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licant School Number or Name and School Address ZIP File Social Security School District License Years of Service ointed -Per Diem Substitute From Illness Since For per diem substitute show only days during immediately prior to absence to be excused* Dates on which absence occurred* Write name of month. Check with an X those days on which absence Month. l which applicant would otherwise s September have been employed in position held 2 3 4 S 6 7 8 9 10 11 12 13 14 IS 16 17 18 19 20 21 22 23 24 ...

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