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JOB1 Employer Placement Form
Employer Info
Today's Date
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Employer Name
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Employer Contact First Name
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Employer Contact Last Name
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Employer Contact Phone #
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Employer Contact Email
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Employee Info #1
Participant First Name
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Participant Last Name
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Last 4 # SSN
Job Title
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Payrate/Salary
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Employer Industry
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Restaurant and Hospitality
Healthcare
Construction / Laborer / Warehouse
CDL / Transportation
STEM / Advanced Manufacturing
Information Technology (IT)
Other
Other
Would you like to enter another placement?
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Yes
No
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