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EMPLOYEE APPLICATION EFFECTIVE DATE OF COVERAGE: MEDICAL PLAN TYPE PPO HSA QUALIFIED HMO OTHER BLUEALLIANCE* BCB SAZ ID NUMBER (existing member) DENTAL EMPLOYEE NUMBER (employer use only) OPTION MEDICAL
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Who needs employee-application accessible pdf?

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Employers who require job applicants to fill out an application form.
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Employee-application accessible pdf is a form that allows individuals to apply for a job in a format that is accessible to people with disabilities.
Employers who are looking to hire individuals with disabilities are required to use employee-application accessible pdf.
Employee-application accessible pdf can be filled out electronically or by hand, following the instructions provided on the form.
The purpose of employee-application accessible pdf is to ensure that individuals with disabilities have equal access to job opportunities.
Employee-application accessible pdf must include personal information, education and work experience, and any accommodations needed for the job application process.
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