ace of Employment: L-Clto 0;41(C. (V Marc IA I. Name of immediate supervisor: Rorck Fenkzen U0AaNn 6°At II. Employer's business address: 810 SOMA Avri1Ve t S+t 410 Mao 'lore, NY too I4 III. Employer's telephone number: 2 - "ft,- 23 IIII. Dates of Employment: 7/ 20 IQ presen4_ B. List all previo