Apd 5A Form PDF Details

If you are a public school employee, then it is possible that at some point during the year you will need to complete an Apd 5A form. This form can be used in many different situations, but most commonly it is used when your child needs to take medications on campus. The process for completing this document can vary depending on what type of medication your child has been prescribed and by whom. Below are some basic guidelines for filling out the Apd 5A Form. If you have any questions or concerns about how to fill out this document please feel free to contact us with details about your situation so we may better assist you with finding appropriate information related to your specific circumstance.

This information will aid you to comprehend better the details of the apd 5a form before starting filling it out.

QuestionAnswer
Form NameApd 5A Form
Form Length24 pages
Fillable?Yes
Fillable fields1118
Avg. time to fill out38 min 16 sec
Other namesnypd forms cas 5a printable, cas 67 telephone reference check, cas 5a form, cas 67 telephone reference check nypd

Form Preview Example

 

POLICE DEPARTMENT

 

 

APD-5A

 

CITY OF NEW YORK

CIVILIAN TITLES

Personal History of: _____________________

 

 

 

 

 

 

 

Surname

 

First Name

 

 

M.I.

Applicant for appointment as:

 

 

 

 

 

 

 

Exam No. __________ List No. __________

Social Security No.:

 

 

 

 

The answers to questions in this questionnaire must be printed in BLACK INK BY THE APPLICANT. TWO (2) copies of this questionnaire are furnished, BOTH are to be completed, notarized in the space provided on page 18, and returned to your assigned investigator as directed. If the space is insufficient to complete your answer to any question, use pages eighteen through twenty-two (18-22) which have been provided for that purpose. Indicate the question number and continue your answer. If a question is not applicable, indicate such by entering “N/A” or “NONE”. Do not leave any question blank. Mistakes made should ONLY be corrected by drawing a single line through the mistake, placing your initials at the end. MISTAKES ARE NEVER TO BE CORRECTED WITH OPAQUE CORRECTION FLUID.

Applicants are cautioned to answer every question, truthfully, completely and without evasion. Both the N.Y. State Civil Service Law and the Personnel Rules of the City of New York, (which have the force and effect of the law) provide penalties for making a false statement of material fact in any application, or for practicing any fraud or deception in obtaining or attempting to obtain municipal employment. Such penalties include rejection for appointment, revocation of appointment, and prosecution.

Civil Service lists are valid for a period of up to four (4) years from the date of promulgation. Once the Civil Service list expires, appointment from that list is no longer possible. For this reason, all candidates are urged to submit all documents as expeditiously as possible. All candidates are cautioned that failing to appear for scheduled appointments could jeopardize chances for appointment.

THE NEW YORK CITY POLICE DEPARTMENT

IS AN EQUAL OPPORTUNITY EMPLOYER

Page 1

 

<![endif]>Control No

<![endif]>Exam No.

 

<![endif]>.

 

 

<![endif]>________________________________

<![endif]>_________ List No.Soc

 

 

<![endif]>. Sec. No.

<![endif]>APD-5A

<![endif]>Surname

<![endif]>__________________________________

 

<![endif]>First Name

<![endif]>____________________

 

<![endif]>Mid. Init

<![endif]>______

 

<![endif]>.

 

PD 407-151A(Rev. 09-10)

I. PERSONAL DATA

1.

Last Name

First Name

Mid. Init.

Social Security No.

a. Have you ever had a legal name change? If so,

 

 

From: ________________________

To: ____________________ Reason: ____________________________

Court: _________________________________________________ Index No.: ___________________________

If by marriage, date of marriage: _____________________________

b. List below, any other name, alias, nickname, by which you have been known, including maiden name if you are a married female, with the reason for such use:

c. Do you have any tattoos, brands, body piercings, or other body art? Yes No

If yes, include the location and complete description, including symbolized meaning and reason for getting same.

2.

Sex: Male Female

3. Date of Birth: Month: __________ Day: _________ Year: ________

4.Birth Certificate:

 

 

 

Certificate Number

City or Town

 

 

County

 

State

5.

 

Citizenship:

Citizen of the U.S.A.?

Yes

No

 

 

 

 

 

 

 

a. What country were you born in? __________________________________

 

 

 

 

b. If not born in U.S.A., date entered U.S.A. _______________________________

 

 

 

 

c. If you are a naturalized citizen of the U.S.A., list below,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Naturalization Certificate No.

Date

Court

 

 

City

 

State

 

d. Do you have dual citizenship with another country? Yes No

 

 

 

 

If yes, what country? ______________________________ When was it obtained? _________________________

 

 

How was it obtained? ___________________________________________________________________________

6.

 

Do you have a U.S. Resident Alien Card?

Yes

No

Expiration: __________________

 

 

If yes, how was it obtained? (Lottery, etc.) ___________________________________________________________

 

 

Alien Registration No. __________________________________________________

 

 

7.

 

Do you have a U.S. passport? Yes

No

 

 

 

 

 

 

 

 

If yes, passport no. ________________________ Date Issued ____________ Expiration Date ________________

 

 

a. Have you ever reported a passport lost or stolen?

Yes

No If yes, describe the circumstances of

 

 

the loss to include the date, location and police report number: __________________________________________

 

______________________________________________________________________________________________

 

 

b. Do you now have or have you ever had a foreign passport?

Yes No If yes, date issued ___________

 

 

Date of Surrender/Expiration ________________

Issuing Country____________________________________

 

 

c. Have you ever applied for a travel visa to travel to or from any country? If so, Date _______________________

 

 

Country ________________

Reason_______________________________________________________________

 

 

Has a visa ever been denied? ______________________________________________________________________

8.What countries outside of the U.S.A. have you traveled to? Include dates and how long you were in the country:

Country & Town, or City

Dates

Length of Stay

Purpose of Visit

 

 

 

 

 

 

 

 

 

 

 

 

Initial this page to indicate that you have provided complete and accurate information: __________

Page 2

9.Marital Status:

 

 

Single Married Legally Separated Divorced Widowed Registered Domestic Partner/Civil Union

 

 

 

 

 

 

 

 

 

Spouse/Registered Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

Home Address (number/street/apt.)

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.O.B.

 

Occupation

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Address (number/street/apt.)

City

State

ZIP

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work Phone

 

Cell Phone

Email

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual?

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Former Spouse/Registered Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

Home Address (number/street/apt.)

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.O.B.

 

Occupation

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Address (number/street/apt.)

City

State

ZIP

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work Phone

 

Cell Phone

Email

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual?

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Former Spouse/Registered Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

Home Address (number/street/apt.)

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.O.B.

 

Occupation

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Address (number/street/apt.)

City

State

ZIP

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work Phone

 

Cell Phone

Email

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual?

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Former Spouse/Registered Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

Home Address (number/street/apt.)

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.O.B.

 

Occupation

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Address (number/street/apt.)

City

State

ZIP

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work Phone

 

Cell Phone

Email

 

 

 

 

 

(

)

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual?

 

 

 

 

Yes

No

 

 

 

 

 

Initial this page to indicate that you have provided complete and accurate information: __________

Page 3

II.RESIDENCE RECORD

10.Starting with your present address and working back, list each address (including temporary addresses) at which you have resided. Please include military and college (campus and/or off-campus) addresses. All foreign addresses must be included:

FROM

TO

Mo. Yr.

Mo.

Yr.

 

 

 

Street

Address

Apt.

No.

City or

Town

County of

Zip

State Code

PRESENT

a. Do you now or have you ever owned/co-owned any home/co-op/condo or other property? Yes No . If yes, list

AddressCity/ TownStateZipCounty

b. With whom do you co-own? ____________________________________________________________________

c. All Residence telephone number(s): (Area Code) _____-_____-________

d. All Cell phone number(s): (Area Code) _____-_____-________

e. Email address(es): _____________________________________, _____________________________________

f. Do you now have or have you ever had an account on a social networking site, such as MySpace, Facebook or Twitter? Yes No

If yes, indicate address(es) ______________________, ______________________, ______________________

III.FAMILY RECORD

11.List below all of your living or deceased children, including natural, adopted, and/or foster care. Include any other children who have ever resided with you. Provide the name and contact information of the other parent or guardian.

Child’s Name (Last, First)

 

Sex

D.O.B.

Does Child Reside with You? Yes No

If No, Enter Full Address

 

 

 

 

 

 

 

 

 

Who has Custody of Child? Include Name and Relationship

Name of other Parent

 

 

 

 

 

 

 

 

 

 

Parent’s D.O.B.

 

Parent’s Home Address

Parent’s Contact Phone No.

 

 

 

 

 

 

 

 

 

Parent’s Occupation

Parent’s Work Address

 

 

Candidate’s Current Relationship with other Parent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child’s Name (Last, First)

 

Sex

D.O.B.

Does Child Reside with You? Yes No

If No, Enter Full Address

 

 

 

 

 

 

 

 

 

Who has Custody of Child? Include Name and Relationship

Name of other Parent

 

 

 

 

 

 

 

 

 

 

Parent’s D.O.B.

 

Parent’s Home Address

Parent’s Contact Phone No.

 

 

 

 

 

 

 

 

 

Parent’s Occupation

Parent’s Work Address

 

 

Candidate’s Current Relationship with other Parent

 

 

 

 

 

 

 

 

 

Initial this page to indicate that you have provided complete and accurate information: __________

Page 4

 

Child’s Name (Last, First)

 

Sex

D.O.B.

Does Child Reside with You? Yes No

If No, Enter Full Address

 

 

 

 

 

 

 

Who has Custody of Child? Include Name and Relationship

Name of other Parent

 

 

 

 

 

 

 

 

 

Parent’s D.O.B.

 

Parent’s Home Address

 

Parent’s Contact Phone No.

 

 

 

 

 

 

 

 

 

Parent’s Occupation

Parent’s Work Address

 

 

Candidate’s Current Relationship with other Parent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child’s Name (Last, First)

 

Sex

D.O.B.

Does Child Reside with You? Yes No

If No, Enter Full Address

 

 

 

 

 

 

 

Who has Custody of Child? Include Name and Relationship

Name of other Parent

 

 

 

 

 

 

 

 

 

Parent’s D.O.B.

 

Parent’s Home Address

 

Parent’s Contact Phone No.

 

 

 

 

 

 

 

 

 

Parent’s Occupation

Parent’s Work Address

 

 

Candidate’s Current Relationship with other Parent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child’s Name (Last, First)

 

Sex

D.O.B.

Does Child Reside with You? Yes No

If No, Enter Full Address

 

 

 

 

 

 

 

 

 

 

 

Who has Custody of Child? Include Name and Relationship

Name of other Parent

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent’s D.O.B.

 

Parent’s Home Address

 

Parent’s Contact Phone No.

 

 

 

 

 

 

 

 

 

 

 

Parent’s Occupation

Parent’s Work Address

 

 

Candidate’s Current Relationship with other Parent

 

 

 

 

 

 

 

 

 

 

a. Additional children listed on pages 18-22?

Yes No

 

 

b. What provisions have you made for the support of the children listed above?

________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

c. Do any of your children receive child support or other supportive income? (Social Security, disability) Yes No If yes, explain: __________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

IV. FAMILY RECORD AND REFERENCES

12.List the full names of biological mother and father; stepmothers/stepfathers; grandfathers; grandmothers; father-in-law; mother-in-law, living or deceased. The complete address for each must be listed (include city and state).

 

Father’s Name

Home Address (number/street/apt.)

 

 

City

State ZIP

 

 

 

 

 

 

 

 

 

Work Address (number/street/apt.)

 

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Phone

 

 

Cell Phone

 

 

 

 

 

 

 

 

 

 

 

D.O.B.

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (Village or Town, City, State, Country)

 

 

 

 

 

 

 

 

 

 

Initial this page to indicate that you have provided complete and accurate information: __________

 

Page 5

Mother’s Name

Home Address (number/street/apt.)

 

 

City

State ZIP

 

 

 

 

 

 

 

Work Address (number/street/apt.)

 

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Phone

 

 

Cell Phone

 

 

 

 

 

 

 

 

 

D.O.B.

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (Village or Town, City, State, Country)

N/A

Stepfather’s Name

Home Address (number/street/apt.)

 

 

City

State ZIP

 

 

 

 

 

 

 

Work Address (number/street/apt.)

 

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Phone

 

 

Cell Phone

 

 

 

 

 

 

 

 

 

D.O.B.

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (Village or Town, City, State, Country)

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stepmother’s

Name

Home Address (number/street/apt.)

 

 

City

State ZIP

 

 

 

 

 

 

 

Work Address (number/street/apt.)

 

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Phone

 

 

Cell Phone

 

 

 

 

 

 

 

 

 

D.O.B.

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (Village or Town, City, State, Country)

N/A

 

Father-in-law’s Name

Home Address (number/street/apt.)

 

 

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

 

Work Address (number/street/apt.)

 

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Phone

 

 

Cell Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.O.B.

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (Village or Town, City, State, Country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mother-in-law’s Name

Home Address (number/street/apt.)

 

 

City

State

ZIP

 

 

 

 

 

 

 

 

 

 

Work Address (number/street/apt.)

 

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Phone

 

 

Cell Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D.O.B.

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (Village or Town, City, State, Country)

 

 

 

 

 

 

 

 

 

 

 

Initial this page to indicate that you have provided complete and accurate information: __________

 

 

Page 6

N/A

Grandmother’s Name

Home Address (number/street/apt.)

 

 

City

State ZIP

 

 

 

 

 

 

 

Work Address (number/street/apt.)

 

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Phone

 

 

Cell Phone

 

 

 

 

 

 

 

 

 

D.O.B.

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (Village or Town, City, State, Country)

N/A

Grandfather’s Name

Home Address (number/street/apt.)

 

 

City

State ZIP

 

 

 

 

 

 

 

Work Address (number/street/apt.)

 

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

 

Home Phone

 

Work Phone

 

 

Cell Phone

 

 

 

 

 

 

 

 

 

D.O.B.

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (Village or Town, City, State, Country)

a.List the full names of all biological brothers and sisters; half-brothers/half-sisters; stepbrothers/stepsisters; uncle; aunt; great aunt; great uncle; first cousin; nephew; niece; fiancé or fiancée, living or deceased (include females’ maiden names). The complete address for each must be listed (must include city and state).

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

Initial this page to indicate that you have provided complete and accurate information: __________

Page 7

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

b.List any person(s) who has ever resided with you, whether related to you or not (include females’ maiden names). The complete address for each must be listed (must include city and state).

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N/A

Name

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

Initial this page to indicate that you have provided complete and accurate information: __________

Page 8

c.List 5-6 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.

Name

 

How do you know this person?

 

 

 

 

 

(for example: friend, teacher,

 

 

 

 

 

family friend, co-worker)

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

How do you know this person?

 

 

 

 

 

(for example: friend, teacher,

 

 

 

 

 

family friend, co-worker)

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

How do you know this person?

 

 

 

 

 

(for example: friend, teacher,

 

 

 

 

 

family friend, co-worker)

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

How do you know this person?

 

 

 

 

 

(for example: friend, teacher,

 

 

 

 

 

family friend, co-worker)

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

How do you know this person?

 

 

 

 

 

(for example: friend, teacher,

 

 

 

 

 

family friend, co-worker)

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

How do you know this person?

 

 

 

 

 

(for example: friend, teacher,

 

 

 

 

 

family friend, co-worker)

 

 

 

Home Address (number/street/apt.)

City

State

ZIP

D.O.B.

 

 

 

 

 

 

Work Address (number/street/apt.)

City

State

ZIP

Occupation

 

 

 

 

 

 

 

Home Phone

Work Phone

 

Cell Phone

 

 

Email

 

 

 

 

 

 

 

Initial this page to indicate that you have provided complete and accurate information: __________

Page 9

V.FOREIGN CONTACTS (OR LANGUAGE)

13a. Do you speak, read, write, or understand a foreign language? Yes No . If Yes, list language(s) and educational level of proficiency: ____________________________________________________________________

b.How often is each language(s) used? ________________________________________________________________

c.With whom is each language used? ____________________________ How often?__________________________

d.Is this person inside or outside of the United States? Inside Outside

If outside, list country ____________________________________________________________________________

VI. EDUCATION RECORD

14. List all schools you have attended beginning with the 9th grade:

School Name,

City, State and Zip Code

Month and Year

Attended

From To

Number of Credit Hours

Completed

Semester Quarter

Type of Degree

(e.g. H.S. Diploma,

B.A., M.A.)

Month and Year

of Graduation,

Degree

a.List any other schools attended, including but not limited to, trade, vocation, business, professional and occupational licenses, training courses, internships, certificate programs, etc. List the dates of attendance.

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

b.

High school diploma from an accredited U.S. Institution? Yes No

G.E.D.

Yes No

 

If “Yes”, G.E.D.-Issuing State _____________________ Date Issued ___________

Other ___________________

c.Were you ever the subject of any disciplinary action at any educational institution which you attended?

Yes No If “yes” give details on pages 18 through 22. (School name, disposition date, etc.)

VII. EMPLOYMENT RECORD

15.Have you ever been fired or suspended from any job, or has any form of disciplinary action been taken against you by any employer? Yes No . If Yes, explain below.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

List below, starting with your current employment-or unemployment - and working back, each period of employ- ment and period of unemployment you have had. Include within the sequence any period of active military ser- vice. If you were discharged from any employment, or requested to resign, so state under “Reason for leaving employment”. DO NOT LEAVE ANY TIME PERIODS UNACCOUNTED FOR.

From

 

 

 

To

 

Full Time

Name of Supervisor:

Mo.:

 

Yr.:

 

 

 

PRESENT

Part Time

 

 

 

 

 

 

Company Name (it unemployed, so state)

 

 

Type of work you performed:

Street Address of Company

Employer’s Telephone Number:

City, State and Zip Code

Reason for leaving employment:

From

 

 

 

To

 

 

Full Time

Name of Supervisor:

Mo.:

Yr.:

 

 

Mo.:

 

Yr.:

 

Part Time

 

 

 

 

 

 

 

 

Company Name (if unemployed, so state)

 

 

 

Type of work you performed:

Street Address of Company

Employer’s Telephone Number:

City, State and Zip Code

Reason for leaving employment:

Continue employment entries on Page 11

Initial this page to indicate that you have provided complete and accurate information: __________

Page 10

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