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STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES DATE PERSONNEL RECORD Form to be completed by employee NAME OF FACILITY FACILITY ADDRESS FACILITY FILE NUMBER NAME LAST FIRST PERSONAL TELEPHONE MIDDLE ADDRESS ARE YOU 18 YEARS OF AGE OR OLDER YES NO IF NO PLEASE STATE YOUR AGE s SOCIAL SECURITY NUMBER VOLUNTARY FOR ID ONLY - DATE OF LAST PHYSICAL EXAMINATION DATE OF LAST TB TEST HAVE YOU EVER BEEN EMPLOYED UNDER A DIFFERENT NAME DO YOU POSSESS A VALID ...

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