{"id":163,"date":"2016-12-01T19:58:25","date_gmt":"2016-12-01T19:58:25","guid":{"rendered":"http:\/\/www.uni-staff.com\/?page_id=163"},"modified":"2017-06-14T23:12:18","modified_gmt":"2017-06-14T23:12:18","slug":"careers-2","status":"publish","type":"page","link":"https:\/\/unistaff.ecmci.com\/?page_id=163","title":{"rendered":"Apply Now"},"content":{"rendered":"<div id=\"vfb-form-2\" class=\"visual-form-builder-container\"><form id=\"application-2\" class=\"visual-form-builder vfb-form-2 \" method=\"post\" enctype=\"multipart\/form-data\">\n\t  \t<input type=\"hidden\" name=\"form_id\" value=\"2\" \/><fieldset class=\"vfb-fieldset vfb-fieldset-1 uni-staff-registry-employment-application \" id=\"item-vfb-12\"><div class=\"vfb-legend\"><h3>UNI-STAFF REGISTRY Employment Application<\/h3><\/div><ul class=\"vfb-section vfb-section-1\"><li class=\"vfb-item vfb-item-instructions  \" id=\"item-vfb-17\"><label class=\"vfb-desc\">1937 Pontius Ave. Los Angeles, CA 90025 <\/label>Programs services and employment are available equally to everyone. The company does not discriminate on the basis of\r\nrace, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, or sexual\r\norientation of any person, in its employment practices. Please inform the Human Resources Department if you require reasonable accommodation to\r\nthe application or interview.<\/li><div id=\"item-vfb-18\" class=\"vfb-section-div \"><h4>General Information<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-19\"><label for=\"vfb-19\" class=\"vfb-desc\">Full Name  <span class=\"vfb-required-asterisk\">*<\/span><\/label><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-19\" id=\"vfb-19\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><label>Last, First Middle<\/label><\/span><\/li><li class=\"vfb-item vfb-item-email   vfb-right-half\" id=\"item-vfb-20\"><label for=\"vfb-20\" class=\"vfb-desc\">Email  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"email\" name=\"vfb-20\" id=\"vfb-20\" value=\"\" class=\"vfb-text  vfb-medium  required  email \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-21\"><label for=\"vfb-21\" class=\"vfb-desc\">Position Applying for  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-21\" id=\"vfb-21\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-auto-column  vfb-right-half\" id=\"item-vfb-22\"><label class=\"vfb-desc\">Location (you may choose more than one location) <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-0\" value=\"Fairfield\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-0\" class=\"vfb-choice\">Fairfield<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-1\" value=\"Fillmore\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-1\" class=\"vfb-choice\">Fillmore<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-2\" value=\"Fullerton\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-2\" class=\"vfb-choice\">Fullerton<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-3\" value=\"Jackson\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-3\" class=\"vfb-choice\">Jackson<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-4\" value=\"Monthclair\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-4\" class=\"vfb-choice\">Monthclair<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-5\" value=\"Pasadena\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-5\" class=\"vfb-choice\">Pasadena<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-6\" value=\"San Bernardino\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-6\" class=\"vfb-choice\">San Bernardino<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-7\" value=\"San Jose\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-7\" class=\"vfb-choice\">San Jose<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-8\" value=\"Southgate\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-8\" class=\"vfb-choice\">Southgate<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-22[]\" id=\"vfb-22-9\" value=\"Home Health Traveling Nurse\" class=\"vfb-checkbox  \" \/><label for=\"vfb-22-9\" class=\"vfb-choice\">Home Health Traveling Nurse<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-address  \" id=\"item-vfb-23\"><label class=\"vfb-desc\">Address <\/label><div><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-23[address]\" id=\"vfb-23-address\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-23-address\">Street Address<\/label><\/span><span class=\"vfb-full\"><input type=\"text\" name=\"vfb-23[address-2]\" id=\"vfb-23-address-2\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-23-address-2\">Apt, Suite, Bldg. (optional)<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-23[city]\" id=\"vfb-23-city\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-23-city\">City<\/label><\/span><span class=\"vfb-right\"><input type=\"text\" name=\"vfb-23[state]\" id=\"vfb-23-state\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-23-state\">State \/ Province \/ Region<\/label><\/span><span class=\"vfb-left\"><input type=\"text\" name=\"vfb-23[zip]\" id=\"vfb-23-zip\" maxlength=\"150\" class=\"vfb-text vfb-medium  \" \/><label for=\"vfb-23-zip\">Postal \/ Zip Code<\/label><\/span><span class=\"vfb-right\"><select name=\"vfb-23[country]\" class=\"vfb-select  \" id=\"vfb-23-country\"><option value=\"\" selected='selected'><\/option><option value=\"Afghanistan\">Afghanistan<\/option><option value=\"Albania\">Albania<\/option><option value=\"Algeria\">Algeria<\/option><option value=\"Andorra\">Andorra<\/option><option value=\"Angola\">Angola<\/option><option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option><option value=\"Argentina\">Argentina<\/option><option value=\"Armenia\">Armenia<\/option><option value=\"Australia\">Australia<\/option><option value=\"Austria\">Austria<\/option><option value=\"Azerbaijan\">Azerbaijan<\/option><option value=\"Bahamas\">Bahamas<\/option><option value=\"Bahrain\">Bahrain<\/option><option value=\"Bangladesh\">Bangladesh<\/option><option value=\"Barbados\">Barbados<\/option><option value=\"Belarus\">Belarus<\/option><option value=\"Belgium\">Belgium<\/option><option value=\"Belize\">Belize<\/option><option value=\"Benin\">Benin<\/option><option value=\"Bhutan\">Bhutan<\/option><option value=\"Bolivia\">Bolivia<\/option><option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option><option value=\"Botswana\">Botswana<\/option><option value=\"Brazil\">Brazil<\/option><option value=\"Brunei\">Brunei<\/option><option value=\"Bulgaria\">Bulgaria<\/option><option value=\"Burkina Faso\">Burkina Faso<\/option><option value=\"Burundi\">Burundi<\/option><option value=\"Cambodia\">Cambodia<\/option><option value=\"Cameroon\">Cameroon<\/option><option value=\"Canada\">Canada<\/option><option value=\"Cape Verde\">Cape Verde<\/option><option value=\"Central African Republic\">Central African Republic<\/option><option value=\"Chad\">Chad<\/option><option value=\"Chile\">Chile<\/option><option value=\"China\">China<\/option><option value=\"Colombia\">Colombia<\/option><option value=\"Comoros\">Comoros<\/option><option value=\"Congo (Brazzaville)\">Congo (Brazzaville)<\/option><option value=\"Congo\">Congo<\/option><option value=\"Costa Rica\">Costa Rica<\/option><option value=\"Cote d\\'Ivoire\">Cote d\\'Ivoire<\/option><option value=\"Croatia\">Croatia<\/option><option value=\"Cuba\">Cuba<\/option><option value=\"Cyprus\">Cyprus<\/option><option value=\"Czech Republic\">Czech Republic<\/option><option value=\"Denmark\">Denmark<\/option><option value=\"Djibouti\">Djibouti<\/option><option value=\"Dominica\">Dominica<\/option><option value=\"Dominican Republic\">Dominican Republic<\/option><option value=\"East Timor (Timor Timur)\">East Timor (Timor Timur)<\/option><option value=\"Ecuador\">Ecuador<\/option><option value=\"Egypt\">Egypt<\/option><option value=\"El Salvador\">El Salvador<\/option><option value=\"Equatorial Guinea\">Equatorial Guinea<\/option><option value=\"Eritrea\">Eritrea<\/option><option value=\"Estonia\">Estonia<\/option><option value=\"Ethiopia\">Ethiopia<\/option><option value=\"Fiji\">Fiji<\/option><option value=\"Finland\">Finland<\/option><option value=\"France\">France<\/option><option value=\"Gabon\">Gabon<\/option><option value=\"Gambia, The\">Gambia, The<\/option><option value=\"Georgia\">Georgia<\/option><option value=\"Germany\">Germany<\/option><option value=\"Ghana\">Ghana<\/option><option value=\"Greece\">Greece<\/option><option value=\"Grenada\">Grenada<\/option><option value=\"Guatemala\">Guatemala<\/option><option value=\"Guinea\">Guinea<\/option><option value=\"Guinea-Bissau\">Guinea-Bissau<\/option><option value=\"Guyana\">Guyana<\/option><option value=\"Haiti\">Haiti<\/option><option value=\"Honduras\">Honduras<\/option><option value=\"Hungary\">Hungary<\/option><option value=\"Iceland\">Iceland<\/option><option value=\"India\">India<\/option><option value=\"Indonesia\">Indonesia<\/option><option value=\"Iran\">Iran<\/option><option value=\"Iraq\">Iraq<\/option><option value=\"Ireland\">Ireland<\/option><option value=\"Israel\">Israel<\/option><option value=\"Italy\">Italy<\/option><option value=\"Jamaica\">Jamaica<\/option><option value=\"Japan\">Japan<\/option><option value=\"Jordan\">Jordan<\/option><option value=\"Kazakhstan\">Kazakhstan<\/option><option value=\"Kenya\">Kenya<\/option><option value=\"Kiribati\">Kiribati<\/option><option value=\"Korea, North\">Korea, North<\/option><option value=\"Korea, South\">Korea, South<\/option><option value=\"Kuwait\">Kuwait<\/option><option value=\"Kyrgyzstan\">Kyrgyzstan<\/option><option value=\"Laos\">Laos<\/option><option value=\"Latvia\">Latvia<\/option><option value=\"Lebanon\">Lebanon<\/option><option value=\"Lesotho\">Lesotho<\/option><option value=\"Liberia\">Liberia<\/option><option value=\"Libya\">Libya<\/option><option value=\"Liechtenstein\">Liechtenstein<\/option><option value=\"Lithuania\">Lithuania<\/option><option value=\"Luxembourg\">Luxembourg<\/option><option value=\"Macedonia\">Macedonia<\/option><option value=\"Madagascar\">Madagascar<\/option><option value=\"Malawi\">Malawi<\/option><option value=\"Malaysia\">Malaysia<\/option><option value=\"Maldives\">Maldives<\/option><option value=\"Mali\">Mali<\/option><option value=\"Malta\">Malta<\/option><option value=\"Marshall Islands\">Marshall Islands<\/option><option value=\"Mauritania\">Mauritania<\/option><option value=\"Mauritius\">Mauritius<\/option><option value=\"Mexico\">Mexico<\/option><option value=\"Micronesia\">Micronesia<\/option><option value=\"Moldova\">Moldova<\/option><option value=\"Monaco\">Monaco<\/option><option value=\"Mongolia\">Mongolia<\/option><option value=\"Montenegro\">Montenegro<\/option><option value=\"Morocco\">Morocco<\/option><option value=\"Mozambique\">Mozambique<\/option><option value=\"Myanmar\">Myanmar<\/option><option value=\"Namibia\">Namibia<\/option><option value=\"Nauru\">Nauru<\/option><option value=\"Nepal\">Nepal<\/option><option value=\"Netherlands\">Netherlands<\/option><option value=\"New Zealand\">New Zealand<\/option><option value=\"Nicaragua\">Nicaragua<\/option><option value=\"Niger\">Niger<\/option><option value=\"Nigeria\">Nigeria<\/option><option value=\"Norway\">Norway<\/option><option value=\"Oman\">Oman<\/option><option value=\"Pakistan\">Pakistan<\/option><option value=\"Palestinian Territory\">Palestinian Territory<\/option><option value=\"Palau\">Palau<\/option><option value=\"Panama\">Panama<\/option><option value=\"Papua New Guinea\">Papua New Guinea<\/option><option value=\"Paraguay\">Paraguay<\/option><option value=\"Peru\">Peru<\/option><option value=\"Philippines\">Philippines<\/option><option value=\"Poland\">Poland<\/option><option value=\"Portugal\">Portugal<\/option><option value=\"Qatar\">Qatar<\/option><option value=\"Romania\">Romania<\/option><option value=\"Russia\">Russia<\/option><option value=\"Rwanda\">Rwanda<\/option><option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\">Saint Lucia<\/option><option value=\"Saint Vincent\">Saint Vincent<\/option><option value=\"Samoa\">Samoa<\/option><option value=\"San Marino\">San Marino<\/option><option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option><option value=\"Saudi Arabia\">Saudi Arabia<\/option><option value=\"Senegal\">Senegal<\/option><option value=\"Serbia\">Serbia<\/option><option value=\"Seychelles\">Seychelles<\/option><option value=\"Sierra Leone\">Sierra Leone<\/option><option value=\"Singapore\">Singapore<\/option><option value=\"Slovakia\">Slovakia<\/option><option value=\"Slovenia\">Slovenia<\/option><option value=\"Solomon Islands\">Solomon Islands<\/option><option value=\"Somalia\">Somalia<\/option><option value=\"South Africa\">South Africa<\/option><option value=\"Spain\">Spain<\/option><option value=\"Sri Lanka\">Sri Lanka<\/option><option value=\"Sudan\">Sudan<\/option><option value=\"Suriname\">Suriname<\/option><option value=\"Swaziland\">Swaziland<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Switzerland\">Switzerland<\/option><option value=\"Syria\">Syria<\/option><option value=\"Taiwan\">Taiwan<\/option><option value=\"Tajikistan\">Tajikistan<\/option><option value=\"Tanzania\">Tanzania<\/option><option value=\"Thailand\">Thailand<\/option><option value=\"Togo\">Togo<\/option><option value=\"Tonga\">Tonga<\/option><option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option><option value=\"Tunisia\">Tunisia<\/option><option value=\"Turkey\">Turkey<\/option><option value=\"Turkmenistan\">Turkmenistan<\/option><option value=\"Tuvalu\">Tuvalu<\/option><option value=\"Uganda\">Uganda<\/option><option value=\"Ukraine\">Ukraine<\/option><option value=\"United Arab Emirates\">United Arab Emirates<\/option><option value=\"United Kingdom\">United Kingdom<\/option><option value=\"United States of America\">United States of America<\/option><option value=\"Uruguay\">Uruguay<\/option><option value=\"Uzbekistan\">Uzbekistan<\/option><option value=\"Vanuatu\">Vanuatu<\/option><option value=\"Vatican City\">Vatican City<\/option><option value=\"Venezuela\">Venezuela<\/option><option value=\"Vietnam\">Vietnam<\/option><option value=\"Western Sahara\">Western Sahara<\/option><option value=\"Western Samoa\">Western Samoa<\/option><option value=\"Yemen\">Yemen<\/option><option value=\"Zambia\">Zambia<\/option><option value=\"Zimbabwe\">Zimbabwe<\/option><\/select><label for=\"vfb-23-country\">Country<\/label><\/span><\/div><\/li><li class=\"vfb-item vfb-item-phone   vfb-left-half\" id=\"item-vfb-24\"><label for=\"vfb-24\" class=\"vfb-desc\">Home Phone <\/label><input type=\"tel\" name=\"vfb-24\" id=\"vfb-24\" value=\"\" class=\"vfb-text  vfb-medium   phone \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-25\"><label for=\"vfb-25\" class=\"vfb-desc\">Mobile Phone <\/label><input type=\"text\" name=\"vfb-25\" id=\"vfb-25\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-26\"><label for=\"vfb-26\" class=\"vfb-desc\">Social Security # <\/label><input type=\"text\" name=\"vfb-26\" id=\"vfb-26\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-27\"><label for=\"vfb-27\" class=\"vfb-desc\">If no, please explain <\/label><input type=\"text\" name=\"vfb-27\" id=\"vfb-27\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-select  \" id=\"item-vfb-119\"><label for=\"vfb-119\" class=\"vfb-desc\">Race <\/label><select name=\"vfb-119\" id=\"vfb-119\" class=\"vfb-select  vfb-medium  \"><option value=\"\"><\/option><option value=\"Do not wish to disclosed\">Do not wish to disclosed<\/option><option value=\"White\">White<\/option><option value=\"Black or African American\">Black or African American<\/option><option value=\"Asian\">Asian<\/option><option value=\"Hispanic or Latino\">Hispanic or Latino<\/option><option value=\"American Indian or Alaska Native\">American Indian or Alaska Native<\/option><option value=\"Two or more races\">Two or more races<\/option><option value=\"Native Hawaiian\/Other Pacific Islander\">Native Hawaiian\/Other Pacific Islander<\/option><\/select><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-three-column \" id=\"item-vfb-28\"><label class=\"vfb-desc\">Can you, at the time of hire, submit verification of your legal right to work in the U.S.? <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-28[]\" id=\"vfb-28-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-28-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-28[]\" id=\"vfb-28-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-28-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-instructions  \" id=\"item-vfb-33\"><label class=\"vfb-desc\">Note <\/label>Company will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of Article 9 of Chapter XVIII of the Los Angeles Municipal Code; Ordinance 184652.<\/li><div id=\"item-vfb-34\" class=\"vfb-section-div \"><h4>Employment Desired<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-date   vfb-left-half\" id=\"item-vfb-35\"><label for=\"vfb-35\" class=\"vfb-desc\">Date available to start <\/label><input type=\"text\" name=\"vfb-35\" id=\"vfb-35\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-number   vfb-right-half\" id=\"item-vfb-36\"><label for=\"vfb-36\" class=\"vfb-desc\">Rate of expected pay <\/label><input type=\"text\" name=\"vfb-36\" id=\"vfb-36\" value=\"\" class=\"vfb-text  vfb-medium   digits \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-auto-column  vfb-left-half\" id=\"item-vfb-37\"><label class=\"vfb-desc\">Shift available <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-37[]\" id=\"vfb-37-0\" value=\"Any\" class=\"vfb-checkbox  \" \/><label for=\"vfb-37-0\" class=\"vfb-choice\">Any<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-37[]\" id=\"vfb-37-1\" value=\"AM\" class=\"vfb-checkbox  \" \/><label for=\"vfb-37-1\" class=\"vfb-choice\">AM<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-37[]\" id=\"vfb-37-2\" value=\"PM\" class=\"vfb-checkbox  \" \/><label for=\"vfb-37-2\" class=\"vfb-choice\">PM<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-37[]\" id=\"vfb-37-3\" value=\"NOC\" class=\"vfb-checkbox  \" \/><label for=\"vfb-37-3\" class=\"vfb-choice\">NOC<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-auto-column  vfb-right-half\" id=\"item-vfb-38\"><label class=\"vfb-desc\">Employment desired <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-38[]\" id=\"vfb-38-0\" value=\"Full-Time\" class=\"vfb-checkbox  \" \/><label for=\"vfb-38-0\" class=\"vfb-choice\">Full-Time<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-38[]\" id=\"vfb-38-1\" value=\"Part-Time\" class=\"vfb-checkbox  \" \/><label for=\"vfb-38-1\" class=\"vfb-choice\">Part-Time<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-38[]\" id=\"vfb-38-2\" value=\"Per Diem\/On Call\" class=\"vfb-checkbox  \" \/><label for=\"vfb-38-2\" class=\"vfb-choice\">Per Diem\/On Call<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-38[]\" id=\"vfb-38-3\" value=\"Temporary\" class=\"vfb-checkbox  \" \/><label for=\"vfb-38-3\" class=\"vfb-choice\">Temporary<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-39\"><label for=\"vfb-39\" class=\"vfb-desc\">How many hours per week are you able to work <\/label><input type=\"text\" name=\"vfb-39\" id=\"vfb-39\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  \" id=\"item-vfb-40\"><label class=\"vfb-desc\">Weekend Availability <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-40[]\" id=\"vfb-40-0\" value=\"Saturday\" class=\"vfb-checkbox  \" \/><label for=\"vfb-40-0\" class=\"vfb-choice\">Saturday<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-40[]\" id=\"vfb-40-1\" value=\"Sunday\" class=\"vfb-checkbox  \" \/><label for=\"vfb-40-1\" class=\"vfb-choice\">Sunday<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-40[]\" id=\"vfb-40-2\" value=\"N\/A\" class=\"vfb-checkbox  \" \/><label for=\"vfb-40-2\" class=\"vfb-choice\">N\/A<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><div id=\"item-vfb-41\" class=\"vfb-section-div \"><h4>Education<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-42\"><label for=\"vfb-42\" class=\"vfb-desc\">High School <\/label><input type=\"text\" name=\"vfb-42\" id=\"vfb-42\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-43\"><label for=\"vfb-43\" class=\"vfb-desc\">City\/State <\/label><input type=\"text\" name=\"vfb-43\" id=\"vfb-43\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-number   vfb-left-third\" id=\"item-vfb-44\"><label for=\"vfb-44\" class=\"vfb-desc\"># of Years Completed <\/label><input type=\"text\" name=\"vfb-44\" id=\"vfb-44\" value=\"\" class=\"vfb-text  vfb-medium   digits \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-two-column  vfb-middle-third\" id=\"item-vfb-45\"><label class=\"vfb-desc\">Did you graduate? <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-45[]\" id=\"vfb-45-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-45-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-45[]\" id=\"vfb-45-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-45-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-46\"><label for=\"vfb-46\" class=\"vfb-desc\">College\/University <\/label><input type=\"text\" name=\"vfb-46\" id=\"vfb-46\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-47\"><label for=\"vfb-47\" class=\"vfb-desc\">City\/State <\/label><input type=\"text\" name=\"vfb-47\" id=\"vfb-47\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-number   vfb-left-third\" id=\"item-vfb-48\"><label for=\"vfb-48\" class=\"vfb-desc\"># of Years Completed <\/label><input type=\"text\" name=\"vfb-48\" id=\"vfb-48\" value=\"\" class=\"vfb-text  vfb-medium   digits \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-two-column  vfb-middle-third\" id=\"item-vfb-49\"><label class=\"vfb-desc\">Did you graduate? <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-49[]\" id=\"vfb-49-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-49-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-49[]\" id=\"vfb-49-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-49-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-50\"><label for=\"vfb-50\" class=\"vfb-desc\">Degree <\/label><input type=\"text\" name=\"vfb-50\" id=\"vfb-50\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-52\"><label for=\"vfb-52\" class=\"vfb-desc\">Major <\/label><input type=\"text\" name=\"vfb-52\" id=\"vfb-52\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-53\"><label for=\"vfb-53\" class=\"vfb-desc\">Others <\/label><input type=\"text\" name=\"vfb-53\" id=\"vfb-53\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-54\"><label for=\"vfb-54\" class=\"vfb-desc\">City\/State: <\/label><input type=\"text\" name=\"vfb-54\" id=\"vfb-54\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-number   vfb-left-third\" id=\"item-vfb-55\"><label for=\"vfb-55\" class=\"vfb-desc\"># of Years Completed: <\/label><input type=\"text\" name=\"vfb-55\" id=\"vfb-55\" value=\"\" class=\"vfb-text  vfb-medium   digits \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-two-column  vfb-middle-third\" id=\"item-vfb-56\"><label class=\"vfb-desc\">Did you graduate? <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-56[]\" id=\"vfb-56-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-56-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-56[]\" id=\"vfb-56-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-56-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-57\"><label for=\"vfb-57\" class=\"vfb-desc\">Degree <\/label><input type=\"text\" name=\"vfb-57\" id=\"vfb-57\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-58\"><label for=\"vfb-58\" class=\"vfb-desc\">Major <\/label><input type=\"text\" name=\"vfb-58\" id=\"vfb-58\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><div id=\"item-vfb-59\" class=\"vfb-section-div \"><h4>Previous Employment (Begin With The Most Recent Position)<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-date   vfb-left-third\" id=\"item-vfb-60\"><label for=\"vfb-60\" class=\"vfb-desc\">I. Date of Employment From <\/label><input type=\"text\" name=\"vfb-60\" id=\"vfb-60\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-middle-third\" id=\"item-vfb-61\"><label for=\"vfb-61\" class=\"vfb-desc\">To <\/label><input type=\"text\" name=\"vfb-61\" id=\"vfb-61\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-62\"><label for=\"vfb-62\" class=\"vfb-desc\">Position(s) Held <\/label><input type=\"text\" name=\"vfb-62\" id=\"vfb-62\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-63\"><label for=\"vfb-63\" class=\"vfb-desc\">Company <\/label><input type=\"text\" name=\"vfb-63\" id=\"vfb-63\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-64\"><label for=\"vfb-64\" class=\"vfb-desc\">Address <\/label><input type=\"text\" name=\"vfb-64\" id=\"vfb-64\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-phone   vfb-left-third\" id=\"item-vfb-65\"><label for=\"vfb-65\" class=\"vfb-desc\">Phone <\/label><input type=\"tel\" name=\"vfb-65\" id=\"vfb-65\" value=\"\" class=\"vfb-text  vfb-medium   phone \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-66\"><label for=\"vfb-66\" class=\"vfb-desc\">Supervisor <\/label><input type=\"text\" name=\"vfb-66\" id=\"vfb-66\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-67\"><label for=\"vfb-67\" class=\"vfb-desc\">Title <\/label><input type=\"text\" name=\"vfb-67\" id=\"vfb-67\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-68\"><label for=\"vfb-68\" class=\"vfb-desc\">Responsibilities <\/label><input type=\"text\" name=\"vfb-68\" id=\"vfb-68\" value=\"\" class=\"vfb-text  vfb-large   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-69\"><label for=\"vfb-69\" class=\"vfb-desc\">Starting Title <\/label><input type=\"text\" name=\"vfb-69\" id=\"vfb-69\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-71\"><label for=\"vfb-71\" class=\"vfb-desc\">Ending Title <\/label><input type=\"text\" name=\"vfb-71\" id=\"vfb-71\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-70\"><label for=\"vfb-70\" class=\"vfb-desc\">Reason for Leaving <\/label><input type=\"text\" name=\"vfb-70\" id=\"vfb-70\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-checkbox   vfb-right-half\" id=\"item-vfb-72\"><label class=\"vfb-desc\">May we contact this employer for reference? <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-72[]\" id=\"vfb-72-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-72-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-72[]\" id=\"vfb-72-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-72-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><div id=\"item-vfb-73\" class=\"vfb-section-div \"><h4>Section<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-date   vfb-left-half\" id=\"item-vfb-74\"><label for=\"vfb-74\" class=\"vfb-desc\">II. Date of Employment From <\/label><input type=\"text\" name=\"vfb-74\" id=\"vfb-74\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-middle-third\" id=\"item-vfb-75\"><label for=\"vfb-75\" class=\"vfb-desc\">To <\/label><input type=\"text\" name=\"vfb-75\" id=\"vfb-75\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-76\"><label for=\"vfb-76\" class=\"vfb-desc\">Position(s) Held <\/label><input type=\"text\" name=\"vfb-76\" id=\"vfb-76\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-77\"><label for=\"vfb-77\" class=\"vfb-desc\">Company <\/label><input type=\"text\" name=\"vfb-77\" id=\"vfb-77\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-78\"><label for=\"vfb-78\" class=\"vfb-desc\">Address <\/label><input type=\"text\" name=\"vfb-78\" id=\"vfb-78\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-third\" id=\"item-vfb-79\"><label for=\"vfb-79\" class=\"vfb-desc\">Phone <\/label><input type=\"text\" name=\"vfb-79\" id=\"vfb-79\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-80\"><label for=\"vfb-80\" class=\"vfb-desc\">Supervisor <\/label><input type=\"text\" name=\"vfb-80\" id=\"vfb-80\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-82\"><label for=\"vfb-82\" class=\"vfb-desc\">Title <\/label><input type=\"text\" name=\"vfb-82\" id=\"vfb-82\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-83\"><label for=\"vfb-83\" class=\"vfb-desc\">Responsibilities <\/label><input type=\"text\" name=\"vfb-83\" id=\"vfb-83\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-84\"><label for=\"vfb-84\" class=\"vfb-desc\">Starting Title <\/label><input type=\"text\" name=\"vfb-84\" id=\"vfb-84\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-85\"><label for=\"vfb-85\" class=\"vfb-desc\">Ending Title <\/label><input type=\"text\" name=\"vfb-85\" id=\"vfb-85\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-81\"><label for=\"vfb-81\" class=\"vfb-desc\">Reason for Leaving <\/label><input type=\"text\" name=\"vfb-81\" id=\"vfb-81\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-two-column  vfb-right-half\" id=\"item-vfb-86\"><label class=\"vfb-desc\">May we contact this employer for reference? <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-86[]\" id=\"vfb-86-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-86-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-86[]\" id=\"vfb-86-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-86-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><div id=\"item-vfb-87\" class=\"vfb-section-div \"><h4>Section<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-date   vfb-left-third\" id=\"item-vfb-88\"><label for=\"vfb-88\" class=\"vfb-desc\">III. Date of Employment From <\/label><input type=\"text\" name=\"vfb-88\" id=\"vfb-88\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-middle-third\" id=\"item-vfb-89\"><label for=\"vfb-89\" class=\"vfb-desc\">To: <\/label><input type=\"text\" name=\"vfb-89\" id=\"vfb-89\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-90\"><label for=\"vfb-90\" class=\"vfb-desc\">Position(s) Held <\/label><input type=\"text\" name=\"vfb-90\" id=\"vfb-90\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-91\"><label for=\"vfb-91\" class=\"vfb-desc\">Company <\/label><input type=\"text\" name=\"vfb-91\" id=\"vfb-91\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-93\"><label for=\"vfb-93\" class=\"vfb-desc\">Address <\/label><input type=\"text\" name=\"vfb-93\" id=\"vfb-93\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-third\" id=\"item-vfb-94\"><label for=\"vfb-94\" class=\"vfb-desc\">Phone <\/label><input type=\"text\" name=\"vfb-94\" id=\"vfb-94\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-95\"><label for=\"vfb-95\" class=\"vfb-desc\">Supervisor <\/label><input type=\"text\" name=\"vfb-95\" id=\"vfb-95\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-96\"><label for=\"vfb-96\" class=\"vfb-desc\">Title: <\/label><input type=\"text\" name=\"vfb-96\" id=\"vfb-96\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text  \" id=\"item-vfb-97\"><label for=\"vfb-97\" class=\"vfb-desc\">Responsibilities <\/label><input type=\"text\" name=\"vfb-97\" id=\"vfb-97\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-98\"><label for=\"vfb-98\" class=\"vfb-desc\">Starting Title <\/label><input type=\"text\" name=\"vfb-98\" id=\"vfb-98\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-99\"><label for=\"vfb-99\" class=\"vfb-desc\">Ending Title <\/label><input type=\"text\" name=\"vfb-99\" id=\"vfb-99\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-92\"><label for=\"vfb-92\" class=\"vfb-desc\">Reason for Leaving <\/label><input type=\"text\" name=\"vfb-92\" id=\"vfb-92\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-two-column  vfb-right-half\" id=\"item-vfb-100\"><label class=\"vfb-desc\">May we contact this employer for reference? <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-100[]\" id=\"vfb-100-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-100-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-100[]\" id=\"vfb-100-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-100-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><div id=\"item-vfb-101\" class=\"vfb-section-div \"><h4>Professional References<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text   vfb-left-third\" id=\"item-vfb-102\"><label for=\"vfb-102\" class=\"vfb-desc\">Reference 1 Name <\/label><input type=\"text\" name=\"vfb-102\" id=\"vfb-102\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-103\"><label for=\"vfb-103\" class=\"vfb-desc\">Occupation <\/label><input type=\"text\" name=\"vfb-103\" id=\"vfb-103\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-104\"><label for=\"vfb-104\" class=\"vfb-desc\">Phone <\/label><input type=\"text\" name=\"vfb-104\" id=\"vfb-104\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><div id=\"item-vfb-105\" class=\"vfb-section-div \"><h4>Section<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text   vfb-left-third\" id=\"item-vfb-106\"><label for=\"vfb-106\" class=\"vfb-desc\">Reference 2 Name <\/label><input type=\"text\" name=\"vfb-106\" id=\"vfb-106\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-107\"><label for=\"vfb-107\" class=\"vfb-desc\">Occupation <\/label><input type=\"text\" name=\"vfb-107\" id=\"vfb-107\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-108\"><label for=\"vfb-108\" class=\"vfb-desc\">Phone <\/label><input type=\"text\" name=\"vfb-108\" id=\"vfb-108\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><div id=\"item-vfb-109\" class=\"vfb-section-div \"><h4>Section<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text   vfb-left-third\" id=\"item-vfb-110\"><label for=\"vfb-110\" class=\"vfb-desc\">Reference 3 Name <\/label><input type=\"text\" name=\"vfb-110\" id=\"vfb-110\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-111\"><label for=\"vfb-111\" class=\"vfb-desc\">Occupation <\/label><input type=\"text\" name=\"vfb-111\" id=\"vfb-111\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-112\"><label for=\"vfb-112\" class=\"vfb-desc\">Phone <\/label><input type=\"text\" name=\"vfb-112\" id=\"vfb-112\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><div id=\"item-vfb-113\" class=\"vfb-section-div \"><h4>Statement of Certification<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-instructions  \" id=\"item-vfb-114\"><label class=\"vfb-desc\">Instructions <\/label><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-115\"><label for=\"vfb-115\" class=\"vfb-desc\">Electronic Signature (type in your full name) <\/label><input type=\"text\" name=\"vfb-115\" id=\"vfb-115\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-right-half\" id=\"item-vfb-116\"><label for=\"vfb-116\" class=\"vfb-desc\">Date <\/label><input type=\"text\" name=\"vfb-116\" id=\"vfb-116\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><\/ul>&nbsp;<\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-2 verification \" id=\"item-vfb-13\" style=\"display:block\"><div class=\"vfb-legend\"><h3>Verification<\/h3><\/div><ul class=\"vfb-section vfb-section-2\"><li class=\"vfb-item vfb-item-secret\"  style=\"display:block\"><label for=\"vfb-14\" class=\"vfb-desc\">Please enter any two digits <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"hidden\" name=\"_vfb-secret\" value=\"vfb-14\" \/><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-14\" id=\"vfb-14\" value=\"\" class=\"vfb-text  vfb-medium  required {digits:true,maxlength:2,minlength:2} \" style=\"display:block\" \/><label>Example: 12<\/label><\/span><li style=\"display:none;\"><label>This box is for spam protection - &lt;strong&gt;please leave it blank&lt;\/strong&gt;:<\/label><div><input name=\"vfb-spam\" \/><\/div><\/li>\n\t\t\t<li class=\"vfb-item vfb-item-submit\" id=\"item-vfb-15\">\n\t\t\t\t<input type=\"submit\" name=\"vfb-submit\" id=\"vfb-15\" value=\"Submit\" class=\"vfb-submit \" 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