc-label\" class=\"forminator-label\">Street Address <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_6a594eb7394bc\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_6a594eb7394bc\" id=\"forminator-field-address-1-address_line_6a594eb7394bc-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_6a594eb7394bc\" id=\"forminator-field-address-1-city_6a594eb7394bc-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-1-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-state_6a594eb7394bc\" id=\"forminator-field-address-1-state_6a594eb7394bc-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-1-state\" placeholder=\"\" id=\"forminator-field-address-1-state_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_6a594eb7394bc\" id=\"forminator-field-address-1-zip_6a594eb7394bc-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_6a594eb7394bc\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_6a594eb7394bc\" id=\"forminator-field-date-1-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date of Birth <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"1\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_6a594eb7394bc\" id=\"forminator-field-text-2_6a594eb7394bc-label\" class=\"forminator-label\">Social Security <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">EDUCATION<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">High School:<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_6a594eb7394bc\" id=\"forminator-field-text-1_6a594eb7394bc-label\" class=\"forminator-label\">Name &amp; Location of School:<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_6a594eb7394bc\" id=\"forminator-field-date-2-picker_6a594eb7394bc-label\" class=\"forminator-label\">Years Attended:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_6a594eb7394bc\" id=\"forminator-field-date-3-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date Graduated Grade:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-3-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-4 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-1-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-1-6a594eb7394bc-label\" class=\"forminator-label\">Complete (Diploma\/Degree)<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><label class=\"forminator-label\">University \/ College Undergraduate<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_6a594eb7394bc\" id=\"forminator-field-text-3_6a594eb7394bc-label\" class=\"forminator-label\">Name &amp; Location of School:<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_6a594eb7394bc\" id=\"forminator-field-date-4-picker_6a594eb7394bc-label\" class=\"forminator-label\">Years Attended:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-4-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-picker_6a594eb7394bc\" id=\"forminator-field-date-5-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date Graduated Grade:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-5\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-5-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-4 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-2-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-2-6a594eb7394bc-label\" class=\"forminator-label\">Complete (Diploma\/Degree)<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><label class=\"forminator-label\">University \/ College Graduate<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-6\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-picker_6a594eb7394bc\" id=\"forminator-field-date-6-picker_6a594eb7394bc-label\" class=\"forminator-label\">Years Attended:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-6\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-6-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-7\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-7-picker_6a594eb7394bc\" id=\"forminator-field-date-7-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date Graduated Grade:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-7\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-7-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-4 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-3-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-3-6a594eb7394bc-label\" class=\"forminator-label\">Complete (Diploma\/Degree)<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-4\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-4\"><label class=\"forminator-label\">Trade, Business, or Correspondence School<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-8\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-8-picker_6a594eb7394bc\" id=\"forminator-field-date-8-picker_6a594eb7394bc-label\" class=\"forminator-label\">Years Attended:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-8\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-8-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-9\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-9-picker_6a594eb7394bc\" id=\"forminator-field-date-9-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date Graduated Grade:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-9\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-9-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-4 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-4-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-4-6a594eb7394bc-label\" class=\"forminator-label\">Complete (Diploma\/Degree)<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_6a594eb7394bc\" id=\"forminator-field-upload-1_6a594eb7394bc-label\" class=\"forminator-label\">Please upload your resume <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_6a594eb7394bc\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_6a594eb7394bc\" class=\"forminator-input-file-required do-validate\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.x-wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\" tabindex=\"-1\"><button id=\"forminator-field-upload-1_6a594eb7394bc_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_6a594eb7394bc\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-10--page-1\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-10--page-1-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"1\"\r\n\t\t\t\tdata-label=\"Page  1\"\r\n\t\t\t\tdata-actual-label=\"Page 2\"\r\n\t\t\t\tdata-name=\"page-break-6\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">EMPLOYMENT HISTORY<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-1\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_6a594eb7394bc\" id=\"forminator-field-text-4_6a594eb7394bc-label\" class=\"forminator-label\">Employer:<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_6a594eb7394bc\" id=\"forminator-field-text-5_6a594eb7394bc-label\" class=\"forminator-label\">Job Title:<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_6a594eb7394bc\" id=\"forminator-field-text-7_6a594eb7394bc-label\" class=\"forminator-label\">Address:<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_6a594eb7394bc\" id=\"forminator-field-text-6_6a594eb7394bc-label\" class=\"forminator-label\">Duties:<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_6a594eb7394bc\" id=\"forminator-field-phone-2_6a594eb7394bc-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-2_6a594eb7394bc\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_6a594eb7394bc\" id=\"forminator-field-text-8_6a594eb7394bc-label\" class=\"forminator-label\">Duties:<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"\" id=\"forminator-field-text-8_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-5-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-5-6a594eb7394bc-label\" class=\"forminator-label\">Are You Currently Employed:<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"date-10\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-10-picker_6a594eb7394bc\" id=\"forminator-field-date-10-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date To:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-10\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-10-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_6a594eb7394bc\" id=\"forminator-field-textarea-1_6a594eb7394bc-label\" class=\"forminator-label\">Reason for Leaving:<\/label><textarea name=\"textarea-1\" placeholder=\"\" id=\"forminator-field-textarea-1_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px solid #aaaaaa;\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-2\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"text-12\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-12_6a594eb7394bc\" id=\"forminator-field-text-12_6a594eb7394bc-label\" class=\"forminator-label\">Employer:<\/label><input type=\"text\" name=\"text-12\" value=\"\" placeholder=\"\" id=\"forminator-field-text-12_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-13\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-13_6a594eb7394bc\" id=\"forminator-field-text-13_6a594eb7394bc-label\" class=\"forminator-label\">Job Title:<\/label><input type=\"text\" name=\"text-13\" value=\"\" placeholder=\"\" id=\"forminator-field-text-13_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-10\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-10_6a594eb7394bc\" id=\"forminator-field-text-10_6a594eb7394bc-label\" class=\"forminator-label\">Address:<\/label><input type=\"text\" name=\"text-10\" value=\"\" placeholder=\"\" id=\"forminator-field-text-10_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-11\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-11_6a594eb7394bc\" id=\"forminator-field-text-11_6a594eb7394bc-label\" class=\"forminator-label\">Duties:<\/label><input type=\"text\" name=\"text-11\" value=\"\" placeholder=\"\" id=\"forminator-field-text-11_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-3\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-3_6a594eb7394bc\" id=\"forminator-field-phone-3_6a594eb7394bc-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-3\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-3_6a594eb7394bc\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_6a594eb7394bc\" id=\"forminator-field-text-9_6a594eb7394bc-label\" class=\"forminator-label\">Duties:<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"\" id=\"forminator-field-text-9_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-6-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-6-6a594eb7394bc-label\" class=\"forminator-label\">Are You Currently Employed:<\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"date-11\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-11-picker_6a594eb7394bc\" id=\"forminator-field-date-11-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date To:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-11\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-11-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_6a594eb7394bc\" id=\"forminator-field-textarea-2_6a594eb7394bc-label\" class=\"forminator-label\">Reason for Leaving:<\/label><textarea name=\"textarea-2\" placeholder=\"\" id=\"forminator-field-textarea-2_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px solid #aaaaaa;\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-3\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"text-17\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-17_6a594eb7394bc\" id=\"forminator-field-text-17_6a594eb7394bc-label\" class=\"forminator-label\">Employer:<\/label><input type=\"text\" name=\"text-17\" value=\"\" placeholder=\"\" id=\"forminator-field-text-17_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-18\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-18_6a594eb7394bc\" id=\"forminator-field-text-18_6a594eb7394bc-label\" class=\"forminator-label\">Job Title:<\/label><input type=\"text\" name=\"text-18\" value=\"\" placeholder=\"\" id=\"forminator-field-text-18_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-15\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-15_6a594eb7394bc\" id=\"forminator-field-text-15_6a594eb7394bc-label\" class=\"forminator-label\">Address:<\/label><input type=\"text\" name=\"text-15\" value=\"\" placeholder=\"\" id=\"forminator-field-text-15_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-16\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-16_6a594eb7394bc\" id=\"forminator-field-text-16_6a594eb7394bc-label\" class=\"forminator-label\">Duties:<\/label><input type=\"text\" name=\"text-16\" value=\"\" placeholder=\"\" id=\"forminator-field-text-16_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-4\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-4_6a594eb7394bc\" id=\"forminator-field-phone-4_6a594eb7394bc-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-4\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-4_6a594eb7394bc\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-14\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-14_6a594eb7394bc\" id=\"forminator-field-text-14_6a594eb7394bc-label\" class=\"forminator-label\">Duties:<\/label><input type=\"text\" name=\"text-14\" value=\"\" placeholder=\"\" id=\"forminator-field-text-14_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-7\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-7-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-7-6a594eb7394bc-label\" class=\"forminator-label\">Are You Currently Employed:<\/span><label id=\"forminator-field-radio-7-label-1\" for=\"forminator-field-radio-7-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-7\" value=\"one\" id=\"forminator-field-radio-7-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-7-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-7-label-2\" for=\"forminator-field-radio-7-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-7\" value=\"two\" id=\"forminator-field-radio-7-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-7-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"date-12\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-12-picker_6a594eb7394bc\" id=\"forminator-field-date-12-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date To:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-12\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-12-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_6a594eb7394bc\" id=\"forminator-field-textarea-3_6a594eb7394bc-label\" class=\"forminator-label\">Reason for Leaving:<\/label><textarea name=\"textarea-3\" placeholder=\"\" id=\"forminator-field-textarea-3_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px solid #aaaaaa;\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-10--page-2\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-10--page-2-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"2\"\r\n\t\t\t\tdata-label=\"Page  2\"\r\n\t\t\t\tdata-actual-label=\"Page 3\"\r\n\t\t\t\tdata-name=\"page-break-7\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">REFERENCES<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-4\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-2_6a594eb7394bc\" id=\"forminator-field-first-name-2_6a594eb7394bc-label\" class=\"forminator-label\">First Name<\/label><input type=\"text\" name=\"name-2-first-name\" placeholder=\"\" id=\"forminator-field-first-name-2_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-2_6a594eb7394bc\" id=\"forminator-field-last-name-2_6a594eb7394bc-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-2-last-name\" placeholder=\"\" id=\"forminator-field-last-name-2_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"text-19\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-19_6a594eb7394bc\" id=\"forminator-field-text-19_6a594eb7394bc-label\" class=\"forminator-label\">Occupation:<\/label><input type=\"text\" name=\"text-19\" value=\"\" placeholder=\"\" id=\"forminator-field-text-19_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-20\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-20_6a594eb7394bc\" id=\"forminator-field-text-20_6a594eb7394bc-label\" class=\"forminator-label\">Address:<\/label><input type=\"text\" name=\"text-20\" value=\"\" placeholder=\"\" id=\"forminator-field-text-20_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-21\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-21_6a594eb7394bc\" id=\"forminator-field-text-21_6a594eb7394bc-label\" class=\"forminator-label\">Relationship:<\/label><input type=\"text\" name=\"text-21\" value=\"\" placeholder=\"\" id=\"forminator-field-text-21_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-5\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-5_6a594eb7394bc\" id=\"forminator-field-phone-5_6a594eb7394bc-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-5\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-5_6a594eb7394bc\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-22\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-22_6a594eb7394bc\" id=\"forminator-field-text-22_6a594eb7394bc-label\" class=\"forminator-label\">Years Known:<\/label><input type=\"text\" name=\"text-22\" value=\"\" placeholder=\"\" id=\"forminator-field-text-22_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-6\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-4_6a594eb7394bc\" id=\"forminator-field-first-name-4_6a594eb7394bc-label\" class=\"forminator-label\">First Name<\/label><input type=\"text\" name=\"name-4-first-name\" placeholder=\"\" id=\"forminator-field-first-name-4_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-4_6a594eb7394bc\" id=\"forminator-field-last-name-4_6a594eb7394bc-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-4-last-name\" placeholder=\"\" id=\"forminator-field-last-name-4_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"text-30\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-30_6a594eb7394bc\" id=\"forminator-field-text-30_6a594eb7394bc-label\" class=\"forminator-label\">Occupation:<\/label><input type=\"text\" name=\"text-30\" value=\"\" placeholder=\"\" id=\"forminator-field-text-30_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-28\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-28_6a594eb7394bc\" id=\"forminator-field-text-28_6a594eb7394bc-label\" class=\"forminator-label\">Address:<\/label><input type=\"text\" name=\"text-28\" value=\"\" placeholder=\"\" id=\"forminator-field-text-28_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-29\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-29_6a594eb7394bc\" id=\"forminator-field-text-29_6a594eb7394bc-label\" class=\"forminator-label\">Relationship:<\/label><input type=\"text\" name=\"text-29\" value=\"\" placeholder=\"\" id=\"forminator-field-text-29_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-7\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-7_6a594eb7394bc\" id=\"forminator-field-phone-7_6a594eb7394bc-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-7\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-7_6a594eb7394bc\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-27\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-27_6a594eb7394bc\" id=\"forminator-field-text-27_6a594eb7394bc-label\" class=\"forminator-label\">Years Known:<\/label><input type=\"text\" name=\"text-27\" value=\"\" placeholder=\"\" id=\"forminator-field-text-27_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-5\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-3_6a594eb7394bc\" id=\"forminator-field-first-name-3_6a594eb7394bc-label\" class=\"forminator-label\">First Name<\/label><input type=\"text\" name=\"name-3-first-name\" placeholder=\"\" id=\"forminator-field-first-name-3_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-3_6a594eb7394bc\" id=\"forminator-field-last-name-3_6a594eb7394bc-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-3-last-name\" placeholder=\"\" id=\"forminator-field-last-name-3_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"text-26\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-26_6a594eb7394bc\" id=\"forminator-field-text-26_6a594eb7394bc-label\" class=\"forminator-label\">Occupation:<\/label><input type=\"text\" name=\"text-26\" value=\"\" placeholder=\"\" id=\"forminator-field-text-26_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-24\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-24_6a594eb7394bc\" id=\"forminator-field-text-24_6a594eb7394bc-label\" class=\"forminator-label\">Address:<\/label><input type=\"text\" name=\"text-24\" value=\"\" placeholder=\"\" id=\"forminator-field-text-24_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-25\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-25_6a594eb7394bc\" id=\"forminator-field-text-25_6a594eb7394bc-label\" class=\"forminator-label\">Relationship:<\/label><input type=\"text\" name=\"text-25\" value=\"\" placeholder=\"\" id=\"forminator-field-text-25_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-6\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-6_6a594eb7394bc\" id=\"forminator-field-phone-6_6a594eb7394bc-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-6\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-6_6a594eb7394bc\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"text-23\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-23_6a594eb7394bc\" id=\"forminator-field-text-23_6a594eb7394bc-label\" class=\"forminator-label\">Years Known:<\/label><input type=\"text\" name=\"text-23\" value=\"\" placeholder=\"\" id=\"forminator-field-text-23_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">PHYSICAL RECORD<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-5\"><label class=\"forminator-label\">Do you have any physical disabilities that prevent you from performing the work<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-31\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-31_6a594eb7394bc\" id=\"forminator-field-text-31_6a594eb7394bc-label\" class=\"forminator-label\">For which you are applying:<\/label><input type=\"text\" name=\"text-31\" value=\"\" placeholder=\"\" id=\"forminator-field-text-31_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-32\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-32_6a594eb7394bc\" id=\"forminator-field-text-32_6a594eb7394bc-label\" class=\"forminator-label\">If so describe:<\/label><input type=\"text\" name=\"text-32\" value=\"\" placeholder=\"\" id=\"forminator-field-text-32_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-8\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-8-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-8-6a594eb7394bc-label\" class=\"forminator-label\">Have you ever been injured:<\/span><label id=\"forminator-field-radio-8-label-1\" for=\"forminator-field-radio-8-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-8\" value=\"one\" id=\"forminator-field-radio-8-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-8-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-8-label-2\" for=\"forminator-field-radio-8-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-8\" value=\"two\" id=\"forminator-field-radio-8-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-8-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-6\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-6\"><label class=\"forminator-label\">In case of emergency notify:<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-33\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-33_6a594eb7394bc\" id=\"forminator-field-text-33_6a594eb7394bc-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"text-33\" value=\"\" placeholder=\"\" id=\"forminator-field-text-33_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-34\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-34_6a594eb7394bc\" id=\"forminator-field-text-34_6a594eb7394bc-label\" class=\"forminator-label\">Adress<\/label><input type=\"text\" name=\"text-34\" value=\"\" placeholder=\"\" id=\"forminator-field-text-34_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"phone-8\" class=\"forminator-field-phone forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-8_6a594eb7394bc\" id=\"forminator-field-phone-8_6a594eb7394bc-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-8\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-8_6a594eb7394bc\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">ADDITIONAL AREAS OF EXPERTISE<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_6a594eb7394bc\" id=\"forminator-field-textarea-4_6a594eb7394bc-label\" class=\"forminator-label\">Areas of specialized study, research, or additional experience<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-7\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-7\"><label class=\"forminator-label\">List the foreign languages you speak fluently:<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-2-6a594eb7394bc-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-2-6a594eb7394bc-label\" class=\"forminator-label\">Read:<\/span><label id=\"forminator-field-checkbox-2-1-6a594eb7394bc-label\" for=\"forminator-field-checkbox-2-1-6a594eb7394bc\" class=\"forminator-checkbox\" title=\"Spanish\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-checkbox-2-1-6a594eb7394bc-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Spanish<\/span><\/label><label id=\"forminator-field-checkbox-2-2-6a594eb7394bc-label\" for=\"forminator-field-checkbox-2-2-6a594eb7394bc\" class=\"forminator-checkbox\" title=\"French\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-checkbox-2-2-6a594eb7394bc-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">French<\/span><\/label><label id=\"forminator-field-checkbox-2-3-6a594eb7394bc-label\" for=\"forminator-field-checkbox-2-3-6a594eb7394bc\" class=\"forminator-checkbox\" title=\"Creole\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"Creole\" id=\"forminator-field-checkbox-2-3-6a594eb7394bc\" aria-labelledby=\"forminator-field-checkbox-2-3-6a594eb7394bc-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Creole<\/span><\/label><\/div><\/div><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-6 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-forminator-field-checkbox-1-6a594eb7394bc-label\"><span id=\"forminator-checkbox-group-forminator-field-checkbox-1-6a594eb7394bc-label\" class=\"forminator-label\">Write:<\/span><label id=\"forminator-field-checkbox-1-1-6a594eb7394bc-label\" for=\"forminator-field-checkbox-1-1-6a594eb7394bc\" class=\"forminator-checkbox\" title=\"Spanish\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-checkbox-1-1-6a594eb7394bc-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Spanish<\/span><\/label><label id=\"forminator-field-checkbox-1-2-6a594eb7394bc-label\" for=\"forminator-field-checkbox-1-2-6a594eb7394bc\" class=\"forminator-checkbox\" title=\"French\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-checkbox-1-2-6a594eb7394bc-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">French<\/span><\/label><label id=\"forminator-field-checkbox-1-3-6a594eb7394bc-label\" for=\"forminator-field-checkbox-1-3-6a594eb7394bc\" class=\"forminator-checkbox\" title=\"Creole\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"Creole\" id=\"forminator-field-checkbox-1-3-6a594eb7394bc\" aria-labelledby=\"forminator-field-checkbox-1-3-6a594eb7394bc-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Creole<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-9\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-10\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-12\" class=\"forminator-field-section forminator-col forminator-col-6 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px solid #aaaaaa;\" \/><\/div><\/div><div id=\"section-11\" class=\"forminator-field-section forminator-col forminator-col-6 \"><div class=\"forminator-field\"><hr class=\"forminator-border\" style=\"border: 1px solid #aaaaaa;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-4\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a594eb74099d\" id=\"forminator-field-ctlSignature6a594eb74099d-label\" class=\"forminator-label\">Signature<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a594eb74099d_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a594eb74099d_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a594eb74099d\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-4\" value=\"6a594eb74099d\" class=\"signature-prefix\"><\/div><\/div><div id=\"html-9\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-9\"><label class=\"forminator-label\">Date<\/label><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-10--page-3\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-10--page-3-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"3\"\r\n\t\t\t\tdata-label=\"Page  3\"\r\n\t\t\t\tdata-actual-label=\"Page 4\"\r\n\t\t\t\tdata-name=\"page-break-4\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-13\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">REFERENCE OF PRIOR EMPLOYMENT:<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-10\" class=\"forminator-field-html forminator-col forminator-col-4 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-10\"><label class=\"forminator-label\">INDIVIDUAL CONTACTED<\/label><\/div><\/div><div id=\"html-11\" class=\"forminator-field-html forminator-col forminator-col-4 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-11\"><label class=\"forminator-label\">NAME OF FIRM<\/label><\/div><\/div><div id=\"html-12\" class=\"forminator-field-html forminator-col forminator-col-4 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-12\"><label class=\"forminator-label\">RESULTS OF CHECK<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-40\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-40_6a594eb7394bc\" id=\"forminator-field-text-40_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-40\" value=\"\" placeholder=\"Input 1\" id=\"forminator-field-text-40_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-37\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-37_6a594eb7394bc\" id=\"forminator-field-text-37_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-37\" value=\"\" placeholder=\"Input 2\" id=\"forminator-field-text-37_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-35\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-35_6a594eb7394bc\" id=\"forminator-field-text-35_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-35\" value=\"\" placeholder=\"Input 3\" id=\"forminator-field-text-35_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-38\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-38_6a594eb7394bc\" id=\"forminator-field-text-38_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-38\" value=\"\" placeholder=\"Input 4\" id=\"forminator-field-text-38_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-36\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-36_6a594eb7394bc\" id=\"forminator-field-text-36_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-36\" value=\"\" placeholder=\"Input 5\" id=\"forminator-field-text-36_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-39\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-39_6a594eb7394bc\" id=\"forminator-field-text-39_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-39\" value=\"\" placeholder=\"Input 6\" id=\"forminator-field-text-39_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-42\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-42_6a594eb7394bc\" id=\"forminator-field-text-42_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-42\" value=\"\" placeholder=\"Input 7\" id=\"forminator-field-text-42_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-43\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-43_6a594eb7394bc\" id=\"forminator-field-text-43_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-43\" value=\"\" placeholder=\"Input 8\" id=\"forminator-field-text-43_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-41\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-41_6a594eb7394bc\" id=\"forminator-field-text-41_6a594eb7394bc-label\" class=\"forminator-label\">Input<\/label><input type=\"text\" name=\"text-41\" value=\"\" placeholder=\"Input 9\" id=\"forminator-field-text-41_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-14\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-13\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-13\"><label class=\"forminator-label\">FOR PERSONNEL OFFICE USE<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-45\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-45_6a594eb7394bc\" id=\"forminator-field-text-45_6a594eb7394bc-label\" class=\"forminator-label\">HIRE<\/label><input type=\"text\" name=\"text-45\" value=\"\" placeholder=\"\" id=\"forminator-field-text-45_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-44\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-44_6a594eb7394bc\" id=\"forminator-field-text-44_6a594eb7394bc-label\" class=\"forminator-label\">FOR WHAT DEPARTMENT:<\/label><input type=\"text\" name=\"text-44\" value=\"\" placeholder=\"\" id=\"forminator-field-text-44_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-47\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-47_6a594eb7394bc\" id=\"forminator-field-text-47_6a594eb7394bc-label\" class=\"forminator-label\">POSITION:<\/label><input type=\"text\" name=\"text-47\" value=\"\" placeholder=\"\" id=\"forminator-field-text-47_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-46\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-46_6a594eb7394bc\" id=\"forminator-field-text-46_6a594eb7394bc-label\" class=\"forminator-label\">SALARY:<\/label><input type=\"text\" name=\"text-46\" value=\"\" placeholder=\"per VISIT\" id=\"forminator-field-text-46_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-50\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-50_6a594eb7394bc\" id=\"forminator-field-text-50_6a594eb7394bc-label\" class=\"forminator-label\">STARTING DATE<\/label><input type=\"text\" name=\"text-50\" value=\"\" placeholder=\"\" id=\"forminator-field-text-50_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-51\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-51_6a594eb7394bc\" id=\"forminator-field-text-51_6a594eb7394bc-label\" class=\"forminator-label\">Bi-WEEKLY HOUR:<\/label><input type=\"text\" name=\"text-51\" value=\"\" placeholder=\"\" id=\"forminator-field-text-51_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-15\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Confidentiality Statement<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-14\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-14\"><p>I have been formally instructed regarding the agency\u2019s policies and procedures for maintaining the confidentiality of all information contained in client and personnel files and records, as well as any other proprietary information regarding the agency that may be obtained verbally or otherwise.<\/p>\n<p>Such information may not be disclosed or used by anyone outside or within the agency unless expressly authorized by the agency\u2019s executive director and\/or designee.<\/p>\n<p>I understand that any breach of confidentiality may be grounds for immediate termination of employment.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-48\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-48_6a594eb7394bc\" id=\"forminator-field-text-48_6a594eb7394bc-label\" class=\"forminator-label\">Employee:<\/label><input type=\"text\" name=\"text-48\" value=\"\" placeholder=\"\" id=\"forminator-field-text-48_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-13\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-13-picker_6a594eb7394bc\" id=\"forminator-field-date-13-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-13\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-13-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-49\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-49_6a594eb7394bc\" id=\"forminator-field-text-49_6a594eb7394bc-label\" class=\"forminator-label\">Witness:<\/label><input type=\"text\" name=\"text-49\" value=\"\" placeholder=\"\" id=\"forminator-field-text-49_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-14\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-14-picker_6a594eb7394bc\" id=\"forminator-field-date-14-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-14\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-14-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-16\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">EMERGENCY NOTIFICATION<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-52\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-52_6a594eb7394bc\" id=\"forminator-field-text-52_6a594eb7394bc-label\" class=\"forminator-label\">EMPLOYEE NAME:<\/label><input type=\"text\" name=\"text-52\" value=\"\" placeholder=\"\" id=\"forminator-field-text-52_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-15\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-15-picker_6a594eb7394bc\" id=\"forminator-field-date-15-picker_6a594eb7394bc-label\" class=\"forminator-label\">DATE:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-15\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-15-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-53\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-53_6a594eb7394bc\" id=\"forminator-field-text-53_6a594eb7394bc-label\" class=\"forminator-label\">Discipline:<\/label><input type=\"text\" name=\"text-53\" value=\"\" placeholder=\"\" id=\"forminator-field-text-53_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-5_6a594eb7394bc\" id=\"forminator-field-first-name-5_6a594eb7394bc-label\" class=\"forminator-label\">First Name<\/label><input type=\"text\" name=\"name-5-first-name\" placeholder=\"\" id=\"forminator-field-first-name-5_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-5_6a594eb7394bc\" id=\"forminator-field-last-name-5_6a594eb7394bc-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-5-last-name\" placeholder=\"\" id=\"forminator-field-last-name-5_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"text-54\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-54_6a594eb7394bc\" id=\"forminator-field-text-54_6a594eb7394bc-label\" class=\"forminator-label\">Relationship:<\/label><input type=\"text\" name=\"text-54\" value=\"\" placeholder=\"\" id=\"forminator-field-text-54_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_6a594eb7394bc\" id=\"forminator-field-address-2-street_address_6a594eb7394bc-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"\" id=\"forminator-field-address-2-street_address_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-address_line_6a594eb7394bc\" id=\"forminator-field-address-2-address_line_6a594eb7394bc-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-2-address_line\" placeholder=\"\" id=\"forminator-field-address-2-address_line_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-2-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-city_6a594eb7394bc\" id=\"forminator-field-address-2-city_6a594eb7394bc-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"\" id=\"forminator-field-address-2-city_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-2-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-state_6a594eb7394bc\" id=\"forminator-field-address-2-state_6a594eb7394bc-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-2-state\" placeholder=\"\" id=\"forminator-field-address-2-state_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-zip_6a594eb7394bc\" id=\"forminator-field-address-2-zip_6a594eb7394bc-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"\" id=\"forminator-field-address-2-zip_6a594eb7394bc\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-17\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">SECOND EMERGENCY CONTACT (Friend or relative not living with you)<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-6_6a594eb7394bc\" id=\"forminator-field-first-name-6_6a594eb7394bc-label\" class=\"forminator-label\">First Name<\/label><input type=\"text\" name=\"name-6-first-name\" placeholder=\"\" id=\"forminator-field-first-name-6_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-6_6a594eb7394bc\" id=\"forminator-field-last-name-6_6a594eb7394bc-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-6-last-name\" placeholder=\"\" id=\"forminator-field-last-name-6_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"text-55\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-55_6a594eb7394bc\" id=\"forminator-field-text-55_6a594eb7394bc-label\" class=\"forminator-label\">Relationship:<\/label><input type=\"text\" name=\"text-55\" value=\"\" placeholder=\"\" id=\"forminator-field-text-55_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-3\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-3-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-street_address_6a594eb7394bc\" id=\"forminator-field-address-3-street_address_6a594eb7394bc-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-3-street_address\" placeholder=\"\" id=\"forminator-field-address-3-street_address_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-3-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-address_line_6a594eb7394bc\" id=\"forminator-field-address-3-address_line_6a594eb7394bc-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-3-address_line\" placeholder=\"\" id=\"forminator-field-address-3-address_line_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-3-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-city_6a594eb7394bc\" id=\"forminator-field-address-3-city_6a594eb7394bc-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-3-city\" placeholder=\"\" id=\"forminator-field-address-3-city_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-3-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-state_6a594eb7394bc\" id=\"forminator-field-address-3-state_6a594eb7394bc-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-3-state\" placeholder=\"\" id=\"forminator-field-address-3-state_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-3-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-zip_6a594eb7394bc\" id=\"forminator-field-address-3-zip_6a594eb7394bc-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-3-zip\" placeholder=\"\" id=\"forminator-field-address-3-zip_6a594eb7394bc\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-18\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Disclosure of interests<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-15\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-15\"><p class=\"p1\">The following questions are designed to assist Governing Body members, Professional Advisory members and staff in determining the nature and extent of any outside interest that might possibly involve conflict of interest with the affairs of the organization. Please read each question carefully and then answer briefly and concisely in the space that follows. In the event that you have any doubts as to what the question means, answer it to the best of your ability and identify the reason for doubt.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-19\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Glossary<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-21\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-21\"><ul>\n<li class=\"p1\"><strong>Competitor: <\/strong>A person offering for sale or selling products and\/or services in competition with this organization.<\/li>\n<li class=\"p1\"><strong>Family: <\/strong>Spouse, parents, children, brothers, sisters.<\/li>\n<li class=\"p1\"><strong>Purchaser: <\/strong>Any person who buys, rents, or otherwise procures, has bought, rented or procured, or in any way has received from this organization any goods, materials, wares, merchandise, supplies, machinery, equipment, or professional and\/or other service.<\/li>\n<li class=\"p1\"><strong>Person: <\/strong>An individual, firm, partnership, trust. corporation, or other business entity.<\/li>\n<li class=\"p1\"><strong>Vendor: <\/strong>Any person who sells, rents, agrees 10 furnish, has offered to sell, rent, or agree to furnish, or has sold supplies, machinery, equipment, real estate, credit, insurance, or service, profession or otherwise, to or on behalf of the organization.<\/li>\n<\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-7\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"html-22\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-22\"><p class=\"p1\"><strong>1. Ownership, Entertainment, Gifts, Loans:<\/strong><\/p>\n<p><strong>A.<\/strong> - Do you or any member of your family directly or indirectly own, or during the past 24 months preceding the date hereof, have you or any member of your family owned, directly or indirectly, any interest whatsoever in, or shared in the profits of income of a vendor, purchaser, or competitor?<\/p><\/div><\/div><div id=\"radio-9\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-9-6a594eb7394bc-label\"><label id=\"forminator-field-radio-9-label-1\" for=\"forminator-field-radio-9-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-9\" value=\"one\" id=\"forminator-field-radio-9-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-9-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-9-label-2\" for=\"forminator-field-radio-9-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-9\" value=\"two\" id=\"forminator-field-radio-9-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-9-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_6a594eb7394bc\" id=\"forminator-field-textarea-5_6a594eb7394bc-label\" class=\"forminator-label\">If &quot;Yes&quot; Explain:<\/label><textarea name=\"textarea-5\" placeholder=\"\" id=\"forminator-field-textarea-5_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-23\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-23\"><p><strong>B.<\/strong> - Do you or any member of your family directly or indirectly own, or during the past 24 months preceding the date hereof, have you or any member of your family owned, directly or indirectly, any interest whatsoever in, or shared in the profits of income of a vendor, purchaser, or competitor?<\/p><\/div><\/div><div id=\"radio-10\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-10-6a594eb7394bc-label\"><label id=\"forminator-field-radio-10-label-1\" for=\"forminator-field-radio-10-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-10\" value=\"one\" id=\"forminator-field-radio-10-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-10-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-10-label-2\" for=\"forminator-field-radio-10-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-10\" value=\"two\" id=\"forminator-field-radio-10-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-10-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-6\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-6_6a594eb7394bc\" id=\"forminator-field-textarea-6_6a594eb7394bc-label\" class=\"forminator-label\">If &quot;Yes&quot; Explain:<\/label><textarea name=\"textarea-6\" placeholder=\"\" id=\"forminator-field-textarea-6_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"group-8\" class=\"forminator-field-group forminator-col forminator-col-12 \"><div class=\"forminator-all-group-copies\"><div class=\"forminator-grouped-fields\" data-options=\"{&quot;is_repeater&quot;:false,&quot;min_type&quot;:&quot;custom&quot;,&quot;max_type&quot;:&quot;custom&quot;,&quot;min&quot;:1,&quot;max&quot;:9223372036854775807,&quot;add_text&quot;:&quot;Add item&quot;,&quot;remove_text&quot;:&quot;Remove item&quot;,&quot;action_element_type&quot;:&quot;button&quot;}\"><div class=\"forminator-row\"><div id=\"html-25\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-25\"><p class=\"p1\"><strong>2. Employment Status:<\/strong><\/p>\n<p class=\"p1\"><strong>A.<\/strong> - Are you or any member of your family presently an officer, director, employee or consultant of, or otherwise employed or retained by, any vendor, purchaser, or competitor?<\/p><\/div><\/div><div id=\"radio-12\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-12-6a594eb7394bc-label\"><label id=\"forminator-field-radio-12-label-1\" for=\"forminator-field-radio-12-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-12\" value=\"one\" id=\"forminator-field-radio-12-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-12-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-12-label-2\" for=\"forminator-field-radio-12-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-12\" value=\"two\" id=\"forminator-field-radio-12-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-12-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-8\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-8_6a594eb7394bc\" id=\"forminator-field-textarea-8_6a594eb7394bc-label\" class=\"forminator-label\">If &quot;Yes&quot; Explain:<\/label><textarea name=\"textarea-8\" placeholder=\"\" id=\"forminator-field-textarea-8_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-24\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-24\"><p class=\"p1\"><strong>B.<\/strong> -\u00a0 During the 24 months preceding the date hereof, have you or any member of vour family been an officer, director. employee, or consultant of, or otherwise employed or retained by, any vendor, purchaser, or competitor?<\/p><\/div><\/div><div id=\"radio-11\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-11-6a594eb7394bc-label\"><label id=\"forminator-field-radio-11-label-1\" for=\"forminator-field-radio-11-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-11\" value=\"one\" id=\"forminator-field-radio-11-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-11-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-11-label-2\" for=\"forminator-field-radio-11-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-11\" value=\"two\" id=\"forminator-field-radio-11-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-11-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-7\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-7_6a594eb7394bc\" id=\"forminator-field-textarea-7_6a594eb7394bc-label\" class=\"forminator-label\">If &quot;Yes&quot; Explain:<\/label><textarea name=\"textarea-7\" placeholder=\"\" id=\"forminator-field-textarea-7_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-27\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-27\"><p class=\"p1\"><strong>3. Related Staff Members:<\/strong><\/p>\n<p class=\"p1\"><strong>A.<\/strong> - Are any present staff members of this organization related to you either by blood or other legal family relationships?<\/p><\/div><\/div><div id=\"radio-14\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-14-6a594eb7394bc-label\"><label id=\"forminator-field-radio-14-label-1\" for=\"forminator-field-radio-14-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-14\" value=\"one\" id=\"forminator-field-radio-14-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-14-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-14-label-2\" for=\"forminator-field-radio-14-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-14\" value=\"two\" id=\"forminator-field-radio-14-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-14-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-10\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-10_6a594eb7394bc\" id=\"forminator-field-textarea-10_6a594eb7394bc-label\" class=\"forminator-label\">If &quot;Yes&quot; Explain:<\/label><textarea name=\"textarea-10\" placeholder=\"\" id=\"forminator-field-textarea-10_6a594eb7394bc\" class=\"forminator-textarea\" rows=\"6\" style=\"--forminator-textarea-min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-28\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-28\"><p class=\"p1\">I certify that the above questions have been answered to the best of my ability, and of my own free will, and in the interest of cooperating with the agency. I also agree that if at any future time I should become aware of any conflict arising, that is not mentioned herein, I shall contact the Governing Body.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-5\" class=\"forminator-field-signature forminator-col forminator-col-4 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a594eb7419f9\" id=\"forminator-field-ctlSignature6a594eb7419f9-label\" class=\"forminator-label\">Signature<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a594eb7419f9_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a594eb7419f9_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a594eb7419f9\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-5\" value=\"6a594eb7419f9\" class=\"signature-prefix\"><\/div><\/div><div id=\"text-57\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-57_6a594eb7394bc\" id=\"forminator-field-text-57_6a594eb7394bc-label\" class=\"forminator-label\">Position<\/label><input type=\"text\" name=\"text-57\" value=\"\" placeholder=\"\" id=\"forminator-field-text-57_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-16\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-16-picker_6a594eb7394bc\" id=\"forminator-field-date-16-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-16\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-16-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-10--page-4\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-10--page-4-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"4\"\r\n\t\t\t\tdata-label=\"Page  4\"\r\n\t\t\t\tdata-actual-label=\"Page 5\"\r\n\t\t\t\tdata-name=\"page-break-2\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-20\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Employee Handbook Acknowledgment of Receipt and Understanding<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-29\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-29\"><p class=\"p1\">I hereby certify that I have read and fully understand the contents of the Employee Handbook. Furthermore, I have been given the opportunity to discuss any information contained therein or any concerns that | may have. I certify that my employment and continued employment is based in part upon my willingness to abide by and follow the Agency's policies, rules, regulations and procedures. My signature below certifies my knowledge, acceptance and adherence to the Agency's policies, rules, regulations and procedures and that the Agency's offer of employment was based on my promise to abide by and follow said policies, rules, regulations and procedures.<\/p>\n<p class=\"p1\">I further certify that my application and subsequent acceptance of employment is true and bona fide, and I am honestly interested in working in the position(s) for which I have been employed. Furthermore, I certify that I have sought and obtained employment with this Agency solely to provide me with the benefits of a job and for no other purpose.<\/p>\n<p class=\"p1\">1 acknowledge that the Agency reserves the right to modify or amend its policies at any time, without prior notice. These policies do not create any promises or contractual obligations. between this Agency and its employees. At this Agency, my employment is at will. This means I am free to terminate my employment at any time, for any reason, with or without cause, and this Agency retains the same rights. I further understand and agree that the Owner\/President of this Agency is the only person who may make an exception to this, including the at-will status of my employment, and it must be in writing and duly executed by the Owner\/President of this Agency.<\/p>\n<p class=\"p1\">If applicable to my employment, I have read and understood the notice regarding polygraph tests and my rights under this state's law.<\/p>\n<p class=\"p1\"><strong>AUTHORIZATION TO RELEASE INFORMATION:<\/strong> 1 authorize the references and\/or employers listed on my employment application, or any other documents I have provided to this Agency, to give the Agency any and all information concerning my previous employment and pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing such information to this Agency. I agree and understand that this Agency and its agents may investigate or seek information concerning my background and\/or previous employment, whether of record or not. I further agree and understand that if employed, the Agency may at any time seek any information from whatever source, which in its discretion, it deems relevant to my employment. I also understand that any investigation or information sought regarding my previous employment or consumer records may not be completed or in possession of this Agency and thus my continued employment may be affected by such information once received. | hereby acknowledge, confirm, convey, agree and grant this Agency's right to act on any additional information received including, at the Agency's sole discretion, termination of my employment.<\/p>\n<p class=\"p1\"><strong>NO DRUG USE POLICY:<\/strong> This Agency does not hire persons who use illegal drugs. All persons seeking employment or employed with this Agency may be required to take and pass a screen for illegal drugs, and may be subject to periodic tests for illegal drugs. I hereby voluntarily consent to provide a urine specimen (or blood specimen as required for alcohol testing only) at a collection facility designated by this Agency, and further consent to have the specimen tested at a laboratory selected by this Agency. I hereby certify that<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-15\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-15-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-15-6a594eb7394bc-label\" class=\"forminator-label\">Use illegal drugs. (check one) <span class=\"forminator-required\">*<\/span><\/span><label id=\"forminator-field-radio-15-label-1\" for=\"forminator-field-radio-15-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Do\"><input type=\"radio\" name=\"radio-15\" value=\"one\" id=\"forminator-field-radio-15-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-15-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Do<\/span><\/label><label id=\"forminator-field-radio-15-label-2\" for=\"forminator-field-radio-15-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"Not Do\"><input type=\"radio\" name=\"radio-15\" value=\"two\" id=\"forminator-field-radio-15-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-15-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Not Do<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-21\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">ELECTRONIC DOCUMENTATION &amp; SIGNATURE AUTHENTICITY AGREEMENT<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-30\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-30\"><p class=\"p1\">I understand that the agency staff may use electronic signatures on all computer- generated documentation. An electronic signature will serve as authentication on patient record documents and other agency documents generated in the electronic system.<\/p>\n<p class=\"p1\">For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge the combined use of my Electronic Signature Passcode and Log In authentication password will serve as my legal signature. I understand that I will be required to update my password regularly for security purposes. I understand that prior to exporting documentation to the agency server, 1 am required to review and authenticate, by use of electronic signature, my documentation on the field-based or office computer. I understand that I am responsible for the security and accuracy of information entered into my organization's Well Sky application, and as such, I will<\/p>\n<ul class=\"ul1\">\n<li class=\"li1\">Not share or otherwise compromise my electronic signature credentials (Log In authentication password or Electronic Signature Passcode)<\/li>\n<li class=\"li1\">Exit the online application at the end of each working day or whenever the computer is not in my immediate possession.<\/li>\n<li class=\"li1\">Not save my Log In password and Electronic Signature Passcode on the computer, but will enter them upon each access of the application.<\/li>\n<li class=\"li1\">Review all of my documentation online prior to submitting to the agency server<\/li>\n<\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-3\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a594eb741f8a\" id=\"forminator-field-ctlSignature6a594eb741f8a-label\" class=\"forminator-label\">Employee&#039;s Signature <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a594eb741f8a_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a594eb741f8a_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a594eb741f8a\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-3\" value=\"6a594eb741f8a\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-17\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-17-picker_6a594eb7394bc\" id=\"forminator-field-date-17-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-17\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-17-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-59\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-59_6a594eb7394bc\" id=\"forminator-field-text-59_6a594eb7394bc-label\" class=\"forminator-label\">Witness:<\/label><input type=\"text\" name=\"text-59\" value=\"\" placeholder=\"\" id=\"forminator-field-text-59_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-18\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-18-picker_6a594eb7394bc\" id=\"forminator-field-date-18-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-18\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-18-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-10--page-5\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-10--page-5-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"5\"\r\n\t\t\t\tdata-label=\"Page  5\"\r\n\t\t\t\tdata-actual-label=\"Page 6\"\r\n\t\t\t\tdata-name=\"page-break-1\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-22\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">DIRECT DEPOSIT AUTHORIZATION PLEASE PRINT AND COMPLETE ALL OF THE INFORMATION BELOW<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-7_6a594eb7394bc\" id=\"forminator-field-first-name-7_6a594eb7394bc-label\" class=\"forminator-label\">First Name<\/label><input type=\"text\" name=\"name-7-first-name\" placeholder=\"\" id=\"forminator-field-first-name-7_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"given-name\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-7_6a594eb7394bc\" id=\"forminator-field-last-name-7_6a594eb7394bc-label\" class=\"forminator-label\">Last Name<\/label><input type=\"text\" name=\"name-7-last-name\" placeholder=\"\" id=\"forminator-field-last-name-7_6a594eb7394bc\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" autocomplete=\"family-name\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-4\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-4-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-street_address_6a594eb7394bc\" id=\"forminator-field-address-4-street_address_6a594eb7394bc-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-4-street_address\" placeholder=\"\" id=\"forminator-field-address-4-street_address_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-4-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-address_line_6a594eb7394bc\" id=\"forminator-field-address-4-address_line_6a594eb7394bc-label\" class=\"forminator-label\">Apartment, suite, etc<\/label><input type=\"text\" name=\"address-4-address_line\" placeholder=\"\" id=\"forminator-field-address-4-address_line_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-line2\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-4-city\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-city_6a594eb7394bc\" id=\"forminator-field-address-4-city_6a594eb7394bc-label\" class=\"forminator-label\">City<\/label><input type=\"text\" name=\"address-4-city\" placeholder=\"\" id=\"forminator-field-address-4-city_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level2\" value=\"\" \/><\/div><\/div><div id=\"address-4-state\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-state_6a594eb7394bc\" id=\"forminator-field-address-4-state_6a594eb7394bc-label\" class=\"forminator-label\">State\/Province<\/label><input type=\"text\" name=\"address-4-state\" placeholder=\"\" id=\"forminator-field-address-4-state_6a594eb7394bc\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" autocomplete=\"address-level1\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-4-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-zip_6a594eb7394bc\" id=\"forminator-field-address-4-zip_6a594eb7394bc-label\" class=\"forminator-label\">ZIP \/ Postal Code<\/label><input type=\"text\" name=\"address-4-zip\" placeholder=\"\" id=\"forminator-field-address-4-zip_6a594eb7394bc\" class=\"forminator-input\" autocomplete=\"postal-code\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-31\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-31\"><label class=\"forminator-label\">Place Voided Check Here<\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-60\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-60_6a594eb7394bc\" id=\"forminator-field-text-60_6a594eb7394bc-label\" class=\"forminator-label\">Name of Bank:<\/label><input type=\"text\" name=\"text-60\" value=\"\" placeholder=\"\" id=\"forminator-field-text-60_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-61\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-61_6a594eb7394bc\" id=\"forminator-field-text-61_6a594eb7394bc-label\" class=\"forminator-label\">#2<\/label><input type=\"text\" name=\"text-61\" value=\"\" placeholder=\"\" id=\"forminator-field-text-61_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-62\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-62_6a594eb7394bc\" id=\"forminator-field-text-62_6a594eb7394bc-label\" class=\"forminator-label\">Account #:<\/label><input type=\"text\" name=\"text-62\" value=\"\" placeholder=\"\" id=\"forminator-field-text-62_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-63\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-63_6a594eb7394bc\" id=\"forminator-field-text-63_6a594eb7394bc-label\" class=\"forminator-label\">#2<\/label><input type=\"text\" name=\"text-63\" value=\"\" placeholder=\"\" id=\"forminator-field-text-63_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-64\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-64_6a594eb7394bc\" id=\"forminator-field-text-64_6a594eb7394bc-label\" class=\"forminator-label\">Amount: Acet. #1 ($)<\/label><input type=\"text\" name=\"text-64\" value=\"\" placeholder=\"\" id=\"forminator-field-text-64_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-65\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-65_6a594eb7394bc\" id=\"forminator-field-text-65_6a594eb7394bc-label\" class=\"forminator-label\">%<\/label><input type=\"text\" name=\"text-65\" value=\"\" placeholder=\"\" id=\"forminator-field-text-65_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-66\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-66_6a594eb7394bc\" id=\"forminator-field-text-66_6a594eb7394bc-label\" class=\"forminator-label\">Or Entire Paycheck<\/label><input type=\"text\" name=\"text-66\" value=\"\" placeholder=\"\" id=\"forminator-field-text-66_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-67\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-67_6a594eb7394bc\" id=\"forminator-field-text-67_6a594eb7394bc-label\" class=\"forminator-label\">Amount: Acet. #2 ($)<\/label><input type=\"text\" name=\"text-67\" value=\"\" placeholder=\"\" id=\"forminator-field-text-67_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-68\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-68_6a594eb7394bc\" id=\"forminator-field-text-68_6a594eb7394bc-label\" class=\"forminator-label\">%<\/label><input type=\"text\" name=\"text-68\" value=\"\" placeholder=\"\" id=\"forminator-field-text-68_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-69\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-69_6a594eb7394bc\" id=\"forminator-field-text-69_6a594eb7394bc-label\" class=\"forminator-label\">Or Entire Paycheck<\/label><input type=\"text\" name=\"text-69\" value=\"\" placeholder=\"\" id=\"forminator-field-text-69_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-70\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-70_6a594eb7394bc\" id=\"forminator-field-text-70_6a594eb7394bc-label\" class=\"forminator-label\">9-Digit Routing #1<\/label><input type=\"text\" name=\"text-70\" value=\"\" placeholder=\"\" id=\"forminator-field-text-70_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"text-71\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-71_6a594eb7394bc\" id=\"forminator-field-text-71_6a594eb7394bc-label\" class=\"forminator-label\">#2<\/label><input type=\"text\" name=\"text-71\" value=\"\" placeholder=\"\" id=\"forminator-field-text-71_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-16\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-16-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-16-6a594eb7394bc-label\" class=\"forminator-label\">Type of Account #1<\/span><label id=\"forminator-field-radio-16-label-1\" for=\"forminator-field-radio-16-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Checking\"><input type=\"radio\" name=\"radio-16\" value=\"two\" id=\"forminator-field-radio-16-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-16-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Checking<\/span><\/label><label id=\"forminator-field-radio-16-label-2\" for=\"forminator-field-radio-16-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"Saving\"><input type=\"radio\" name=\"radio-16\" value=\"one\" id=\"forminator-field-radio-16-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-16-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Saving<\/span><\/label><\/div><\/div><div id=\"radio-17\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-radio-17-6a594eb7394bc-label\"><span id=\"forminator-radiogroup-radio-17-6a594eb7394bc-label\" class=\"forminator-label\">Type of Account #2<\/span><label id=\"forminator-field-radio-17-label-1\" for=\"forminator-field-radio-17-1-6a594eb7394bc\" class=\"forminator-radio\" title=\"Checking\"><input type=\"radio\" name=\"radio-17\" value=\"two\" id=\"forminator-field-radio-17-1-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-17-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Checking<\/span><\/label><label id=\"forminator-field-radio-17-label-2\" for=\"forminator-field-radio-17-2-6a594eb7394bc\" class=\"forminator-radio\" title=\"Saving\"><input type=\"radio\" name=\"radio-17\" value=\"one\" id=\"forminator-field-radio-17-2-6a594eb7394bc\" aria-labelledby=\"forminator-field-radio-17-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Saving<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-32\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-32\"><p class=\"p1\">Attach a voided check for bank accounts to which funds should be deposited (if necessary)<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-72\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><input type=\"text\" name=\"text-72\" value=\"\" placeholder=\"\" id=\"forminator-field-text-72_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"html-33\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-33\"><p class=\"p1\">is hereby authorized to directly deposit my pay to the account(s) listed above. This authorization will remain in effect until I modify or cancel it in writing.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-2\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a594eb742700\" id=\"forminator-field-ctlSignature6a594eb742700-label\" class=\"forminator-label\">Employee&#039;s Signature<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a594eb742700_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a594eb742700_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a594eb742700\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-2\" value=\"6a594eb742700\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-19\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-19-picker_6a594eb7394bc\" id=\"forminator-field-date-19-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-19\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-19-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-10--page-6\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-10--page-6-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"6\"\r\n\t\t\t\tdata-label=\"Page  6\"\r\n\t\t\t\tdata-actual-label=\"Page 7\"\r\n\t\t\t\tdata-name=\"page-break-3\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><div class=\"forminator-row\"><div id=\"section-23\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">NOTIFICATION OF INTRODUCTORY PERIOD<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-74\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-74_6a594eb7394bc\" id=\"forminator-field-text-74_6a594eb7394bc-label\" class=\"forminator-label\">EMPLOYEE:<\/label><input type=\"text\" name=\"text-74\" value=\"\" placeholder=\"\" id=\"forminator-field-text-74_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-75\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-75_6a594eb7394bc\" id=\"forminator-field-text-75_6a594eb7394bc-label\" class=\"forminator-label\">JOB TITLE:<\/label><input type=\"text\" name=\"text-75\" value=\"\" placeholder=\"\" id=\"forminator-field-text-75_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-76\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-76_6a594eb7394bc\" id=\"forminator-field-text-76_6a594eb7394bc-label\" class=\"forminator-label\">SOCIAL SECURITY NUMBER:<\/label><input type=\"text\" name=\"text-76\" value=\"\" placeholder=\"\" id=\"forminator-field-text-76_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-20\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-20-picker_6a594eb7394bc\" id=\"forminator-field-date-20-picker_6a594eb7394bc-label\" class=\"forminator-label\">DATE OF HIRE:<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-20\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-20-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-21\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-21-picker_6a594eb7394bc\" id=\"forminator-field-date-21-picker_6a594eb7394bc-label\" class=\"forminator-label\">PROBATIONARY DATE<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-21\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-21-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"date-22\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-22-picker_6a594eb7394bc\" id=\"forminator-field-date-22-picker_6a594eb7394bc-label\" class=\"forminator-label\">TO<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-22\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-22-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-77\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-77_6a594eb7394bc\" id=\"forminator-field-text-77_6a594eb7394bc-label\" class=\"forminator-label\">I,<\/label><input type=\"text\" name=\"text-77\" value=\"\" placeholder=\"\" id=\"forminator-field-text-77_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"html-34\" class=\"forminator-field-html forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-34\"><p class=\"p1\">in accepting employment with the Agency accept and understand the first 90 days of employment will be considered my introductory period. If for any reason my employment is terminated during this period, I understand and accept this account will not be charged with any unemployment benefits I may be eligible to receive under the State Unemployment Compensation Law.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-35\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-35\"><p class=\"p1\">I also understand and accept that at the end of the 90-day period, I will receive a written evaluation of my work performance. Should the Agency fail to provide this written evaluation, it shall be understood and accepted by all involved that the introductory period will have been completed satisfactorily.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"signature-1\" class=\"forminator-field-signature forminator-col forminator-col-6 \"><div class=\"forminator-field forminator-field-signature\"><label for=\"forminator-field-ctlSignature6a594eb742bac\" id=\"forminator-field-ctlSignature6a594eb742bac-label\" class=\"forminator-label\">Employee&#039;s Signature<\/label><div class=\"forminator-signature\" data-elementheight=\"180\"><span id=\"ctlSignature6a594eb742bac_placeholder\" class=\"forminator-signature--placeholder\" aria-hidden=\"true\">Start signing your signature here<\/span><div id=\"ctlSignature6a594eb742bac_Container\" class=\"forminator-signature--container\"><canvas id=\"ctlSignature6a594eb742bac\" class=\"forminator-signature-canvas\" height=\"180\" tabindex=\"-1\"><p>Your browser does not support e-Signature field.<\/p><\/canvas><\/div><\/div><input type=\"hidden\" name=\"field-signature-1\" value=\"6a594eb742bac\" class=\"signature-prefix\"><\/div><\/div><div id=\"date-23\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-23-picker_6a594eb7394bc\" id=\"forminator-field-date-23-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-23\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-23-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-79\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-79_6a594eb7394bc\" id=\"forminator-field-text-79_6a594eb7394bc-label\" class=\"forminator-label\">Administrative Signature<\/label><input type=\"text\" name=\"text-79\" value=\"\" placeholder=\"\" id=\"forminator-field-text-79_6a594eb7394bc\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"date-24\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-24-picker_6a594eb7394bc\" id=\"forminator-field-date-24-picker_6a594eb7394bc-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-24\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-24-picker_6a594eb7394bc\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div\r\n\t\t\t\ttabindex=\"-1\"\r\n\t\t\t\trole=\"tabpanel\"\r\n\t\t\t\tid=\"forminator-custom-form-10--page-7\"\r\n\t\t\t\tclass=\"forminator-pagination\"\r\n\t\t\t\taria-labelledby=\"forminator-custom-form-10--page-7-label\"\r\n\t\t\t\taria-hidden=\"true\"\r\n\t\t\t\tdata-step=\"7\"\r\n\t\t\t\tdata-label=\"Page  7\"\r\n\t\t\t\tdata-actual-label=\"Page 8\"\r\n\t\t\t\tdata-name=\"\"\r\n\t\t\t\thidden\r\n\t\t\t><div class=\"forminator-pagination--content\"><\/div><button class=\"forminator-button forminator-pagination-submit\" style=\"display: none;\" disabled><span class=\"forminator-button--mask\" aria-label=\"hidden\"><\/span><span class=\"forminator-button--text\">Submit<\/span><\/button><a href=\"#\" class=\"forminator-save-draft-link disabled\" title=\"Fill in form fields before saving it as a draft\" formnovalidate>Save as Draft<\/a><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"c1bd2a487f\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/forms\/wp-json\/wp\/v2\/pages\/12\" \/><input type=\"hidden\" name=\"form_id\" value=\"10\"><input type=\"hidden\" name=\"page_id\" value=\"12\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/privatecareathome.com\/forms\/career\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><input type=\"hidden\" name=\"save_draft\" value=\"false\"><\/form><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\n<\/div>\n<div class=\"elementor-element elementor-element-2c35ada e-con e-atomic-element e-flexbox-base e-2c35ada-538215b \" data-id=\"2c35ada\" data-element_type=\"e-flexbox\" data-e-type=\"e-flexbox\" data-interaction-id=\"2c35ada\">\n    \n<\/div>\n\n<\/div>\n\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Home About Services Mission &amp; Values Contact Us Book an Appointment<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"footnotes":""},"class_list":["post-12","page","type-page","status-publish","hentry"],"_hostinger_reach_plugin_has_subscription_block":false,"_hostinger_reach_plugin_is_elementor":false,"_links":{"self":[{"href":"https:\/\/privatecareathome.com\/forms\/wp-json\/wp\/v2\/pages\/12","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/privatecareathome.com\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/privatecareathome.com\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/privatecareathome.com\/forms\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/privatecareathome.com\/forms\/wp-json\/wp\/v2\/comments?post=12"}],"version-history":[{"count":145,"href":"https:\/\/privatecareathome.com\/forms\/wp-json\/wp\/v2\/pages\/12\/revisions"}],"predecessor-version":[{"id":165,"href":"https:\/\/privatecareathome.com\/forms\/wp-json\/wp\/v2\/pages\/12\/revisions\/165"}],"wp:attachment":[{"href":"https:\/\/privatecareathome.com\/forms\/wp-json\/wp\/v2\/media?parent=12"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}