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* 1. First and Last Name

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* 2. Email Address

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* 3. Phone Number

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* 4. Age

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* 5. County of Residency

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* 6. Postsecondary Education Credential (e.g. Degree or License)

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* 7. Current Employment Status

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* 8. If employed, is your current job in your field of study?

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* 9. If employed, what is your wage?

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* 10. If not employed, what is your source of income?

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* 11. What type of work experience are you looking for?

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* 12. Check all barriers to employment that may apply

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