
Initial this page to indicate that you have provided complete and accurate information: __________
Page 10
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 9
th
grade:
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
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.
From To
Full Time Name of Supervisor:
Mo.: Yr.: PRESENT Part Time
Company Name (it unemployed, so state) Type of work you performed:
Street Address of Company Employer’s Telephone Number:
City, State and Zip Code Reason for leaving employment:
From To
Full Time Name of Supervisor:
Mo.: Yr.: Mo.: Yr.: Part Time
Company Name (if unemployed, so state) Type of work you performed:
Street Address of Company Employer’s Telephone Number:
City, State and Zip Code Reason for leaving employment:
Continue employment entries on Page 11
School Name, Month and Year Number of Credit Hours Type of Degree Month and Year
City, State and Zip Code Attended Completed (e.g. H.S. Diploma, of Graduation,
From To Semester Quarter B.A., M.A.) Degree