Candidate Acknowledgement Form Des Moines, IA I, LOKESH PANCHETI (Candidate Print Name) hereby request Technisource

to submit my resume in response to a request by Wellmark Blue Cross Blue Shield. Technisource will be the only firm submitting my name for the period of time beginning August 22, 2011 and continuing for a duration of 60 calendar days ending September 22, 2011. Wellmark reserves the right to disqualify a candidate in Wellmark’s sole discretion for any reason. __________________________ Candidate Handwritten Signature __LOKESH PANCHETI_______ Candidate Printed Name __________________________ Date __________________________ Signature of Recruiting Firm Representative __________________________ Recruiting Representative Printed Name __________________________ Date

Sign up to vote on this title
UsefulNot useful