JOB TITLE &
ANNOUNCEMENT #
SOCIAL SECURITY number
Sex - MALE = YES, FEMALE = NO
Sex - FEMALE?
Birth  DATE as Mo/Day/Year
Birth place (City,St/County)
Name (Last, First, Middle)
LastName, First Middle
Mailing address (& Apart #)
# of Street/PO Box, etc
City
AnyTown
State
ST
ZIP CODE
0
Other NAMES ever used (maiden)
none
Home phone AREA CODE
Home PHONE number
Work phone AREA CODE
Work PHONE number
Work phone extension
Employed as civ by gov? TEMP
Employed as civ by gov? C-CO
Employed as civ by gov? Care
Employed as civ by gov? Except
What was highest grade & job?
US Employee FROM DATE
US Employee TO DATE
When can you start work?
What is the lowest pay acceptable?
Payment per what time period?
OR Grade number?
What geographic area(s)
What geographic area, line2
Willing to work 40 hr week?
Willing to work 40 hr week?  N
Willing to work 25-32 hrs?
Willing to work 25-32 hrs?  N
Willing to work 17-24 hrs?
Willing to work 17-24 hrs?  N
Willing to work 16 or less?
Willing to work 16 of less?  N
An Intermittent job?
An Intermittent job?  N
Weekends, shifts or rotate?
Weekends, shifts or rotate?  N
Temporary 5 to 12 mo?
Temporary 5 to 12 mo?  N
Temporary, 1 to 4 mo?
Temporary, 1 to 4 mo?   N
Temporary, less than 1 mo?
Temporary, less than 1 mo?  N
Travel, 1 to 5 nights/mo?
Travel, 1 to 5 nights/mo?  N
Travel, 6 to 10 nights/mo?
Travel, 6 to 10 nights/mo?  N
Travel, 11 or more nights?
Travel, 11 or more nights?  N
Have you served in military?
Have you served in military? N
Did / Will you retire beyond Major?
Did/Will you retire>Major?  N
Were you Discharged with honorable?
Discharged w/o honorable
Discharge date
Type of discharge
Active duty from date
Active duty to date
Branch of service
2nd active duty from date
2nd active duty to date
2nd active duty branch
If after 10/14/76, list Campaign(s)
line 2
NO Veteran preference
5-Point veteran preference
Non-Compensable Disabled
Compensably Disabled, 30%
Spouse, widow or mother of
Compensably Disabled, + 30%
May we ask present employer?
Ask present employer? N
Block A, EMPLOYER NAME
ADDRESS line 1
Date employed, FROM
Date employed, TO
Avg number of HOURS per week
Number of employees supervised
Starting salary or earnings
Salary per ? pay period
Ending salary of earnings
Your Reason for leaving?
Name of immediate supervisor
AREA CODE
PHONE number
Exact TITLE of your job
If FEDERAL, list series/grade/rank
Full Description of WORK
* * * * * * * * * * * Line 1 * * * * * * * * * * * * * * * * * * * * * *
* * * * * * * * * * * * Line 15 * * * * * * * * * * * *
Block B, EMPLOYER Name
ADDRESS, line 1
Avg Number of HOURS per week
Starting Salary or earnings
Ending salary or earnings
Your Reason for leaving
Name of immediate Supervisor
PHONE Number
* * * * * * * * * * * * Line 14 * * * * * * * * * * * *
Give NAME & Location of HS
LOCATION of HS
Did you GRADUATE from High School?
DID NOT Graduate from HS
If YES, give MONTH & YEAR
If NO, give highest GRADE passe
Did you attend college/grad school?
Did not attend college/grad
Name of COLLEGE #1
CITY
STATE
ZIP Code
From MONTH
From YEAR
To MONTH
To YEAR
Semester HOURS completed
Quarter HOURS completed
DEGREE, What type?
MONTH of Degree
YEAR of Degree
Name of COLLEGE #2
DEGREE, What Type?
Name of COLLEGE #3
Chief Undergrad SUBJECT,  MAJOR
Semester HOURS
Quarter HOURS
Chief Undergrad SUBJECT,   # 2
Chief Undergrad SUBJECT,   # 3
Chief Graduate SUBJECT,   MAJOR
Chief Graduate SUBJECT,    # 2
Chief Graduate SUBJECT,    # 3
Other Courses, NAME of SCHOOL #1
Attended From  MONTH
From  YEAR
To  MONTH
To  YEAR
Classroom HOURS
SUBJECTS,line 1
Completed Training?
DID NOT Complete
SUBJECT, line 2
SUBJECT, line 3
Other Courses, NAME of SCHOOL # 2
AWARDS/FELLOWSHIPS - Title & Year
WORDS/MIN - Type? Take Dictation?
List Job LICENSES/CERTIFICATES, #1
Latest DATE
STATE or Other AGENCY
List Job LICENSES/CERTIFICATE,  #2
STATE of Other AGENCY
Speak or Read Other LANGUAGE?
(NO)
LANGUAGE #1
PREPARE/GIVE Lectures -  FLUENTLY
"      "      "  WITH DIFFICUTY
Can SPEAK & UNDERSTAND - FLUENTLY
"   "          "        PASSABLY
Can TRANSLATE Articles Into English
"      "        "     From English
READ Articles For Own use - EASILY
"      "      "   WITH DIFFICULTY
LANGUAGE #2
"      "    "    WITH DIFFICULTY
"    "         "        PASSABLY
READ Articles For Own Use - EASILY
"      "      "    WITH DIFFICULTY
FULL NAME - Reference #1
"   "        "    line 2
AREA Code & PHONE NUMBER - #1
"    "      "      "   - #2
ADDRESS, Business or Home
ZIP
FULL NAME - Reference #2
FULL NAME - Reference #3
ARE YOU A U.S. CITIZEN??
(NOT U.S. CITIZEN)
During past 10 yrs, were you FIRED?
EVER been Convicted of any FELONY?
EVER Convicted FIREARMS/EXPLOSIVES?
(no)
NOW Under Charges for Any VIOLATION
Past 10 Y CONVICT/PRISON/PAROL/PROB
Ever CONVICTED by COURT-MARTIAL?
Are you DELINQUENT of Federal Debt?
Explanation - - - - - ITEM #1
MONTH
YEAR
EXPLANATION  - - line 1
"            line 2
"            line 3
"            line 4
NAME of Employer/Police/Court/Agncy
Explanation - - - - - ITEM #2
Recieve RETIREMENT Mil/Fed Civil/DC
Do ANY RELATIVES Work for U.S.
NAME of First Relative
"       "      "         line 2
RELATIONSHIP
"                 line 2
DEPT/AGENCY/BRANCH of MIL
"     "     "        line 2
NAME of Second Relative
"       "       "        line 2
"    "      "       line 2
NAME of Third Relative
"     "      "       line 2