California State Senate Employment Application Form Page 2
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2EMPLOYMENT RECORD
(Start with current or most recent employer and include military service, if any. Attach additional sheets if necessary.)
Job Title and Duties
Reason for leaving
Company Name:
Address:
City:
State:
From (mm/yy):
To (mm/yy):
Supervisor:
Phone:
Hours per week:
Ending Salary:
Job Title and Duties
Reason for leaving
Company Name:
Address:
City:
State:
From (mm/yy):
To (mm/yy):
Supervisor:
Phone:
Hours per week:
Ending Salary:
Job Title and Duties
Reason for leaving
Company Name:
Address:
City:
State:
From (mm/yy):
To (mm/yy):
Supervisor:
Phone:
Hours per week:
Ending Salary:
Certification: I declare under the penalty of perjury, that this statement has been completed by me and to the best of my knowledge and
belief, is a true, correct, and complete statement in answer to the questions contained herein.
SIGNATURE:
DATE:
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