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Community Youth Advance Mentor Form
Contact Information

First Name
Last Name

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country


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Educational and Professional Background
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Criminal History Check
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CERTIFICATION: I hereby certify that the information contained in this application is true, correct and complete. AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the references, employers, and educational institutions listed above, and any and all other individuals and entities contacted by CYAdvance for information about me, to release all information. RELEASE FROM LIABILITY: I release all parties and persons from any and all liability for any damages, which may result from furnishing such information to CYAdvance, as well as from the use or disclosure of such information by CYAdvance or any of its agents, co-workers or representatives. The undersigned acknowledges and agrees to the above-stated information and that:
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