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<tbody>
<tr class="odd">
<td colspan="25">The formT This form is available electronically. Form
Approved - OMB No. 0560-0016</td>
</tr>
<tr class="even">
<td colspan="15" rowspan="2"><p><strong>FSA-675 U. S. DEPARTMENT OF
AGRICULTURE</strong></p>
<p>(07-02-99) Farm Service Agency</p>
<p><strong>APPLICATION FOR FSA COUNTY EMPLOYMENT</strong></p></td>
<td colspan="3"><strong>1</strong>. STATE</td>
<td colspan="7"><strong>2</strong>. COUNTY</td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="25"><p><strong>NOTE:</strong> <em>The following statement
is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the
Paperwork Reduction Act of 1980, as amended. The authority for
requesting the following information is 7 CFR Part 7. The information
will be used for recruitment, screening and selection of candidates for
FSA County Office employment. Furnishing the requested information is
voluntary; however, persons not furnishing it will not be considered for
employment. This information may be provided to other agencies, IRS,
Department of Justice, or other State and Federal Law enforcement
agencies, and in response to a court magistrate or administrative
tribunal. The provisions of criminal and civil fraud statutes, including
18 USC 286, 287, 371, 651, 1001; 15 USC 714m; and 31 USC 3729, may be
applicable to the information provided.</em></p>
<p><em>According to the Paperwork Reduction Act of 1995, an agency may
not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is
0560-0016. The time required to complete this information collection is
estimated to average 64 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection
of information. RETURN THIS <strong>COMPLETED FORM TO YOUR COUNTY FSA
OFFICE.</strong></em></p></td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="2"><p><strong>3.</strong> POSITION APPLIED
FOR</p>
<p>     </p></td>
<td colspan="8"><strong>4</strong>. LOWEST SALARY ACCEPTABLE</td>
<td colspan="9"><p><strong>5</strong>. NO. DAYS NOTICE REQUIRED</p>
<p>BEFORE REPORTING TO DUTY</p></td>
</tr>
<tr class="even">
<td colspan="2">$</td>
<td colspan="6">     </td>
<td colspan="9">    </td>
</tr>
<tr class="odd">
<td colspan="4"><strong>6</strong>. NAME <em>(First)</em></td>
<td colspan="2"><em>(Middle)</em></td>
<td colspan="3"><em>(Maiden)</em></td>
<td colspan="7"><em>(Last)</em></td>
<td colspan="9"><strong>7.</strong> SOCIAL SECURITY NUMBER</td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">    </td>
<td colspan="7">     </td>
<td colspan="9">     </td>
</tr>
<tr class="odd">
<td colspan="13"><strong>8</strong>. ADDRESS (<em>street, rural route,
city, state, zip code)</em></td>
<td colspan="12"><strong>9.</strong> U.S. CITIZEN?</td>
</tr>
<tr class="even">
<td colspan="13" rowspan="3">     </td>
<td colspan="3"></td>
<td colspan="2">YES</td>
<td></td>
<td></td>
<td></td>
<td colspan="2">NO</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>10</strong>. TELEPHONE NUMBER <em>(Include area
code)</em></td>
</tr>
<tr class="even">
<td colspan="12">     </td>
</tr>
<tr class="odd">
<td colspan="25"><strong>11</strong>. PLACE OF BIRTH (town or city,
state)</td>
</tr>
<tr class="even">
<td colspan="25">     </td>
</tr>
<tr class="odd">
<td colspan="21"></td>
<td colspan="2">YES</td>
<td colspan="2">NO</td>
</tr>
<tr class="even">
<td colspan="21"><strong>12.</strong> Have you <strong>ever</strong>
been convicted of, or forfeited collateral for <strong>any firearms or
explosive violation</strong>?</td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="21"><strong>13.</strong> Are you <strong>now</strong> under
charges for <strong>any</strong> violation of law?</td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="21"><ol start="14" type="1">
<li><p>During the <strong>last 10 years</strong> have you forfeited
collateral, been convicted, been imprisoned, been on probation, or been
on parole? Do <strong>not</strong> include v</p></li>
</ol>
<blockquote>
<p>violations reported in 13 or 14, above.</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="21"><strong>15</strong>. Have you <strong>ever</strong>
been convicted by a military <strong>court-martial</strong>? If no
military service, answer <strong>“NO”.</strong></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="21"><ol start="16" type="1">
<li><p>Are you <strong>delinquent</strong> on any Federal debt? (Include
delinquencies arising from Federal taxes, loans, overpayment of
benefits, and other debts to the</p></li>
</ol>
<blockquote>
<p>U.S. Government <strong>plus</strong> defaults on Federally
guaranteed or insured loans such as student and home mortgage
loans.)</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>17</strong>. <strong>If “YES” in</strong>:</td>
<td colspan="23"><p>15 - Explain each violation. Give place of
occurrence and name/address of police or court involved.</p>
<p>16 - Explain the type, length and amount of the delinquency or
default, and steps you are taking to correct errors or repay the debt.
Give any identification</p>
<p>number associated with the debt and the address of the Federal agency
involved.</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="24"><strong>NOTE</strong>: If you need more space, use a
sheet of paper, and include the item number.</td>
</tr>
<tr class="odd">
<td colspan="3">ITEM NO.</td>
<td colspan="2"><p>DATE</p>
<p>(Mo./Yr.)</p></td>
<td colspan="10">EXPLANATION</td>
<td colspan="10">MAILING ADDRESS</td>
</tr>
<tr class="even">
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="10">     </td>
<td colspan="10" rowspan="2"><p>Name of Employer, Police, Court, or
Federal Agency</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="10">     </td>
<td colspan="3">City</td>
<td colspan="3">State</td>
<td colspan="4">ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="10">     </td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="10">     </td>
<td colspan="10">Name of Employer, Police, Court, or Federal Agency</td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="10">     </td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="10">     </td>
<td colspan="3">City</td>
<td colspan="3">State</td>
<td colspan="4">ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="10">     </td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="21"></td>
<td colspan="2">YES</td>
<td colspan="2">NO</td>
</tr>
<tr class="odd">
<td colspan="21"><p><strong>18</strong>.Do any of your relatives work
for the United States Government, the United States Armed Forces, or any
County FSA Office? If “yes”, include: father;</p>
<p>mother; husband, wife; son; daughter; brother; sister; uncle; aunt;
first cousin, nephew; niece; father-in-law; mother-in-law; son-in-law;
daughter-in-law, brother-in-law, and sister-in-law.</p></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="7">NAME</td>
<td colspan="8">RELATIONSHIP</td>
<td colspan="10">DEPARTMENT, AGENCY, OR BRANCH OF ARMED FORCES</td>
</tr>
<tr class="odd">
<td colspan="7">     </td>
<td colspan="8">     </td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td colspan="7">     </td>
<td colspan="8">     </td>
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td colspan="7">     </td>
<td colspan="8">     </td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td rowspan="2"><strong>19.</strong></td>
<td colspan="20" rowspan="2">During the last <strong>10 years</strong>,
were you fired from any job for any reason, did you <strong>quit after
being told that you would be fired</strong>, or did you leave by mutual
agreement because of specific problems?</td>
<td colspan="2">YES</td>
<td colspan="2">NO</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td><strong>20.</strong></td>
<td colspan="20">Do you receive, or have you applied for retirement pay,
pension or other based on military, Federal civilian, or District of
Columbia Government service?</td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="25"><em>The U.S. Department of Agriculture (USDA) prohibits
discrimination in all its programs and activities on the basis of race,
color, national origin, age, disability, and where applicable, sex,
marital status, familial status, parental status, religion, sexual
orientation, genetic information, political beliefs, reprisal, or
because all or part of an individual's income is derived from any public
assistance program. (Not all prohibited bases apply to all programs.)
Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape,
etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and
TDD). To file a complaint of discrimination, write to USDA, Director,
Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C.
20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA
is an equal opportunity provider and employer.</em></td>
</tr>
<tr class="even">
<td colspan="10" rowspan="2"><strong>21</strong>. Do you hold any office
or serve in any position with a general or specialized farm or commodity
organization?</td>
<td><strong>YES</strong></td>
<td colspan="3"><strong>NO</strong></td>
<td colspan="11"><p>If yes, give the names of the organization and the
offices and positions held. You may be required to give up these
positions if you are accepted for employment with FSA.</p>
<p><em>(Attach a separate sheet, if necessary.)</em></p></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3"></td>
<td colspan="11">     </td>
</tr>
<tr class="even">
<td colspan="10"><strong>22</strong>. During any past FSA service, have
you ever been removed from office or are you at present disqualified for
future FSA employment?</td>
<td></td>
<td colspan="3"></td>
<td colspan="11"><p>If yes, give details and attach a separate
sheet.</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="25"><strong>23. EDUCATION</strong></td>
</tr>
<tr class="even">
<td colspan="10" rowspan="4"><strong>A</strong>. Did you graduate from
high school? <em>If you have a GED high school equivalency or will
graduate within the next nine months, answer
“<strong>YES</strong>”.</em></td>
<td rowspan="2"><strong>YES</strong></td>
<td colspan="3" rowspan="2"></td>
<td colspan="4" rowspan="2">If “<strong>YES</strong>”, give month, and
year graduated or received GED equivalency.</td>
<td colspan="4">MONTH</td>
<td colspan="3">YEAR</td>
</tr>
<tr class="odd">
<td colspan="4">     </td>
<td colspan="3">    </td>
</tr>
<tr class="even">
<td rowspan="2"><strong>NO</strong></td>
<td colspan="3" rowspan="2"></td>
<td colspan="4" rowspan="2">If “<strong>NO</strong>”, give the highest
grade you completed.</td>
<td colspan="7">HIGHEST GRADE COMPLETED</td>
</tr>
<tr class="odd">
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="25"><strong>B</strong>. DESCRIBE ANY SPECIAL TRAINING YOU
RECEIVED WHICH MAY BE HELPFUL TO YOU IN WORKING FOR THE COUNTY FSA
OFFICE.</td>
</tr>
<tr class="odd">
<td colspan="25">     </td>
</tr>
<tr class="even">
<td colspan="25"><strong>C</strong>.<strong>List All Other Schools
Attended Above High School Level and Give the Following
Information:</strong></td>
</tr>
<tr class="odd">
<td colspan="7" rowspan="2"><strong>1</strong>. NAME AND LOCATION</td>
<td colspan="5"><strong>2</strong>. DATES ATTENDED</td>
<td colspan="5"><strong>3</strong>. COMPLETED</td>
<td colspan="4"><strong>4</strong>. CHECK</td>
<td colspan="4" rowspan="2"><p><strong>5</strong>. DEGREES</p>
<p>RECEIVED</p></td>
</tr>
<tr class="even">
<td colspan="3">FROM</td>
<td colspan="2">TO</td>
<td colspan="3"><p>SCHOOL</p>
<p>YEARS</p></td>
<td colspan="2"><p>CREDIT HOURS</p>
<p><em>(Semester or Quarters)</em></p></td>
<td colspan="2">DAY</td>
<td colspan="2">NIGHT</td>
</tr>
<tr class="odd">
<td colspan="7">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">    </td>
<td colspan="2">     </td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="7">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">    </td>
<td colspan="2">     </td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="7">     </td>
<td colspan="3">     </td>
<td colspan="2">    </td>
<td colspan="3">    </td>
<td colspan="2">     </td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="7">     </td>
<td colspan="3">     </td>
<td colspan="2">     </td>
<td colspan="3">    </td>
<td colspan="2">     </td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="25" rowspan="2"><p><strong>D. Major field of study at
highest level of college work:</strong></p>
<p><strong>     </strong></p></td>
</tr>
<tr class="even">
</tr>
<tr class="odd">
<td colspan="5" rowspan="2"><strong>1</strong>. CHIEF UNDERGRADUATE
COLLEGE SUBJECTS STUDIED AND/OR DEGREE LEVEL</td>
<td colspan="3"><strong>2</strong>. CREDIT HOURS EARNED</td>
<td colspan="8" rowspan="2"><p><strong>3.</strong> CHIEF GRADUATE
COLLEGE SUBJECTS</p>
<p>STUDIED</p></td>
<td colspan="9"><strong>4</strong>. CREDIT HOURS EARNED</td>
</tr>
<tr class="even">
<td colspan="2">SEMESTER</td>
<td>QUARTER</td>
<td colspan="5">SEMESTER</td>
<td colspan="4">QUARTER</td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="8">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="8">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="8">     </td>
<td colspan="5">     </td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="25"><ol start="24" type="1">
<li><p><strong>MILITARY SERVICE</strong></p></li>
</ol>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="5"><strong>A</strong>. BRANCH OF SERVICE</td>
<td colspan="3"><strong>B.</strong> DATE OF ENTRY</td>
<td colspan="8"><strong>C</strong>. DATE OF DISCHARGE</td>
<td colspan="9"><strong>D</strong>. TYPE OF DISCHARGE</td>
</tr>
<tr class="even">
<td colspan="5">     </td>
<td colspan="3">     </td>
<td colspan="8">     </td>
<td colspan="9">     </td>
</tr>
<tr class="odd">
<td colspan="25"><strong>25. REFERENCES <em>(Give name, address and
occupation of two persons not related to you who have knowledge of your
qualifications and abilities)</em></strong></td>
</tr>
<tr class="even">
<td colspan="6"><em><strong>A.</strong> NAME</em></td>
<td colspan="10"><em>ADDRESS</em></td>
<td colspan="9"><em>OCCUPATION</em></td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="10">     </td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="6"><em><strong>B.</strong> NAME</em></td>
<td colspan="10"><em>ADDRESS</em></td>
<td colspan="9"><em>OCCUPATION</em></td>
</tr>
<tr class="odd">
<td colspan="6">     </td>
<td colspan="10">     </td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="25"><em><strong>26. FARM/AGRI-BUSINESS EXPERIENCE (Give
dates, nature, type, and extent of your experience)</strong></em></td>
</tr>
<tr class="odd">
<td colspan="25">     </td>
</tr>
</tbody>
</table>

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| n |       |          |          |   |         |   |                 |
| d |       |          |          |   |         |   |                 |
| w |       |          |          |   |         |   |                 |
| o |       |          |          |   |         |   |                 |
| r |       |          |          |   |         |   |                 |
| k |       |          |          |   |         |   |                 |
| b |       |          |          |   |         |   |                 |
| a |       |          |          |   |         |   |                 |
| c |       |          |          |   |         |   |                 |
| k |       |          |          |   |         |   |                 |
| ) |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * | *     |          | **B**.   |   |         |   | **C**. TITLE OF |
| * | *A**. |          | SALARY   |   |         |   | POSITION        |
| 1 | DATE  |          |          |   |         |   |                 |
| * | OF    |          |          |   |         |   |                 |
| * | EMPLO |          |          |   |         |   |                 |
|   | YMENT |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| F |       | TO*(Mo., | STARTING | P | FINAL   | P |                 |
| R |       | Yr..)*   |          | E |         | E |                 |
| O |       |          |          | R |         | R |                 |
| M |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| ( |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| o |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| , |       |          |          |   |         |   |                 |
| Y |       |          |          |   |         |   |                 |
| r |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| ) |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          | \$       |   | \$      |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * |       |          |          |   |         |   | **E.** NO.      |
| * |       |          |          |   |         |   | HOURS PER WEEK  |
| D |       |          |          |   |         |   | WORKED *(If     |
| * |       |          |          |   |         |   | other than full |
| * |       |          |          |   |         |   | time)*          |
| . |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| F |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| P |       |          |          |   |         |   |                 |
| L |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| Y |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   | **F**. REASON   |
|   |       |          |          |   |         |   | FOR LEAVING     |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| G |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| C |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| I |       |          |          |   |         |   |                 |
| P |       |          |          |   |         |   |                 |
| T |       |          |          |   |         |   |                 |
| I |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| F |       |          |          |   |         |   |                 |
| W |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| K |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * | *     |          | **B.**   |   |         |   | **C**. TITLE OF |
| * | *A**. |          | SALARY   |   |         |   | POSITION        |
| 2 | DATE  |          |          |   |         |   |                 |
| * | OF    |          |          |   |         |   |                 |
| * | EMPLO |          |          |   |         |   |                 |
|   | YMENT |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| F |       | TO*(Mo., | STARTING | P | FINAL   | P |                 |
| R |       | Yr..)*   |          | E |         | E |                 |
| O |       |          |          | R |         | R |                 |
| M |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| ( |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| o |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| , |       |          |          |   |         |   |                 |
| Y |       |          |          |   |         |   |                 |
| r |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| ) |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          | \$       |   | \$      |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * |       |          |          |   |         |   | **E.** NO.      |
| * |       |          |          |   |         |   | HOURS PER WEEK  |
| D |       |          |          |   |         |   | WORKED *(If     |
| * |       |          |          |   |         |   | other than full |
| * |       |          |          |   |         |   | time)*          |
| . |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| F |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| P |       |          |          |   |         |   |                 |
| L |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| Y |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   | **F**. REASON   |
|   |       |          |          |   |         |   | FOR LEAVING     |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| G |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| C |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| I |       |          |          |   |         |   |                 |
| P |       |          |          |   |         |   |                 |
| T |       |          |          |   |         |   |                 |
| I |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| F |       |          |          |   |         |   |                 |
| W |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| K |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * | *     |          | **B**.   |   |         |   | **C**. TITLE OF |
| * | *A**. |          | SALARY   |   |         |   | POSITION        |
| 3 | DATE  |          |          |   |         |   |                 |
| * | OF    |          |          |   |         |   |                 |
| * | EMPLO |          |          |   |         |   |                 |
|   | YMENT |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| F |       | TO(*Mo., | STARTING | P | FINAL   | P |                 |
| R |       | Yr..)*   |          | E |         | E |                 |
| O |       |          |          | R |         | R |                 |
| M |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| ( |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| o |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| , |       |          |          |   |         |   |                 |
| Y |       |          |          |   |         |   |                 |
| r |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| ) |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          | **\      |   | **\$    |   |                 |
|   |       |          | $**      |   | **      |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * |       |          |          |   |         |   | **E**. NO.      |
| * |       |          |          |   |         |   | HOURS PER WEEK  |
| D |       |          |          |   |         |   | WORKED *(If     |
| * |       |          |          |   |         |   | other than full |
| * |       |          |          |   |         |   | time)*          |
| . |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| A |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| F |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| M |       |          |          |   |         |   |                 |
| P |       |          |          |   |         |   |                 |
| L |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| Y |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   | **F**. REASON   |
|   |       |          |          |   |         |   | FOR LEAVING     |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
| * |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| G |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| * |       |          |          |   |         |   |                 |
| . |       |          |          |   |         |   |                 |
| D |       |          |          |   |         |   |                 |
| E |       |          |          |   |         |   |                 |
| S |       |          |          |   |         |   |                 |
| C |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| I |       |          |          |   |         |   |                 |
| P |       |          |          |   |         |   |                 |
| T |       |          |          |   |         |   |                 |
| I |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| N |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| F |       |          |          |   |         |   |                 |
| W |       |          |          |   |         |   |                 |
| O |       |          |          |   |         |   |                 |
| R |       |          |          |   |         |   |                 |
| K |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
|   |       |          |          |   |         |   |                 |
+---+-------+----------+----------+---+---------+---+-----------------+

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 16%" />
<col style="width: 3%" />
<col style="width: 11%" />
<col style="width: 6%" />
<col style="width: 14%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 19%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>4</strong></td>
<td colspan="2"><strong>A</strong>. DATE OF EMPLOYMENT</td>
<td colspan="5"><strong>B</strong>. SALARY</td>
<td colspan="2"><strong>C</strong>. TITLE OF POSITION</td>
</tr>
<tr class="even">
<td colspan="2">FROM <em>(Mo., Yr..)</em></td>
<td>TO<em>(Mo., Yr..)</em></td>
<td colspan="2">STARTING</td>
<td>PER</td>
<td>FINAL</td>
<td>PER</td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td>     </td>
<td colspan="2"><strong>$</strong>      </td>
<td>    </td>
<td><strong>$</strong>      </td>
<td>    </td>
</tr>
<tr class="even">
<td colspan="8"><strong>D</strong>. NAME AND ADDRESS OF EMPLOYER</td>
<td colspan="2" rowspan="2"><p><strong>E</strong>. NO. HOURS PER WEEK
WORKED <em>(If</em></p>
<p><em>other than full time)</em></p>
<p>    </p></td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="3">     </td>
</tr>
<tr class="even">
<td colspan="2" rowspan="2"><p><strong>F</strong>. REASON FOR
LEAVING</p>
<p>     </p></td>
</tr>
<tr class="odd">
</tr>
<tr class="even">
<td colspan="10" rowspan="2"><p><strong>G</strong>. DESCRIPTION OF
WORK</p>
<p>     </p></td>
</tr>
<tr class="odd">
</tr>
<tr class="even">
<td><strong>5</strong></td>
<td colspan="2"><strong>A</strong>. DATE OF EMPLOYMENT</td>
<td colspan="5">B. SALARY</td>
<td colspan="2"><strong>C</strong>. TITLE OF POSITION</td>
</tr>
<tr class="odd">
<td colspan="2">FROM <em>(Mo., Yr..)</em></td>
<td>TO<em>(Mo., Yr..)</em></td>
<td colspan="2">STARTING</td>
<td>PER</td>
<td>FINAL</td>
<td>PER</td>
<td colspan="2" rowspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td>     </td>
<td colspan="2"><strong>$</strong>      </td>
<td>    </td>
<td><strong>$</strong>      </td>
<td>    </td>
</tr>
<tr class="odd">
<td colspan="8"><strong>D</strong>. NAME AND ADDRESS OF EMPLOYER</td>
<td colspan="2" rowspan="2"><p><strong>E</strong>. NO. HOURS PER WEEK
WORKED</p>
<p><em>(If other than full time)</em></p>
<p>    </p></td>
</tr>
<tr class="even">
<td colspan="8" rowspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="2"><p><strong>F</strong>. REASON FOR LEAVING</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="10" rowspan="2"><p><strong>G</strong>. DESCRIPTION OF
WORK</p>
<p>     </p></td>
</tr>
<tr class="odd">
</tr>
<tr class="even">
<td colspan="10"><strong>NOTE:</strong> It is important that all periods
of County FSA employee service and Civil Service employment be reflected
in this application. If you have service of this type which has not
already been noted in this application, attach a separate sheet citing
each period of such service.</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>28. CERTIFICATION</strong></td>
</tr>
<tr class="even">
<td colspan="10"><em>I certify that the statements made by me in this
application are true, complete, and correct and made in good faith. A
false statement on any part of your application may be grounds for not
hiring you, or for firing you after you begin work.</em></td>
</tr>
<tr class="odd">
<td colspan="8">SIGNATURE OF APPLICANT</td>
<td colspan="2"><p>DATE</p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="10"><strong>29. APPROVALS</strong></td>
</tr>
<tr class="odd">
<td colspan="6"><strong>A. MEETS QUALIFICATION STANDARDS</strong></td>
<td colspan="4"><strong>B. APPROVED FOR EMPLOYMENT</strong></td>
</tr>
<tr class="even">
<td colspan="6"><p>NAME</p>
<p>     </p></td>
<td colspan="4"><p>NAME</p>
<p>     </p></td>
</tr>
<tr class="odd">
<td colspan="4">TITLE</td>
<td colspan="2">DATE</td>
<td colspan="3">TITLE</td>
<td>DATE</td>
</tr>
<tr class="even">
<td colspan="4">     </td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td>     </td>
</tr>
</tbody>
</table>