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Name as it appears on your passport
*
First Name
*
Last Name
*
Maiden Name
Do you have any other aliases or other names?
*
Yes
No
If yes please list
Personal Email
*
Cell Phone
*
Include Country Code
Address
Address Line 1
Address Line 2
City
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Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Local Aruba Address:
Address Line 1
City
Name of Landlord
Phone Number of Landlord
Permanent Address
Address Line 1
Address Line 2
City
State/Province
ZIP / Postal
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
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Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Korea, Republic of
Kosovo
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Lao People\'s Democratic Republic
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Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Republic of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
How many years have you lived here?
If less than one year, please put 0 (zero)
If less than 5 years, please include all previous addresses and how long you have lived there.
Contact Information
Are you legally married?
*
Yes
No
Spouses Name?
Date Married?
Do you have any children?
*
Yes
No
List their names and age, one per line
Do any of your children live with you?
Yes
No
If yes, please list their names below
Please list two emergency contacts who do not live with you.
Contact 1
*
First Name
*
Last Name
*
Relationship
Phone Number
E-mail address
Physical Address
Address Line 1
Address Line 2
City
State/Province
ZIP / Postal
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People\'s Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People\'s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Republic of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Contact 2
First Name
Last Name
Relationship
Phone Number
E-mail address
Physical Address
Address Line 1
Address Line 2
City
State/Province
ZIP / Postal
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People\'s Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People\'s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Republic of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Travel Documents
Do you have a drivers license?
*
Yes
No
Is it valid internationally?
Yes
No
Can you drive in Aruba?
Yes
No
License Number:
Country Issued
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius And Saba
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
The Democratic Republic Of The Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Republic Of Korea
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
The Former Yugoslav Republic Of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Federated States Of Micronesia
Republic Of Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin (French Part)
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch Part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
South Sudan
Spain
Sri Lanka
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela
Vietnam
British Virgin Islands
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Do you have a passport?
*
Yes
No
Passport Number
Passport Expiration Date
Please upload a full, color copy of your passport (cover-to-cover, including front and back covers)
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Please upload a high resolution copy of your passport photo
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Have you ever been deported from a country?
*
Yes
No
If yes, please explain
Please list all visas that you currently have with expiration dates below
Visa #1 with Expiration
Visa #2 with Expiration
Visa #3 with Expiration
Visa #4 with Expiration
Visa #5 with Expiration
Military Service
Have you ever been in the armed forces?
*
Yes
No
If yes, for which country?
Are you a reserve?
Specialty:
Date Entered / Date Discharged?
Were you honorably discharged?
Yes
No
Degrees - All College / University Degrees Must be listed including Bachelors and Up
Name of College / University
*
Website of College / University
*
Address of College / University
*
Is the College / University accredited by the Local State / Country in which it is located?
*
Yes
No
Degree Awarded
*
Bachelors
Masters
PHD
MD
Post Doctorate
Other:
Other Value
Degree Description / Specialization
*
Were classes for this degree taken online?
*
Yes
No
Do you have any more degrees to enter?
*
Yes
No
Name of College / University - 2
*
Website of College / University - 2
*
Address of College / University - 2
*
Degree Awarded - 2
*
Bachelors
Masters
PHD
MD
Post Doctorate
Other:
Other Value
Is the College / University accredited by the Local State / Country in which it is located? - 2
*
Yes
No
Degree Description / Specialization - 2
*
Were classes for this degree taken online? - 2
*
Yes
No
Do you have any more degrees to enter? - 2
*
Yes
No
Name of College / University - 3
*
Website of College / University - 3
*
Address of College / University - 3
*
Is the College / University accredited by the Local State / Country in which it is located? - 3
*
Yes
No
Degree Awarded - 3
*
Bachelors
Masters
PHD
MD
Post Doctorate
Other:
Other Value
Degree Description / Specialization - 3
*
Were classes for this degree taken online? - 3
*
Yes
No
Do you have any more degrees to enter? - 3
*
Yes
No
Name of College / University - 4
*
Website of College / University - 4
*
Address of College / University - 4
*
Is the College / University accredited by the Local State / Country in which it is located? - 4
*
Yes
No
Degree Awarded - 4
*
Bachelors
Masters
PHD
MD
Post Doctorate
Other:
Other Value
Degree Description / Specialization - 4
*
Were classes for this degree taken online? - 4
*
Yes
No
Do you have any more degrees to enter - 4
*
Yes
No
Name of College / University - 5
*
Website of College / University - 5
*
Is the College / University accredited by the Local State / Country where it resides - 5
*
Yes
No
Degree Awarded - 5
*
Bachelors
Masters
PHD
MD
Post Doctorate
Other:
Other Value
Degree Description / Specialization - 5
*
Were classes for this degree taken online? - 5
*
Yes
No
Do you have any more degrees to enter - 5
*
Yes
No
Name of College / University - 6
*
Website of College / University - 6
*
Is the College / University accredited by the Local State / Country in which it is located? - 6
*
Yes
No
Degree Awarded - 6
*
Bachelors
Masters
PHD
MD
Post Doctorate
Other:
Other Value
Degree Description / Specialization - 6
*
Were classes for this degree taken online? - 6
*
Yes
No
Employment History
Have you been awarded or recognized for outstanding work from previous jobs or any institutions?
Yes
No
If yes, please explain in a few sentences.
Work History
No File Chosen
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Please upload a file of your current CV (pdf, doc, docx)
Education
No File Chosen
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Please upload a copy of your current CV with education (pdf, doc, docx)
Financial History
Have you ever defaulted on any loans, promissory notes, credit cards or any other debt?
*
Yes
No
If yes, please explain:
Have you ever filed for bankruptcy?
*
Yes
No
If yes, please explain:
Do you have any unsatisfied judgement or leans against you?
*
Yes
No
If yes, please explain:
Are there any wage garnishments / child support / alimony / judgements present or pending against you?
*
Yes
No
If yes, please explain:
Personal History
Have you ever been convicted, plead guilty, or pleaded no contest to a felony?
*
Yes
No
If yes, please explain:
Have you been treated for any serious medical conditions before?
*
Yes
No
If yes, please explain
Have you ever been convicted, plead guilty, or pleaded no contest of a misdemeanor? (not including traffic violations)
*
Yes
No
If yes, please explain:
Within the past ten years, have you ever used marijuana, cocaine, barbiturates, tranquilizers, heroin, LSD, amphetamines, morphine, narcotics; or any other drug, except as legally prescribed by a physician?
*
Yes
No
If yes, please explain
Within the past ten years, have you ever sought or received medical treatment or professional advice for a drug / alcohol/ substance abuse problem?
*
Yes
No
If yes, please explain:
Professional History
License Number:
Do you hold a medical license?
*
Yes
No
Are you currently registered with any state / country?
*
Yes
No
Registration Number:
Have you been subject to a complaint, reprimand, or disciplinary action by any previous employer?
*
Yes
No
If yes, please explain:
Have you been subject to a complaint, reprimand, or disciplinary / criminal action by a legal authority?
*
Yes
No
If yes, please explain:
Have you had your professional license suspended or revoked?
*
Yes
No
If yes, please explain why:
Have you had any claims, suits, or proceedings or claims pending against you?
*
Yes
No
If yes, please explain:
Are there any incidents that you know of from your actions that can result in a future claim against you?
*
Yes
No
If yes, please explain:
Previous Information Submitted
Has any of your Degree History / Professional History / Personal History Changed since you have become employed by Xavier School of Medicine
No
Yes
Please explain why the information has changed
Date/Time
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
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Year
2023
Employment Application Disclaimer and Acknowledgement
I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify/misrepresent/mislead/conceal information is grounds for refusing to hire me, or for discharge should I be hired. I understand that if any of the information on this application is to change during the application process or once hired I am required to notify the company within 7 days. Failure to notify the company within 7 days is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for employment. I also authorize you to request and receive such information. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added or interpreted at any time, at the company’s sole option and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself. Faculty Handbook is provided for all other employment details.
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