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* 1. What is your first name?

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* 2. What is your last name?

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* 3. Date of Layoff

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* 4. Company

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* 5. Most recent job title

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* 6. Length of employment

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* 7. Phone number

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* 8. Email

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* 9. What is the address where you currently live?

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* 10. City

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* 11. State

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* 12. Zip

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