[124-10271-10003_multirif.pdf — page 53]
## 6. EMPLOYMENTList chronologically all employments, including summer and part-time employments while attending school. All time must be accounted for. If unemployed for a period, indicate, setting forth dates of unemployment.| Name and Address of Employer | Dates            | Salary         | Position and Kind of Work | Name of Supervisor | Reason for Leaving || ---------------------------- | ---------------- | -------------- | ------------------------- | ------------------ | ------------------ || b. Name                      | From Mo. Day Yr. | To Mo. Day Yr. |                           |                    |                    || Address                      |                  |                |                           |                    |                    || City & State                 |                  |                |                           |                    |                    || c. Name                      |                  |                |                           |                    |                    || Address                      |                  |                |                           |                    |                    || City & State                 |                  |                |                           |                    |                    || d. Name                      |                  |                |                           |                    |                    || Address                      |                  |                |                           |                    |                    || City & State                 |                  |                |                           |                    |                    || e. Name                      |                  |                |                           |                    |                    || Address                      |                  |                |                           |                    |                    || City & State                 |                  |                |                           |                    |                    || f. Name                      |                  |                |                           |                    |                    || Address                      |                  |                |                           |                    |                    || City & State                 |                  |                |                           |                    |                    |g. Have you ever been dismissed or asked to resign from any employment or position you have held?No ☐ YesEmployer's Name ________________________________________________ Date __________________________________ Reason ________________________________________________________________________________________h. Are you now or have you ever been employed by an agency of the Federal Government? (Include part-time employment.) ☐ No ☐ YesFrom ____________ To ____________ Agency ________________________________________________ Location ________________________________________________________i. Do you have any sources of income other than your salary or that of your spouse? ☐ No ☐ YesSpecify each with amount __________________________________________________________________________________________________________________________## 7. MILITARY RECORDa. Are you registered for Selective Service? ☐ No ☐ YesSelective Service # ________________________ Lottery #. ________________________ Local Board # ________________________ City ________________________________________________ State ________________b. What is your current classification? Have you received any notice indicating you may be called into the Armed Forces in the near future? ☐ No ☐ YesIf so, give approximate date. ________________________________________________________________________________________________________________c. If ever classified 1-Y (registrant qualified for military service only in time of d. Have you ever served on active duty in the Armed Forces of the United States?war or national emergency) or 4-F (registrant not qualified for any militaryservice), furnish reasons. ☐ No ☐ Yese. Branch of military service ______________________________________________________________________________________________________ Highest rank attained __________________________________________________________ Date commissioned,if applicable _________________________________________________f. Serial number __________________________________________________________________________________________________________ g. Dates of active duty (month, day & year)From ____________ To ____________h. Type of Discharge ________________________________________________ Basis for Discharge ________________________________________________________________________________________________ i. Member of Reserve? ☐ No ☐ Yes ☐ Ready ☐ StandbyService Branch _____________________________________________________________________________________________________________________________________________________________________________3