[124-10271-10299_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?Employer's Name __________ Date __________ Reason __________<br>[] No  [] Yesh. 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 war or national emergency) or 4-F (registrant not qualified for any military service), furnish reasons.d. Have you ever served on active duty in the Armed Forces of the United States? [] No [] Yese. Branch of military service __________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