[124-10271-10011_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 ____________Are you now or have you ever been employed by an agency of the Federal Government? (Include part-time employment.)From ____________ To ____________ Agency ____________ Location ____________i. Do you have any sources of income other than your salary or that of your spouse?Specify each with amount ____________## 7. MILITARY RECORDa. Are you registered for Selective Service?Selective 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?If 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?Highest rank attained ____________ Date commissioned, if applicable ____________e. 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?  Ready  StandbyService Branch ____________