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Representative Application
First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Highest Level of Education:
College/University (if attended):
Degree(s) received:
Marital Status:  
Spouse Name (if married):
Rate your computer skills:  
Current Computer:
Operating System:
Do you have High Speed Internet?: yes no  
Do you have Unlimited Long Distance phone service?: yes no  
Do you have a quiet place to work from?: yes no  
Are you a United States Citizen?: yes no  
Have you ever been convicted of a felony?: yes no  
Have you ever or do you now use illegal drugs?: yes no  
Any health issues that we should be aware of:  
Personal References
Name: Relationship: Phone:
Name: Relationship: Phone:
Name: Relationship: Phone:
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