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Date Of Birth *

Phone *

Current Location *

City and State

Nationality / Country of Origin *

Current Immigration Status *

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Type of Farm Work Preferred *

Fruit Picking

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If 'other' selected, please specify what type of work

Arrival or Start Availability Date *

Language Spoken *

Willing to Relocate *

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Work Experience in Agriculture *

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Housing Preference *

Provided Housing

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Preferred Communication Channel *

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Emergency Contact Information *

Name, Phone Number, Address

Consent to Background Verification & Data Use: *

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