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On the following questions, any "Yes" answer requires a separate statement, including dates, location, basis of charge, and legal documentation indicating disposition of case.
Please include information for all locations you would like included with your appointment.
I hereby certify under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge and belief. I also hereby agree to the disclosure and release of any information pertinent to this application held by any person or any educational, law enforcement, governmental or business entity.
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