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Employment Application Please fill out this pre-application form and we will contact you shortly. Last Name First Name Middle Initial Today's Date Phone Number Are you age 18 or older? Yes No Are you authorized to work in the U.S.? Yes No Street Address Apartment # City State Zip Position Desired Date Available Check all that apply Full-Time Part-Time Standby/Per Diem Day Shift Evening Shift Night Shift Weekends

10807 E. Montgomery, Suite 8         Spokane, WA 99206          509-924-1826          800-365-4429          Fax: 509-924-6258 Copyright 2006, Integrated Health Professionals, Inc.