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SECTION 1B: WORK TERMINATIONS/RESIGNATIONS <br /> NO YES HAVE YOU EVER BEEN FIRED OR FORCED TO RESIGN FROM A JOB? IF YES, <br /> PROVIDE DETAILS BELOW. <br /> NOTE: Complete the following section only if you have been terminated or forced to resign <br /> from a position. <br /> 1.) Date of Termination/Resignation <br /> Employer <br /> Length of Employent: Start date: <br /> Reason for Termination/Departure: <br /> 2.) Date of Termination/Resignation <br /> Employer <br /> Length of Employent: Start date: <br /> Reason for Termination: <br /> If you need more space use the back of this form or a separate sheet of paper to provide <br /> additional information. <br /> SECTION 2A. SUBSTANCE USE Name <br /> (please print) <br /> f NO YES HAVE YOU EVER USED OR EXPERIMENTED WITH ANY ILLEGAL, OR CONTROLLED DRUGS, <br /> WITHOUT A PRESCRIPTION. IF YES, PLEASE PROVIDE THE DETAILS BELOW: <br /> Year first used Year last used Total times used <br /> Marijuana <br /> Hash, THC, Thai Sticks <br /> Cocaine <br /> Crack Cocaine <br /> Methamphetamine, Crank <br /> Other Stimulants,/amphetamine, <br /> dexedrine <br /> Ecstacy <br /> Designer drugs; e.g. Ice, MDMA, etc. <br /> Hallucinogens, LSD, Mushrooms <br /> PCP, Crystal, Angel Dust <br /> Opium, Morphine, Heroin <br /> Steroids (pills /injections) <br /> Tranquilizers (quaaludes) <br /> Other (specify): <br /> (c) Law Enforcement Psychological Services, Inc. (408) 356-9696 <br /> PSS/LEPS PLLC 50 <br />