Portage Detasseling with Andy Simmons

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Information Request Form

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Detasseling Information Request Form

This Information Request is not an offer of employment. An offer of employment, if made at all, will be made at a later time.

We hire all of our employees from the , , Portage North, Portage Central, area(s). If you are not from the above area(s) you should not fill out this request form.

Name:

Address:

City:

State:

Zip:

Age:

Birthdate:

Phone:

E-mail:

School:

Have You Detasseled Before:

If you Answered Yes Above, How Many Years?: