home BUSINESS 7. ? 8. ( / / / 9. 10. – – 11. 12. No. state exp date HEIGHT wEIGHT HAIR COLOR EYE COLOR SECTION 2: RELATIVES AND REFERENCES FAMILY Provide all applicable information in the spaces below. Mark “N/A” if a category is not applicable or if the individual is deceased. If more space is needed, continue your response on page 24. N/A A. Father HOME / / STATE ZIP HOME PHONE ( ) / / CITY STATE ZIP PHONE ( ) CELL PHONE ( ) N/A B. Step-father NAME HOME ADDRESS / / CITY ZIP HOME PHONE ( ) ADDRESS / / CITY STATE ZIP ( ) CELL ( ) EMAIL N/A C. Mother NAME HOME ADDRESS / / CITY STATE ZIP HOME ( ) ADDRESS / / CITY STATE ZIP PHONE ( ) CELL PHONE ( ) EMAIL SECTION 2: RELATIVES AND REFERENCES continued FAMILY N/A D. Step-mother NAME HOME ADDRESS / / CITY STATE ZIP HOME ( ) ADDRESS / / CITY STATE ZIP PHONE ( ) CELL PHONE ( ) EMAIL N/A E. Spouse / Registered Domestic Partner NAME HOME ADDRESS / / CITY STATE ZIP HOME PHONE ( ) ADDRESS / / CITY ZIP PHONE ( ) CELL PHONE ( ) EMAIL NUMBER EMPLOYMENT (NUMBER STREET (NUMBER STREET (NUMBER STREET (NUMBER STREET (NUMBER STREET (NUMBER STREET FOR (NUMBER STREET (NUMBER STREET (NUMBER STREET
F under age 18 PHONE ( ) CELL PHONE ( ) EMAIL 4) NAME ADDRESS / / CITY STATE ZIP M F age 18 HOME ( ) ADDRESS / / CITY STATE ZIP PHONE ( ) CELL PHONE ( ) EMAIL 5) NAME ADDRESS / / CITY ZIP M F under age 18 HOME PHONE ( ) ADDRESS / / CITY STATE ZIP PHONE ( ) CELL PHONE ( ) EMAIL 6) NAME ADDRESS / / CITY STATE ZIP M F under age 18 HOME ( ) ADDRESS / / CITY STATE ZIP PHONE ( ) CELL ( ) EMAIL N/A J. Children List all of your living children, including natural, adopted, step, and/or foster care. Include any other children who reside with you. Provide the name and contact information of the custodial parent or guardian, if other than you. 1) NAME M F ADDRESS / / CITY STATE ZIP ( ) EMAIL 2) NAME M F ADDRESS / / CITY STATE ZIP ( ) EMAIL SECTION 2: RELATIVES AND REFERENCES continued FAMILY J. 3) NAME M F ADDRESS / / CITY STATE ZIP ( ) EMAIL 4) NAME M F ADDRESS / / CITY ZIP ( ) EMAIL 5) NAME M F ADDRESS / / CITY STATE ZIP ( ) EMAIL CONTACT CONTACT NUMBER CONTACT NUMBER CONTACT NUMBER CONTACT NUMBER NUMBER OR OR OR OR OR (IF (IF (IF
How long have you this person? NAME ADDRESS / / CITY STATE ZIP HOME ( ) ADDRESS / / CITY STATE ZIP ( ) CELL ( ) EMAIL How long have you known this person? SECTION 3: EDUCATION NOTE: You may be required to furnish transcripts or other proof to support all of your educational claims. 15. GED, ………………………………………… 16. A) NAME FROM TO Yes No CITY NAME TO Yes No CITY 17. A) NAME FROM TO CITY STATE SECTION 3: EDUCATION continued 17. B) NAME FROM TO CITY STATE NAME FROM TO CITY STATE 18. A) NAME FROM TO Yes No CITY STATE B) NAME FROM TO Yes No CITY C) NAME FROM TO Yes No CITY STATE OF G) OF OF OF OF OF OR OR OR OR OR OR OR
Names of those with whom you lived: Reason for moving: ADDRESS / / FROM CITY ZIP MANAGER, RENT COLLECTOR, OR ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER / / ( ) CITY STATE ZIP EMAIL Names of those with whom you lived: Reason for moving: ADDRESS / / FROM CITY STATE ZIP MANAGER, RENT COLLECTOR, OR ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER / / ( ) CITY ZIP EMAIL Names of those with whom you lived: Reason for moving: SECTION 4: RESIDENCE continued OF RESIDENCES ADDRESS / / FROM CITY STATE ZIP MANAGER, RENT COLLECTOR, OR ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER / / ( ) CITY STATE ZIP EMAIL Names of those with whom you lived: Reason for moving: ADDRESS / / FROM CITY ZIP MANAGER, RENT COLLECTOR, ADDRESS OF PROPERTY MANAGER, RENT COLLECTOR, OR OWNER / / ( ) CITY STATE ZIP EMAIL Names of those with whom you lived: Reason for moving: TO TO TO TO E) F)
CITY ZIP ( ) EXT EMAIL DUTIES / ASSIGNMENTS F-T P-T Temp Self-employed Volunteer NAMES OF CO-WORKERS 1) X 2) REASON FOR LEAVING Check applicable: Student Between jobs Leave of absence Travel Other FROM NAME OF EMPLOYER MILITARY UNIT FROM ADDRESS / BASE) SUPERVISOR CITY STATE ZIP ( ) EXT EMAIL DUTIES / ASSIGNMENTS F-T P-T Temp Self-employed Volunteer NAMES CO-WORKERS 1) X 2) REASON FOR LEAVING SECTION 5: EXPERIENCE AND EMPLOYMENT continued 25. JOB EXPERIENCE Check applicable: Student Between jobs Leave of absence Travel Other FROM NAME EMPLOYER MILITARY UNIT FROM ADDRESS / BASE) SUPERVISOR CITY STATE ZIP ( ) EXT EMAIL DUTIES / ASSIGNMENTS F-T P-T Temp Self-employed Volunteer NAMES CO-WORKERS 1) X 2) REASON FOR LEAVING Check applicable: Student Between jobs Leave of absence Travel Other FROM I) NAME EMPLOYER MILITARY UNIT FROM TO ADDRESS / OR BASE) SUPERVISOR CITY STATE ZIP ( ) EXT JOB
44. Entry Level Honorable General OTH (Other than Honorable) Bad Conduct Dishonorable Code (1–4) if applicable – refer to your DD-214: 45. 46. 47. If you answered yes to Questions 46 and/or 47, explain (include dates and circumstances): SECTION 7: FINANCIAL 48. For each of the following questions fill in the amounts to the nearest dollar. A) From your employer(s), what is your take-home monthly income? $ per month B) Do you have income other than from your salary or wages? Yes No If yes, fill in amount: $ per month C) How much do you spend each month? $ per month 49. 7, 11 13)? 50. 51. 52. 53. 54. 55. 56. DATE ACTION