Uson Employment Application Form PDF Details

The Uson Employment Application form serves as a comprehensive resource for individuals seeking employment with US Oncology or any affiliated medical practice. Given its nature as an Equal Opportunity Employer, the form is meticulously designed to ensure fairness and compliance with employment laws, outlining personal data, work preferences, educational background, professional licenses or certifications, additional skills, and military service. It also inquires about an applicant's employment history, driving record (if applicable to the job), and provides space for business references. Importantly, the form includes a section dedicated to Applicant Statements, where individuals can disclose any past convictions or current investigations related to professional conduct, which is vital in the healthcare sector. Furthermore, the application emphasizes the at-will employment agreement, confirming that either party may terminate the employment relationship at any time. A certification and attestation section requires applicants to verify the accuracy of their provided information, understanding that any falsification may lead to termination if hired. Lastly, the form is clear about its stance on equal employment opportunities, disregarding any discrimination based on race, religion, color, national origin, sex, age, ancestry, handicap/disability, veteran's status, or any other protected category, aligning with federal, state, and local laws to ensure fair treatment for all candidates.

QuestionAnswer
Form NameUson Employment Application Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesuson application, uson application form printable, uson employment, employment application uson make

Form Preview Example

USON* EMPLOYMENT APPLICATION

AN EQUAL OPPORTUNITY EMPLOYER

*In this Application and in various other documents, forms, guidelines, etc., “USON,” “the company,” and similar terms refer to the employer of the applicable employee. The use of these general terms is for the ease and convenience of the reader and should be read to refer to, as applicable, (1) US Oncology or (2) a separate, physician-owned Affiliated Medical Practice. Use of these terms and/or an Affiliated Medical Practice’s use of this Application or other documents, forms, or guidelines should not be construed as signifying US Oncology’s ownership in or control of any Affiliated Medical Practice (or vice versa) or US Oncology’s employment or control of the Affiliated Medical Practice’s employees(or vice versa). All employment decisions are solely the responsibility of the company or entity that employs the applicable employee

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PERSONAL DATA

 

(Print) First Name

 

 

 

 

 

 

 

 

 

 

 

Middle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Address (number and street)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

State

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List any other names used (alias, maiden, nickname, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home E-mail Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Telephone

 

 

 

 

 

 

 

 

 

 

 

Other Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you eligible to work in the United States?

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of relative(s) employed by USON

 

 

 

 

 

 

 

Relationship

 

 

 

 

 

 

 

 

Occupation

 

 

 

Location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WORK PREFERENCES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of employment for which you are applying

 

 

 

 

 

 

 

 

 

 

Nature of position you seek

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full-time

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Regular

 

Temporary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position(s) desired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What is your career objective?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location preferences

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Approximate salary expected

Date available

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REMARKS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How did you hear about this position? If employee referral,

 

 

 

 

Do you know any of our employees?

 

 

If Yes, please provide their names.

 

 

Relationship?

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

please provide the name of the person who referred you.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever been employed by this company or any

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

Position

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location

 

medical practice affiliated with US Oncology?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EDUCATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City and State

 

 

 

 

 

Did you

 

 

 

Degrees and Honors

Name under which you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

graduate?

 

 

 

Include Field of Study

graduated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

Diploma

 

 

GED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

College or University + Campus Name, if known

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Post Graduate Education + Campus Name, if known

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language #1 __________________________________________

 

 

Language #2 ___________________________________________

 

 

 

 

 

Fluently

 

 

 

Moderately well

 

 

With difficulty

 

 

 

Read

 

 

Fluently

 

 

Moderately well

 

 

With difficulty

 

Foreign Languages

Read

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Write

Fluently

 

Moderately well

 

With difficulty

 

 

Write

 

Fluently

Moderately well

 

With difficulty

 

 

 

 

 

 

 

 

 

Speak

Fluently

 

Moderately well

 

With difficulty

 

 

Speak

 

Fluently

Moderately well

 

With difficulty

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROFESSIONAL LICENSE/CERTIFICATION

Type:

Professional License/Certification Number:

State of issuance:

 

 

 

Type:

Professional License/Certification Number:

State of issuance:

THIS IS NOT AN EMPLOYMENT CONTRACT AND DOES NOT ALTER ANY EMPLOYEE’S AT-WILL EMPLOYMENT STATUS, WHICH MEANS EITHER THE EMPLOYEE OR THE EMPLOYER MAY TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANYTIME, FOR ANY REASON, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE.

Applicant Name: _____________________________________________________________________

ADDITIONAL SKILLS

APPLICANT SHOULD NOTE ANY INFORMATION PERTINENT TO HIS OR HER QUALIFICATIONS NOT COVERED BY THIS APPLICATION. USE BACK PAGE AS NEEDED.

Special Abilities, Computer Skills, Machines Operated, Professional Activities & Achievements, Patents, Significant Projects, etc.

U.S. MILITARY SERVICE

Branch of U.S. Services

 

Date Entered

Date Discharged

 

 

Month

 

Year

Month

 

Year

 

 

 

 

 

 

 

 

Nature of duties and any special training and honors received

EMPLOYMENT

LIST THE TWO MOST RECENT EMPLOYERS IN THE PAST FIVE YEARS

 

 

 

Date

Company Name, Street Address, City, and State

Position

 

Ending Salary/Wage

 

 

 

Month and Year

List Temp/Staffing Agency if that is actual employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. From:

 

 

 

 

 

$__________________

 

 

 

 

 

 

 

 

 

1. To:

 

 

 

 

 

per ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Supervisor:

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

Name used if different from current name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for Leaving:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

Company Name, Street Address, City, and State

Position

 

Ending Salary/Wage

 

 

 

Month and Year

List Temp/Staffing Agency if that is actual employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. From:

 

 

 

 

 

$__________________

 

 

 

 

 

 

 

 

 

2. To:

 

 

 

 

 

per ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Supervisor:

 

 

Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

Name used if different from current name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for Leaving:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BUSINESS REFERENCES

 

 

 

 

 

 

 

 

 

 

 

Name and Relationship

 

 

Company Name and Location City and State

 

Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DRIVING RECORD

 

 

 

 

 

 

 

(TO BE COMPLETED IF IT IS A JOB REQUIREMENT)

 

 

Type of driver’s license held

 

License Number

Expiration Date

State of Issue

 

 

 

 

 

 

 

 

 

Have you ever had a driver's license revoked?

 

If Yes, please explain.

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HR 02-11-2009

2

Applicant Name: _____________________________________________________________________

APPLICANT STATEMENTS (USE THE BACK PAGE IF MORE SPACE IS NEEDED)

1.Have you ever been convicted of, or pled guilty or nolo contendere to, or participated in pre-trial intervention or the equivalent (e.g., in some states, Deferred Adjudication) for any criminal violation of law (felony or misdemeanor), other than minor traffic

violations?

 

Yes

 

No

If “yes,” please explain (also see the following page):

2.In this or any other state, have you ever been, or are you currently subject to investigation or proceedings which may lead to being sanctioned for, disciplined for, debarred from, and/or excluded from (1) employment within a health care services organization and/or

(2)any activity connected with any governmentally-funded healthcare services (e.g. Medicare, Medicaid, Champus, etc.) organization by a duly authorized regulatory agency for conduct-based or performance-based actions or any other reasons?

Yes

No

If “yes,” please explain:

3.Are there now or have there ever been restrictions, limits, sanctions, revocation and/or any other disciplinary measures imposed upon your current or previous professional, vocational, and/or technical licensure(s), certification(s) and/or registration(s) in this or

any other state?

 

Yes

No If “yes,” please explain:

For Distribution Center Applicants Only:

The Distribution Center is subject to Drug Enforcement Administration regulations that require USON to ask these additional questions. Information furnished or recovered as a result of this inquiry will be treated as confidential and will not necessarily preclude employment, but will be considered as part of an overall evaluation of your qualifications. Any false information or omission of information, however, will jeopardize your position with respect to employment.

4.In the past three years, have you ever knowingly used any narcotics, amphetamines or barbiturates, other than those prescribed to

you by a physician?

 

Yes

No If “yes,” please explain:

 

5.Are you presently formally charged with committing a criminal offense? (Do not include any traffic violations, juvenile offenses or

military convictions, except by general court-martial.)

 

Yes

 

No If “yes,” please explain:

APPLICANT CERTIFICATION AND ATTESTATION OF UNDERSTANDING

“I certify that the facts contained in this employment application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.”

“I UNDERSTAND AND AGREE THAT, IF EMPLOYED, MY EMPLOYMENT IS AT WILL. THAT IS, IT IS FOR NO DEFINITE PERIOD AND MAY BE TERMINATED AT ANY TIME, FOR ANY REASON, WITH OR WITHOUT CAUSE AND WITHOUT ANY PRIOR NOTICE."

“If employed, I agree to notify USON in writing within five (5) days of receiving any written or oral notice of any adverse action, including, without limitation, any filed and served malpractice suit or arbitration action; any adverse action by a State Licensing Board taken or pending; any adverse action which has resulted in the filing of a report with the State Licensing Board or a report to the National Practitioner Data Bank; any revocation of DEA license; a conviction of any felony or a misdemeanor of moral turpitude; any action against any certification under the Medicare or Medicaid programs; or any cancellation, non-renewal or material reduction in medical liability insurance policy coverage. I acknowledge that failure to comply with the above measures, in the event I become employed, can result in disciplinary action or in the termination of my employment.”

Signature of Applicant

Date

USON is an Equal Opportunity Employer.

Employment decisions are made without regard to race, religion, color, national origin, sex, age, ancestry, visible or nonvisible handicap/disability, Veteran's

status, or other characteristics protected under federal, state, or local law.

HR 02-11-2009

3

Applicant Name: _____________________________________________________________________

ADDITIONAL PAGE

Continuation of Question #1 from the previous page:

Offense:

State:

County:

When?

Additional Comments:

Offense:

State:

County:

When?

Additional Comments:

Additional Remarks for Other Questions:

HR 02-11-2009

4

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