WPCH nA 􎽋) W܋]V(ڞ[l1mza\mFjضlʭK?kţNԟOwmKz夯NO o[jlpbI8Ⱥ6AAAA!@C  HCLISTNAMESOFTHREEPERSONS(NOTFORMEREMPLOYERSORRELATIVES).   *01 Xddd Xdd Xdd XX%X%,: bb, bb,bb,fbb+  9EEF$ 8d9NAME ;EEF&EEFd d;ADDRESS ;EEF&EEFd d;BUSINESS&POSITION ;EEEF&EEFd d;TELEPHONE HEE9$ 8 EEEFd 8dH >EE/EEd d> >EE/'EEd d> 9EEE&EEd d9 HEE9$! 8 EEEd 8dH 5EE& "EEd d5 5EE& #EEd d5 9EEE& $EEd d9 JEEE9$) 8 EEEd 8dJ 7EEE&-EEEd d7 7EEE&.EEEd d7 9EEEE&/EEEd d94*(3 8  EEEEd 4U*JjU5k!!!!5MILITARYEXPERIENCE 5   5D 5*23dXd: bb:  bb bbfbbf01X%X%, dd , dd , dd +  &EEF 6  &BRANCHOFSERVICE /EEF!67EEF /OCCUPATIONALSPECIALTY /EEEF!68EEF /TYPEOFDISCHARGE 2EE#!69EEEF 2 2EE#!^"~ :EE 2 -EEE^"~ ;EE - 4EEE#^"~ <EEE 4 4EEE#!#!=EEE 4 -EEEE#!>EEE -(#!?  EEEE (  EDUCATION:VERIFICATIONOFCOMPLETIONOFANYDEGREEREQUESTED.COPIESOFATRANSCRIPTWILLBEACCEPTED. %$A @\ W g &$ AA@@\ W g&$@7C  H&$C*45 Xdd dd dd  dd  23X%X%,bb,P bb,)bb,bb,jbb+  9EEF$&$B&$ 8d9SCHOOL ;EEF&&$CEEFd d;NAMEANDADDRESS ;EEF&&$DEEFd d;COURSEOF &$E STUDY ;EEF&'%FEEFd d;CIRCLELAST &$G YEAR '%H COMPLETED DEEEF/F(f&IEEFd dDLISTDIPLOMAOR &$J DEGREE WEEFB-'%K 8 EEEFd 8dWELEMENTARY 5EE&)(MEEFd d5 5EE&B)b'NEEd d5 5EE&B)b'OEEd d55678 9EEE&)(QEEd d9 NEEF9$)(S 8 EEEd 8dNHIGH 5EE&+)UEEFd d5 5EE&*)VEEd d5 5EE&*)WEEd d51234 9EEE&+)YEEd d9 NEEF9$*)Z 8 EEEd 8dNCOLLEGE >EE/V-v+\EEFd d> >EE/',*]EEd d> 5EE&,*^EEd d51234 9EEE&V-v+`EEd d9. NEEEF9$V-v+b 8 EEEd 8dNOTHER /&-d (SPECIFY) @EEE//-eEEEFd d@ @EEE/'R.r,fEEEd d@ 7EEE&R.r,gEEEd d71234 9EEEE&/&-iEEEd d94*(R.r,j 8  EEEEd 4  ~0.j F <2hh<   EMPLOYMENTHISTORY    LISTBELOWALLPRESENTANDPASTEMPLOYMENT,BEGINNINGWITHYOURMOSTRECENT.   ^ *(*XdXdbbP bbP )bb)bbjbbj45X%X%,( bb,bb,bb,bb,bb,bb+  9EEF$ 8d9 NAMEANDADDRESSOFCOMPANY  J ANDTYPEOFBUSINESS ;EEF&EEFd d;  FROM  J MO./YR. DEEF/' EEFd dD  TO  J MO./YR. DEEF/'  EEFd dD  POSITION DEEF/' J  EEFd dDT!MONTHLY  J  STARTING   SALARY ;EEEF&t EEFd d;MONTHLY  J LAST  SALARY HEE9$t 8 EEEFd 8dH 5EE&XEEd d5 5EE&pEEd d5 5EE&pEEd d5 5EE&pEEd d5 9EEE&pEEd d9 NEEF9$p 8 EEEd 8dN TELEPHONE   J  5EE&EEFd d5 5EE& JEEd d5 5EE& JEEd d5 5EE& JEEd d5 9EEE& JEEd d9 NEEF9$ J 8 EEEd 8dN REASONFORLEAVING     5EE&f  EEFd d5 5EE& !EEd d5 5EE& "EEd d5 5EE& #EEd d5 9EEE& $EEd d9 NEEEF9$ % 8 EEEd 8dN NAMEOFSUPERVISOR  X &  1EEE  J 'EEEFd 1 +EEEX (EEE + +EEEX )EEE + +EEEX *EEE + 3EEEE X +EEE d34*(X , 8  EEEEd 4*+,XdXd( bb( bbbbbbbbbb(*X%X%,( bb,bb,bb,bb,bb,bb+  9EEF$p -p  8d9 NAMEANDADDRESSOFCOMPANY  . ANDTYPEOFBUSINESS ;EEF&\ /EEFd d;  FROM  0 MO./YR. DEEF/'\ 1 EEFd dD  TO  2 MO./YR. DEEF/'\ 3 EEFd dD  POSITION DEEF/' 4 EEFd dDw+MONTHLY  5 STARTING \ 6 SALARY ;EEEF&N 7EEFd d;MONTHLY  8 LAST \ 9 SALARY HEE9$N : 8 EEEFd 8dH 5EE&<EEd d5 5EE& J=EEd d5 5EE& J>EEd d5 5EE& J?EEd d5 9EEE& J@EEd d9 NEEF9$ JA 8 EEEd 8dN TELEPHONE B  5EE&\CEEFd d5 5EE&DEEd d5 5EE&EEEd d5 5EE&FEEd d5 9EEE&GEEd d9 NEEF9$H 8 EEEd 8dN REASONFORLEAVING XI  5EE& JJEEFd d5 5EE&XKEEd d5 5EE&XLEEd d5 5EE&XMEEd d5 9EEE&XNEEd d9 NEEEF9$XO 8 EEEd 8dN NAMEOFSUPERVISOR FP  7EEE&QEEEFd d7 7EEE&FREEEd d7 7EEE&FSEEEd d7 7EEE&FTEEEd d7 9EEEE&FUEEEd d94*(FV 8  EEEEd 4*-/ XdXd( bb( bbbbbbbbbb+,X%X%,( bb,bb,bb,bb,bb,bb+  9EEF$*hW*h 8d9 NAMEANDADDRESSOFCOMPANY bX ANDTYPEOFBUSINESS ;EEF&TYEEFd d;  FROM bZ MO./YR. DEEF/'T[ EEFd dD  TO b\ MO./YR. DEEF/'T] EEFd dD  POSITION DEEF/'b^ EEFd dD5MONTHLY b_ STARTING T` SALARY ;EEEF&aEEFd d;MONTHLY bb LAST Tc SALARY HEE9$d 8 EEEFd 8dH 5EE&pfEEd d5 5EE&gEEd d5 5EE&hEEd d5 5EE&iEEd d5 9EEE&jEEd d9 NEEF9$k 8 EEEd 8dN TELEPHONE bl  5EE&TmEEFd d5 5EE&bnEEd d5 5EE&boEEd d5 5EE&bpEEd d5 9EEE&bqEEd d9 NEEF9$br 8 EEEd 8dN REASONFORLEAVING Ps  5EE&tEEFd d5 5EE&PuEEd d5 5EE&PvEEd d5 5EE&PwEEd d5 9EEE&PxEEd d9 NEEEF9$Py 8 EEEd 8dN NAMEOFSUPERVISOR z  7EEE&v{EEEFd d7 7EEE&|EEEd d7 7EEE&}EEEd d7 7EEE&~EEEd d7 9EEEE&EEEd d94*( 8  EEEEd 4 *AB XdXd( bb( bbbbbbbbbb-/X%X%,#bb+  @EEEE- " " 8d@SUMMARIZEHEREANYADDITIONALEXPERIENCESAND/ORSKILLSYOUMAYHAVE. !Z A) xxdEG""A !  A) xxdE""A W"  =31"! 8 EEEEd = *eCGdXd#bb#ABX%X%e,#dd +  $EEEE#!#! $  IFYOUHAVEEVERASANADULTBEENCONVICTEDOFAMISDEMEANORORFELONYOTHERTHANAMINORTRAFFIC $D" VIOLATIONPLEASELISTDATEANDNATUREOFOFFENSE. #Cf##Xm~XC#CXXm~fC A)dE:%A $" @A) xxdE%"A n%#   HAVEYOUBEENCONVICTEDOFANYOFFENSEINVOLVINGTHESEXUALMOLESTATION,PHYSICALORSEXUALABUSE,OR &$ RAPEOFACHILD?IFYESEXPLAINA)( dE( 'A ]'% BA) xxdE("A (O& #Cf:A##Xm~XCA#XrXXXm~fXXr((& EEEE (*_HI Xdd#dd #CGX%X%_,#bb+  7EEEE$|)'|)' 8d7#XrXfC#XXr  THEANSWERSTOTHEFOREGOINGQUESTIONSARETRUEANDCORRECTTOTHEBESTOFMYKNOWLEDGE.IUNDERSTANDTHATAS )' PARTOFNORMALEMPLOYMENTPROCEDURES,AROUTINEINQUIRYMAYBEMADECONCERNINGINFORMATIONONMYCHARACTER, T*( GENERALREPUTATION,CREDIT,PERSONALCHARACTERISTICSANDMODEOFLIVING.IAUTHORIZESUCHINVESTIGATIONAND *2) UNDERSTANDTHAT,UPONWRITTENREQUEST,INFORMATIONASTOTHENATUREANDSCOPEOFTHEINQUIRY,IFONEISMADE,WILL +) BEPROVIDED. 4,r* #XrXE#%EfXXrSIGNATURE򀀀__Ԁ____DATE_򀀀__ -+ SOCIALSECURITYNO.򀀀󀀀ORDRIVERSLICENSENO.򀀀 ..-   9/-/- 8  EEEEd 9   1/ APPLICANTDATARECORD R   QUALIFIEDAPPLICANTSARECONSIDEREDFORALLPOSITIONS,ANDEMPLOYEESARETREATEDDURINGEMPLOYMENT h WITHOUTREGARDTORACE,COLOR,RELIGION,SEX,NATIONALORIGIN,AGE,MARITALORVETERANSTATUS,MEDICAL P CONDITIONORHANDICAP.   ASEMPLOYERS/GOVERNMENTCONTRACTORS,WECOMPLYWITHGOVERNMENTREGULATIONSANDAFFIRMATIVE  N  ACTIONRESPONSIBILITIES.    SOLELY,TOHELPUSCOMPLYWITHGOVERNMENTRECORDKEEPING,REPORTINGANDOTHERREQUIREMENTS,PLEASE  L  FILLOUTTHEDATARECORD.   THISDATAWILLBEKEPTINACONFIDENTIALFILE.  J  SEX:M___________________________________________________________F_______________________________________  H  RACE:WHITE____________BLACK________________HISPANIC________________AMERICANINDIAN_______________ F ASIAN:____________________________________________OTHER:#XrXfG#fXXr#CfC#fC__________________________________________________ \ AREYOUACITIZENOFTHEU.S.A.? Z HAVEYOUEVERBEENBONDED?________IFYES,ONWHATJOBS?___________________________________________  ___________________________________________________________________________________________________________ @  XHAVEYOUEVERBEENCONVICTEDOFACRIME,EXCLUDINGMISDEMEANORSANDSUMMARYOFFENSES,INTHEPAST ># TENYEARSWHICHHASNOTBEENANNULLEDOREXPUNGEDORSEALEDBYACOURT?_____IFYES,DESCRIBEINFULL $ Ѐ̀ ' ___________________________________________________________________________________________________________ R( ___________________________________________________________________________________________________________ * ___________________________________________________________________________________________________________ 8, ___________________________________________________________________________________________________________ N . LISTANYFRIENDSORRELATIVESWORKINGFORUS,OTHERTHANSPOUSE:______________________________________ L" 1 ___________________________________________________________________________________________________________ #!3 ___________________________________________________________________________________________________________ $2#5 ___________________________________________________________________________________________________________ H&$7 ___________________________________________________________________________________________________________ '%9 #XrXfN# XXr#  ^N#^  #  ^V##Xm~X U#