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POLICE DEPARTMENT |
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APD-5A |
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CITY OF NEW YORK |
CIVILIAN TITLES |
Personal History of: _____________________ |
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Surname |
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First Name |
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M.I. |
Applicant for appointment as: |
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Exam No. __________ List No. __________ |
Social Security No.: |
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The answers to questions in this questionnaire must be printed in BLACK INK BY THE APPLICANT. TWO (2) copies of this questionnaire are furnished, BOTH are to be completed, notarized in the space provided on page 18, and returned to your assigned investigator as directed. If the space is insufficient to complete your answer to any question, use pages eighteen through twenty-two (18-22) which have been provided for that purpose. Indicate the question number and continue your answer. If a question is not applicable, indicate such by entering “N/A” or “NONE”. Do not leave any question blank. Mistakes made should ONLY be corrected by drawing a single line through the mistake, placing your initials at the end. MISTAKES ARE NEVER TO BE CORRECTED WITH OPAQUE CORRECTION FLUID.
Applicants are cautioned to answer every question, truthfully, completely and without evasion. Both the N.Y. State Civil Service Law and the Personnel Rules of the City of New York, (which have the force and effect of the law) provide penalties for making a false statement of material fact in any application, or for practicing any fraud or deception in obtaining or attempting to obtain municipal employment. Such penalties include rejection for appointment, revocation of appointment, and prosecution.
Civil Service lists are valid for a period of up to four (4) years from the date of promulgation. Once the Civil Service list expires, appointment from that list is no longer possible. For this reason, all candidates are urged to submit all documents as expeditiously as possible. All candidates are cautioned that failing to appear for scheduled appointments could jeopardize chances for appointment.
THE NEW YORK CITY POLICE DEPARTMENT
IS AN EQUAL OPPORTUNITY EMPLOYER
Page 1
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Control No |
Exam No. |
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_________ List No.Soc |
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. Sec. No. |
APD-5A |
Surname |
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First Name |
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Mid. Init |
______ |
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I. PERSONAL DATA
1.
Last Name |
First Name |
Mid. Init. |
Social Security No. |
a. Have you ever had a legal name change? If so, |
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From: ________________________ |
To: ____________________ Reason: ____________________________ |
Court: _________________________________________________ Index No.: ___________________________
If by marriage, date of marriage: _____________________________
b. List below, any other name, alias, nickname, by which you have been known, including maiden name if you are a married female, with the reason for such use:
c. Do you have any tattoos, brands, body piercings, or other body art? Yes No
If yes, include the location and complete description, including symbolized meaning and reason for getting same.
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Sex: Male Female |
3. Date of Birth: Month: __________ Day: _________ Year: ________ |
4.Birth Certificate:
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Certificate Number |
City or Town |
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Citizenship: |
Citizen of the U.S.A.? |
Yes |
No |
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a. What country were you born in? __________________________________ |
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b. If not born in U.S.A., date entered U.S.A. _______________________________ |
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c. If you are a naturalized citizen of the U.S.A., list below, |
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Naturalization Certificate No. |
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d. Do you have dual citizenship with another country? Yes No |
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If yes, what country? ______________________________ When was it obtained? _________________________ |
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How was it obtained? ___________________________________________________________________________ |
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Do you have a U.S. Resident Alien Card? |
Yes |
No |
Expiration: __________________ |
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If yes, how was it obtained? (Lottery, etc.) ___________________________________________________________ |
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Alien Registration No. __________________________________________________ |
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Do you have a U.S. passport? Yes |
No |
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If yes, passport no. ________________________ Date Issued ____________ Expiration Date ________________ |
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a. Have you ever reported a passport lost or stolen? |
Yes |
No If yes, describe the circumstances of |
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the loss to include the date, location and police report number: __________________________________________ |
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b. Do you now have or have you ever had a foreign passport? |
Yes No If yes, date issued ___________ |
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Date of Surrender/Expiration ________________ |
Issuing Country____________________________________ |
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c. Have you ever applied for a travel visa to travel to or from any country? If so, Date _______________________ |
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Country ________________ |
Reason_______________________________________________________________ |
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Has a visa ever been denied? ______________________________________________________________________ |
8.What countries outside of the U.S.A. have you traveled to? Include dates and how long you were in the country:
Country & Town, or City |
Dates |
Length of Stay |
Purpose of Visit |
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Initial this page to indicate that you have provided complete and accurate information: __________
Page 2
9.Marital Status:
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Single Married Legally Separated Divorced Widowed Registered Domestic Partner/Civil Union |
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Spouse/Registered Domestic Partner |
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Home Address (number/street/apt.) |
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ZIP |
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D.O.B. |
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Occupation |
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N/A |
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Home Phone |
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Work Address (number/street/apt.) |
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Work Phone |
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Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual? |
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Yes |
No |
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Former Spouse/Registered Domestic Partner |
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Name |
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Home Address (number/street/apt.) |
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D.O.B. |
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Occupation |
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N/A |
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Home Phone |
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Work Phone |
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Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual? |
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Yes |
No |
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Former Spouse/Registered Domestic Partner |
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Name |
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Home Address (number/street/apt.) |
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ZIP |
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D.O.B. |
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Occupation |
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N/A |
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Home Phone |
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Work Address (number/street/apt.) |
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Work Phone |
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Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual? |
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Yes |
No |
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Former Spouse/Registered Domestic Partner |
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Name |
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Home Address (number/street/apt.) |
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D.O.B. |
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Occupation |
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Home Phone |
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Work Phone |
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Is There, Or Has There Ever Been, An Order Of Protection Or Restraining Order Issued Against This Individual? |
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Initial this page to indicate that you have provided complete and accurate information: __________
Page 3
II.RESIDENCE RECORD
10.Starting with your present address and working back, list each address (including temporary addresses) at which you have resided. Please include military and college (campus and/or off-campus) addresses. All foreign addresses must be included:
PRESENT
a. Do you now or have you ever owned/co-owned any home/co-op/condo or other property? Yes No . If yes, list
AddressCity/ TownStateZipCounty
b. With whom do you co-own? ____________________________________________________________________
c. All Residence telephone number(s): (Area Code) _____-_____-________
d. All Cell phone number(s): (Area Code) _____-_____-________
e. Email address(es): _____________________________________, _____________________________________
f. Do you now have or have you ever had an account on a social networking site, such as MySpace, Facebook or Twitter? Yes No
If yes, indicate address(es) ______________________, ______________________, ______________________
III.FAMILY RECORD
11.List below all of your living or deceased children, including natural, adopted, and/or foster care. Include any other children who have ever resided with you. Provide the name and contact information of the other parent or guardian.
Child’s Name (Last, First) |
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Sex |
D.O.B. |
Does Child Reside with You? Yes No |
If No, Enter Full Address |
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Who has Custody of Child? Include Name and Relationship |
Name of other Parent |
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Parent’s D.O.B. |
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Parent’s Home Address |
Parent’s Contact Phone No. |
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Parent’s Occupation |
Parent’s Work Address |
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Candidate’s Current Relationship with other Parent |
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Child’s Name (Last, First) |
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Sex |
D.O.B. |
Does Child Reside with You? Yes No |
If No, Enter Full Address |
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Who has Custody of Child? Include Name and Relationship |
Name of other Parent |
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Parent’s D.O.B. |
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Parent’s Home Address |
Parent’s Contact Phone No. |
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Parent’s Occupation |
Parent’s Work Address |
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Candidate’s Current Relationship with other Parent |
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Initial this page to indicate that you have provided complete and accurate information: __________
Page 4
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Child’s Name (Last, First) |
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Sex |
D.O.B. |
Does Child Reside with You? Yes No |
If No, Enter Full Address |
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Who has Custody of Child? Include Name and Relationship |
Name of other Parent |
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Parent’s D.O.B. |
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Parent’s Home Address |
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Parent’s Contact Phone No. |
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Parent’s Occupation |
Parent’s Work Address |
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Candidate’s Current Relationship with other Parent |
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Child’s Name (Last, First) |
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Sex |
D.O.B. |
Does Child Reside with You? Yes No |
If No, Enter Full Address |
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Who has Custody of Child? Include Name and Relationship |
Name of other Parent |
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Parent’s D.O.B. |
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Parent’s Home Address |
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Parent’s Contact Phone No. |
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Parent’s Occupation |
Parent’s Work Address |
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Candidate’s Current Relationship with other Parent |
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Child’s Name (Last, First) |
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Sex |
D.O.B. |
Does Child Reside with You? Yes No |
If No, Enter Full Address |
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Who has Custody of Child? Include Name and Relationship |
Name of other Parent |
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Parent’s D.O.B. |
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Parent’s Home Address |
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Parent’s Contact Phone No. |
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Parent’s Occupation |
Parent’s Work Address |
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Candidate’s Current Relationship with other Parent |
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a. Additional children listed on pages 18-22? |
Yes No |
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b. What provisions have you made for the support of the children listed above? |
________________________________ |
_______________________________________________________________________________________________
_______________________________________________________________________________________________
c. Do any of your children receive child support or other supportive income? (Social Security, disability) Yes No If yes, explain: __________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
IV. FAMILY RECORD AND REFERENCES
12.List the full names of biological mother and father; stepmothers/stepfathers; grandfathers; grandmothers; father-in-law; mother-in-law, living or deceased. The complete address for each must be listed (include city and state).
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Father’s Name |
Home Address (number/street/apt.) |
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City |
State ZIP |
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Work Address (number/street/apt.) |
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ZIP |
Occupation |
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Home Phone |
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Work Phone |
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Cell Phone |
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D.O.B. |
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Email |
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Place of Birth (Village or Town, City, State, Country) |
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Initial this page to indicate that you have provided complete and accurate information: __________ |
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Page 5
Mother’s Name |
Home Address (number/street/apt.) |
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City |
State ZIP |
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Work Address (number/street/apt.) |
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City |
State |
ZIP |
Occupation |
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Home Phone |
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Work Phone |
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Cell Phone |
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D.O.B. |
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Email |
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Place of Birth (Village or Town, City, State, Country)
N/A
Stepfather’s Name |
Home Address (number/street/apt.) |
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State ZIP |
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Work Address (number/street/apt.) |
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Home Phone |
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D.O.B. |
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Email |
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Place of Birth (Village or Town, City, State, Country)
N/A |
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Stepmother’s |
Name |
Home Address (number/street/apt.) |
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State ZIP |
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Work Address (number/street/apt.) |
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ZIP |
Occupation |
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Home Phone |
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D.O.B. |
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Email |
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Place of Birth (Village or Town, City, State, Country)
N/A
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Father-in-law’s Name |
Home Address (number/street/apt.) |
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Work Address (number/street/apt.) |
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Home Phone |
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D.O.B. |
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Email |
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Place of Birth (Village or Town, City, State, Country) |
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N/A |
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Mother-in-law’s Name |
Home Address (number/street/apt.) |
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ZIP |
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Work Address (number/street/apt.) |
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Occupation |
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Home Phone |
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D.O.B. |
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Email |
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Place of Birth (Village or Town, City, State, Country) |
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Initial this page to indicate that you have provided complete and accurate information: __________ |
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Page 6
N/A
Grandmother’s Name |
Home Address (number/street/apt.) |
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City |
State ZIP |
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Work Address (number/street/apt.) |
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State |
ZIP |
Occupation |
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Home Phone |
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Work Phone |
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Cell Phone |
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D.O.B. |
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Email |
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Place of Birth (Village or Town, City, State, Country)
N/A
Grandfather’s Name |
Home Address (number/street/apt.) |
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City |
State ZIP |
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Work Address (number/street/apt.) |
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ZIP |
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Home Phone |
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Place of Birth (Village or Town, City, State, Country)
a.List the full names of all biological brothers and sisters; half-brothers/half-sisters; stepbrothers/stepsisters; uncle; aunt; great aunt; great uncle; first cousin; nephew; niece; fiancé or fiancée, living or deceased (include females’ maiden names). The complete address for each must be listed (must include city and state).
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Initial this page to indicate that you have provided complete and accurate information: __________
Page 7
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b.List any person(s) who has ever resided with you, whether related to you or not (include females’ maiden names). The complete address for each must be listed (must include city and state).
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Initial this page to indicate that you have provided complete and accurate information: __________
Page 8
c.List 5-6 people who know you well, such as social and family friends, co-workers, military acquaintances. Do not include relatives, employers or housemates, or other individuals listed elsewhere.
Name |
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How do you know this person? |
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(for example: friend, teacher, |
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family friend, co-worker) |
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family friend, co-worker) |
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(for example: friend, teacher, |
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family friend, co-worker) |
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Home Address (number/street/apt.) |
City |
State |
ZIP |
D.O.B. |
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Work Address (number/street/apt.) |
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ZIP |
Occupation |
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How do you know this person? |
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(for example: friend, teacher, |
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family friend, co-worker) |
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Home Address (number/street/apt.) |
City |
State |
ZIP |
D.O.B. |
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Work Address (number/street/apt.) |
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ZIP |
Occupation |
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Work Phone |
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Name |
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How do you know this person? |
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(for example: friend, teacher, |
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family friend, co-worker) |
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Home Address (number/street/apt.) |
City |
State |
ZIP |
D.O.B. |
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Work Address (number/street/apt.) |
City |
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ZIP |
Occupation |
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Work Phone |
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Name |
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How do you know this person? |
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(for example: friend, teacher, |
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family friend, co-worker) |
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Home Address (number/street/apt.) |
City |
State |
ZIP |
D.O.B. |
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Work Address (number/street/apt.) |
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ZIP |
Occupation |
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Initial this page to indicate that you have provided complete and accurate information: __________
Page 9
V.FOREIGN CONTACTS (OR LANGUAGE)
13a. Do you speak, read, write, or understand a foreign language? Yes No . If Yes, list language(s) and educational level of proficiency: ____________________________________________________________________
b.How often is each language(s) used? ________________________________________________________________
c.With whom is each language used? ____________________________ How often?__________________________
d.Is this person inside or outside of the United States? Inside Outside
If outside, list country ____________________________________________________________________________
VI. EDUCATION RECORD
14. List all schools you have attended beginning with the 9th grade:
School Name,
City, State and Zip Code
Month and Year
Attended
From To
Number of Credit Hours
Completed
Semester Quarter
Type of Degree
(e.g. H.S. Diploma,
B.A., M.A.)
Month and Year
of Graduation,
Degree
a.List any other schools attended, including but not limited to, trade, vocation, business, professional and occupational licenses, training courses, internships, certificate programs, etc. List the dates of attendance.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
b. |
High school diploma from an accredited U.S. Institution? Yes No |
G.E.D. |
Yes No |
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If “Yes”, G.E.D.-Issuing State _____________________ Date Issued ___________ |
Other ___________________ |
c.Were you ever the subject of any disciplinary action at any educational institution which you attended?
Yes No If “yes” give details on pages 18 through 22. (School name, disposition date, etc.)
VII. EMPLOYMENT RECORD
15.Have you ever been fired or suspended from any job, or has any form of disciplinary action been taken against you by any employer? Yes No . If Yes, explain below.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
List below, starting with your current employment-or unemployment - and working back, each period of employ- ment and period of unemployment you have had. Include within the sequence any period of active military ser- vice. If you were discharged from any employment, or requested to resign, so state under “Reason for leaving employment”. DO NOT LEAVE ANY TIME PERIODS UNACCOUNTED FOR.
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Name of Supervisor: |
Mo.: |
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Yr.: |
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PRESENT |
Part Time |
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Company Name (it unemployed, so state) |
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Type of work you performed: |
Street Address of Company
Employer’s Telephone Number:
Reason for leaving employment:
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To |
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Full Time |
Name of Supervisor: |
Mo.: |
Yr.: |
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Mo.: |
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Yr.: |
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Part Time |
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Company Name (if unemployed, so state) |
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Type of work you performed: |
Street Address of Company
Employer’s Telephone Number:
Reason for leaving employment:
Continue employment entries on Page 11
Initial this page to indicate that you have provided complete and accurate information: __________
Page 10