U.S. ARMY MEDICAL DEPARTMENT (AMEDD) APPLICANT WORKSHEET (Rev.

201102)

PRIVACY ACT STATEMENT AUTHORITY: Collection of the information request by the recruiter and recorded on this form is authorized by Title 10 U.S. Code, Section 591. PRINCIPAL PURPOSE: To provide such data as is requested by the recruiter to contact, process, and enlist prospects for Army service. ROUTINE USES: a. Used by the recruiter to contact and process interested prospects. b. Used by the recruiter in making such routine contacts as many be necessary to verify information provided by the prospects. c. Used by the Army to transcribe data on application forms. d. Used by recruiting personnel in the formulation of market data to determine current recruiting tools. EFFECT OF NOT PROVIDING INFORMAITON: The discloser, by the prospect, of the information request is entirely voluntary. Failure to provide this information, however, will result in discontinuance of processing.

GENERAL INSTRUCTIONS

Ensure all sections contained this application that may apply, are completed. Note N/A for sections that do not apply. Provide all Yes answers to include information that may apply: Name(s), date(s), address/location, phone number(s), explanation and supportive documentation. Dates: Must be in (DDMMMYYYY, i.e. 01 JAN 2011) format or unless otherwise specified. If To date(s) are current, indicate Current or Present. Addresses: P.O. Box addresses are unacceptable, must be street addresses. References: Be sure to include full name, address and phone number of references, do not use the same reference more than once within the entire application and references cannot be family members (i.e. parent, sibling, spouse, child, etc.). All entries are to be legible and complete. Use the TAB key to move through the fields; not the ENTER key.

PERSON PHYSICAL SCREENING Social Security Number: Complete Name: for YES answers Y/N Legal Last all questions. If additional information is requiredLegal Middle Name: given, the question Sr., III, etc.): Legal First Name: Suffix (Jr., requiring additional information will be specified. Refer to the end of the Physical Screening section for further information needed for all other YES answers provided. PHYSICAL INFORMATION 1. Asthma, wheezing or inhaler use (4) Hair hip, shoulder, elbow, ankle, or otherEye Color: joint (1)(7) Gender: Height: Weight: Color: 2. Dislocated joint, including knee, LastEpilepsy, fits, seizures, or convulsions (4) 3. Menstrual Cycle Date (Females only): (DDMMMYYYY) ETHNICITY 4. Sleepwalking (4) Primary Race: neck or back pain (4)(1)(7) Religion: 5. Recurrent DATE AND PLACE(4) BIRTH 6. Rheumatic Fever OF Date of Birth: (3) Age: City: State: County: Country: 7. Foot pain (DDMMYYYY) 8. A swollen, painful, or dislocated joint or fluid in a joint (knee, shoulder, wrist, elbow, etc.) (1)(7) 9. Double vision (4) CITIZENSHIP (Mark X to one that applies) 10. Periods of unconsciousness Federal States Micronesia or Virgin Island Nonor severe headaches or taking medication to prevent 11. Frequentat Birth, Native Born causing loss of time from work or schoolForeign National U.S. Citizen Immigrant frequent or severe headaches (4) of U.S. Parents U.S. Citizen at Birth, Born Abroad Immigrant Alien and solution so you can remove your contact when 12. Wear contact lenses (If so, bring your contact lens kit Marshall Islands or Northern Mariana Islands we U.S. Naturalized test your vision atNational-American Samoa or a pair of eyeglasses, bring them with you no matter how old they the MEPS; also, if you have U.S. Non-citizen are.) (4) Guam Non Immigrant Foreign National-Other 13. Fainting spells or passing out (4) Palau or U.S. Minor Outlying islands-Non14. Head injury, including skull fracture, resulting in concussion, loss of consciousness, headaches, etc. (4) Immigrant Foreign National 15. Back surgery (4) HOME OF RECORD ADDRESS (HOR) 16. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any reason (inpatient or Street: City: State: County: Zip Code: Country: outpatient) including counseling or treatment for school, adjustment, family, marriage or any other problem, to includeNo.-HOR: depression, or treatment for alcohol, drug or substance abuse (6)(2) Phone 17. Skin disease: Eczema (5) CURRENT ADDRESS Skin disease: Psoriasis (5) City: 18. Street: State: County: Zip Code: Country: 19. Skin disease: Atopic Dermatitis (5) Irregular heartbeat, including abnormally rapid or slow rates (4) heart 20. Where do you want Mail Sent? HOR or Current address: 21. Allergic to bee, wasp, or other insects stings (itching/swelling all over and/or get short of breath) (4) CURRENT PHONE NUMBER 22. Heart murmur, valve problem or mitral valve prolapsed (4) Home: Mobile: Business: 23. Allergic to - () wool (4) () - () - 24. Heart surgery (4) DRIVERS LICENSE State: License No.: Exp. Date: (DDMMMYYYY) 25. Been rejected for military service (temporary or permanent) for medical or other reasons (4) MARITAL STATUS (Mark (4) to one that applies) 26. Any other heart problems X Divorced blood pressure (4) Legally Separated Marriage Annulled 27. High Married Never reasons Widowed 28. Discharged from military service for medical Married (4) No. Ulcer (stomach, duodenum, or other part of intestine) (4) Total No. of Dependents: of Minor Dependents (Custody): 29. Legal, Medical or Othercompensation for an injury or other medical condition (4) 30. Received disability Concerns, Remarks: ADDITIONAL INFORMATION 31. Hepatitis (liver infection or inflammation) (4) Foreign Education? Y/N:(locked bowels), or any other chronic or recurrent intestinal problem, including small 32. Intestinal obstruction (If Yes, ECFMG, problems,Fifth Pathway or disease or Colitis Graduate): intestine or colon ECFVG, such as Crohn's Foreign Medical (4) Registered to Vote? or surgery for a detached retina (4) Prior Military Service? Y/N: 33. Detached retina Y/N: 34. Surgery to remove a portion of the intestine (other than the appendix) (4) 35. Any other eye conditions, injury or surgery (4) 36. Are you over 40? 37. Gall bladder trouble or gall stones (4) 38. Jaundice (4) 39. Missing a kidney (4) 40. Allergy to common food (milk, bread, eggs, meat, fish, or other common food) (4) 2 41. (Females only) Abnormal PAP smear or gynecological problem (4) 42. (Males only) Missing a testicle, testicular implant, or undescended testicle (4)

Complete all questions. If additional information is required for YES answers given, the question requiring additional information will be specified. Refer to the end of the Personal Screening Questionnaire section for additional space if needed. 1. Have you ever been divorced? 2. Are you legally separated? 3. Are you married? 4. Have you ever been married? 5. Have you fathered/mothered any children? How many? 6. Is anyone dependent upon you for financial support? How many? 7. Do you have custody of any minor children? How many? 8. Are you now or have you ever been negligent in providing alimony or support for children? 9. Have you served in any branch of Armed Services to include the National Guard? 10. Been rejected for military service (temporary or permanent) for medical or other reasons (4) Date (DDMMMYYYY): Explanation: 11. Do you have an immediate relative (father, mother, brother or sister) who: (1) is now a prisoner of war or is missing in action (MIA); or (2) died or became 100% permanently disabled while serving in the Armed Services? Explanation: Are you the only living child in your immediate family? 12. Have you ever been rejected for enlistment, reenlistment, or induction by any branch of the Armed Services to include the National Guard? Explanation: 13. Have you ever been required to appear before a medical or state regulating authority, regardless of the result, concerning your health status as an impaired, hindered, or otherwise restricted practitioner? Doctors Last Name: Street address, City, State, Zip Code, Country: Country Code: Telephone No.: () - Extension: Explanation: 14. Have you ever had a license to practice health care profession denied in any state? 15. Have you ever had a license to prescribe narcotics voluntarily or involuntarily refused, revoked, suspended, or denied or have you ever voluntarily surrendered a license to prescribe narcotics? Explanation: 16. Have you ever had professional privileges denied, withdrawn, or restricted by any health care facility? 17. Have you ever been asked to resign from a facility or organization staff or professional society? 18. Have you ever been denied membership or renewal or been subject to disciplinary procedures in any health care organization? 19. Do you currently have Malpractice Insurance? 20. Have you ever had Malpractice Insurance (other than current Malpractice Insurance)? 21. Are you currently a defendant in a Malpractice Claim? 22. Have you ever been a defendant in a Malpractice Claim (other than current Malpractice Claim)? Include question number and continue explanations below for all YES answers that may apply:

Y/N

MORAL SCREENING QUESTIONNAIRE Complete all questions. If additional information is required for YES answers given, additional information will be specified. Refer to the end of the Moral Screening Questionnaire section for additional space if needed. Report information regardless of whether the record in your case has been sealed, 4 expunged, or otherwise stricken from the court record, or the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an expungement

TECHNOLOGY INFORMATION QUESTIONNAIRE Complete all questions. Additional information is required for YES answers given. Refer to the end of the Technology Information Questionnaire section for additional information. Y/N 1. Have you illegally or without proper authorization entered into any information technology system? Have you illegally or without proper authorization modified, destroyed, manipulated, or denied others access 2. to information residing on an information technology system? 3. Have you introduced, removed, or used hardware, software, or media in connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations? Include question number and explain all YES answers that apply to include the following information: Date(s) (DDMMMYYYY) of Incident, Street address, City, State, County, Zip Code, Country, Nature of Incident and Action Taken.

GROUP/MEMBER ASSOCIATIONS QUESTIONNAIRE Complete all questions. Additional information is required for YES answers given. Refer to the end of Y/N the Group/Member Associations Questionnaire section for additional information. 1. Have you ever been an officer or a member of, or made a contribution to, an organization dedicated to terrorism, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal activities? 2. Have you ever been an officer or a member of, or made a contribution to, an organization dedicated to the use of violence or force to overthrow the U.S. Government, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal activities? 3. Have you ever been an officer or a member of, or made a contribution to, an organization that unlawfully advocates or practices the commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the U.S. with the specific intent to further such illegal activities? 4. Have you ever advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force with the specific intent to incite others to unlawful action in furtherance of such aims? 5. Have you ever knowingly engaged in any activities designed to overthrow the U.S. Government by force? 6. Have you ever knowingly engaged in any acts of terrorism? Neither your truthful responses nor information derived from your response to this question will be used as evidence against you in any subsequent criminal proceeding? 7. Have you ever participated in militias (not including official state government militias) or paramilitary groups? Include question number and explain all YES answers that apply to include the following information: From-To Date(s) (DDMMMYYYY), Organization Name and Group/Member Association Information (Street address, City, State, County, Zip Code, Country).

CONTACT INFORMATION AND METHOD 8 List the contact information below along with the best method to contact you. Permanent phone number, current phone number and an email are required (Permanent and current phone number can be the same).

ALIAS Provide other names used and the time period used (i.e., your maiden name, name(s) by a former marriage, nickname(s), etc. Name Type Other #1 Last Suffix (Maiden, Former Marriage, Name Other #1 First Name Other #1 Middle Name (Jr., II, etc.) Nickname, etc.) From (DDMMMYYYY): To (DDMMMYYYY): Name Type Other #2 Last Suffix (Maiden, Former Marriage, Name Other #2 First Name Other #2 Middle Name (Jr., II, etc.) Nickname, etc.) From (DDMMMYYYY): To (DDMMMYYYY): Name Type Other #3 Last Suffix (Maiden, Former Marriage, Name Other #3 First Name Other #3 Middle Name (Jr., II, etc.) Nickname, etc.) From (DDMMMYYYY): To (DDMMMYYYY):

RESIDENCES 10 List the places where you lived beginning with your current address (#1) (include temporary school addresses) and working back 7 years from NOW with NO GAPs in dates (NO P.O. boxes). For all addresses in the last 7 years,

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RESIDENCES Reference Information: Last Name: First Name: Middle Name: Residence Information: (Mark X to one that applies) Suffix: Status: Relationship: (Mark X to one that applies) Military Housing Business Associate Own Friend Rent Landlord Other Explanation: Neighbor Other Explanation: Address Type: Previous Reference Address: Street: Street: City: City: State: State: County: County: Zip Code: Zip Code: Country: Country: Reference Phone Number: Set as Mailing Address? Y/N: Country Code: Set as Permanent Address? Y/N: Telephone No.: () - Extension: Reference Alternate Phone No.: Country Code: Telephone No.: () - Extension: Time at Residence: To Date (DDYYYYMM): From Date (DDYYYYMM):

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RESIDENCES Reference Information: Last Name: First Name: Middle Name: Residence Information: (Mark X to one that applies) Suffix: Status: Relationship: (Mark X to one that applies) Military Housing Business Associate Own Friend Rent Landlord Other Explanation: Neighbor Other Explanation: Address Type: Previous Reference Address: Street: Street: City: City: State: State: County: County: Zip Code: Zip Code: Country: Country: Reference Phone Number: Set as Mailing Address? Y/N: Country Code: Set as Permanent Address? Y/N: Telephone No.: () - Extension: Reference Alternate Phone No.: Country Code: Telephone No.: () - Extension: Time at Residence: To Date (DDYYYYMM): From Date (DDYYYYMM):

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RESIDENCES Time at Residence: Reference Information: To Date (DDYYYYMM): Last Name: From Date (DDYYYYMM): First Name: Middle Name: Residence Information: (Mark X to one that applies) Suffix: Status: Relationship: (Mark X to one that applies) Military Housing Business Associate Own Friend Rent Landlord Other Explanation: Neighbor Other Explanation: Address Type: Previous Reference Address: Street: Street: City: City: State: State: County: County: Zip Code: Zip Code: Country: Country: Reference Phone Number: Set as Mailing Address? Y/N: Country Code: Set as Permanent Address? Y/N: Telephone No.: () - Extension: Reference Alternate Phone No.: Country Code: Telephone No.: () - Extension:

PERMANENT ADDRESS Complete below if you need to add a Permanent Address for a location that is not a former or current address. Street: City: State: County: Zip Code: Country: Start Date: (DDMMMYYYY):

**More residences need to be added? Continue on blank sheet providing the above information.

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Primary Foreign Language: Proficiency: (Mark X to those that apply) Read Speak Understand Write

FOREIGN LANGUAGES Secondary Foreign Language: Proficiency: (Mark X to those that apply) Read Speak Understand Write

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EMPLOYMENT SCREENING/MILITARY SERVICE HISTORY Complete all questions. If additional information is required for YES answers given, additional information will be specified. Refer to the end of the Employment Screening section for additional space if needed. 1. Have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace? Violation: Date of Violation (DDMMMYYYY): Date of Official Action (DDMMMYYYY): Explanation of Violation: Employer Name:
Location of Violation (Street address, City, State, County, Zip Code, Country):

Y/N

2. Have you received a written warning, been officially reprimanded, suspended, or disciplined for violating a security rule or policy? Violation: Date of Violation (DDMMMYYYY): Date of Official Action (DDMMMYYYY): Explanation of Violation:
Location of Violation (Street address, City, State, County, Zip Code, Country):

Include question number and continue explanations below for all YES answers that may apply:

EMPLOYMENT HISTORY DETAIL (Civilian) 16

ALL Civilian Employment History (paid full time, paid part time and unemployment) must cover the last 7 years. **Provide ALL medical professional employment (i.e. Nurse, MD, etc.) to back date up to the start of initial licensing even if beyond the last 7 years. Indicate all periods of unemployment between jobs if applicable. For periods of unemployment, list reference name, address and phone number. List employment in strict chronological order beginning with the present employment and working back with no gaps. Do not use reference more than once. Employer: Position: Employer Name Position Title Full Time: Part Time: Number of hours worked (per week): Employment Code: (Mark X to one that applies) Job Responsibilities: Federal Contractor - (List contractor, not Federal Agency) Self-Employment-
(Include business name and name of person who can verify)

State Government (Nonfederal Employment) Other Federal Employment Other Explanation: Date Range of Employment: Supervisor/Verifier Information: From Date (DDMMMYYYY): Last Name: To Date (yyyymmdd): Present First Name: Employer/Verifier Address and Phone No.: Middle Name: Street: Suffix: City: Title: State: County: Zip Code: Country: Country Code: Telephone No.: () - Extension: Applicant work address same as Employer Address? Supervisor work address same as Employer Address? If No, provide address and phone number. If No, provide address and phone number. Street: Street: City: City: State: State: County: County: Zip Code: Zip Code: Country: Country: Country Code: Country Code: Telephone No.: () - Telephone No.: () - Extension: Extension: Did you leave this position for favorable reasons (such as to pursue education, transfer to another job, promotion, FMLA, humanitarian reason, or other)? If Yes, complete information below. If No, continue to the next question. Favorable Reason for Leaving: ( Mark X to one that applies) Family Medical Leave Act Further Education Humanitarian Reason Promotion Transferred Other Personal Reasons Brief Explanation: Did any of the following happen to you: fired from a job, laid off from job by employer, left a job by mutual agreement following allegations of misconduct, quit a job after being told you'd be fired, left a job by mutual agreement following allegations of unsatisfactory performance or left a job for other reason under unfavorable circumstance? If Yes, list the Type of Termination and Reason for Termination below. Termination Type: Reason for Termination: EMPLOYMENT HISTORY DETAIL (Civilian) Employer: Position: Employer Name Position Title 17 Full Time: Part Time: Number of hours worked (per week):

Did you leave this position for favorable reasons (such as to pursue education, transfer to another job, promotion, FMLA, humanitarian reason, or other)? If Yes, complete information below. If No, continue to the next question. Favorable Reason for Leaving: ( Mark X to one that applies) Family Medical Leave Act Further Education Humanitarian Reason Promotion Transferred Other Personal Reasons Brief Explanation: Did any of the following happen to you: fired from a job, laid off from job by employer, left a job by mutual agreement following allegations of misconduct, quit a job after being told you'd be fired, left a job by mutual agreement following allegations of unsatisfactory performance or left a job for other reason under unfavorable circumstance? If Yes, list the Type of Termination and Reason for Termination below. Termination Type: Reason for Termination:

Employer: Employer Name

EMPLOYMENT HISTORY DETAIL (Civilian) 18 Position: Position Title

Did you leave this position for favorable reasons (such as to pursue education, transfer to another job, promotion, FMLA, humanitarian reason, or other)? If Yes, complete information below. If No, continue to the next question. Favorable Reason for Leaving: ( Mark X to one that applies) Family Medical Leave Act Further Education Humanitarian Reason Promotion Transferred Other Personal Reasons Brief Explanation: Did any of the following happen to you: fired from a job, laid off from job by employer, left a job by mutual agreement following allegations of misconduct, quit a job after being told you'd be fired, left a job by mutual agreement following allegations of unsatisfactory performance or left a job for other reason under unfavorable circumstance? If Yes, list the Type of Termination and Reason for Termination below. Termination Type: Reason for Termination:

Employer: Employer Name

EMPLOYMENT HISTORY DETAIL (Civilian) 19 Position: Position Title

Did you leave this position for favorable reasons (such as to pursue education, transfer to another job, promotion, FMLA, humanitarian reason, or other)? If Yes, complete information below. If No, continue to the next question. Favorable Reason for Leaving: ( Mark X to one that applies) Family Medical Leave Act Further Education Humanitarian Reason Promotion Transferred Other Personal Reasons Brief Explanation: Did any of the following happen to you: fired from a job, laid off from job by employer, left a job by mutual agreement following allegations of misconduct, quit a job after being told you'd be fired, left a job by mutual agreement following allegations of unsatisfactory performance or left a job for other reason under unfavorable circumstance? If Yes, list the Type of Termination and Reason for Termination below. Termination Type: Reason for Termination:

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EMPLOYMENT HISTORY DETAIL (U.S. Military) United States Military Employment History (Active Duty, National Guard/Reserve, Commissioned Corps) must be provided for each unit assigned to within the last 7 years. Unit: Position: Unit Name: Rank: Employment Code: (Mark X to one that applies) Full Time: Part Time: Active Military Duty Stations National Guard/Reserve U.S.P.H.S. Commissioned Corps Date Range of Employment Supervisor/Verifier Information From Date (DDMMMYYYY): Last Name: To Date (DDMMMYYYY): First Name: Unit Address and Phone No.: Middle Name: Street: Suffix: City: Title: State: County: Zip Code: Country: Country Code: Telephone No.: () - Extension: Applicant work address same as Unit? Supervisor work address same as Unit? If No, provide address and phone number. If No, provide address and phone number. Street: Street: City: City: State: State: County: County: Zip Code: Zip Code: Country: Country: Country Code: Country Code: Telephone No.: () - Telephone No.: () - Extension: Extension:

Did you leave this position for favorable reasons (such as to pursue education, transfer to another job, promotion, FMLA, humanitarian reason, or other)? If Yes, complete information below. If No, continue to the next question. Favorable Reason for Leaving: ( Mark X to one that applies) Family Medical Leave Act Further Education Humanitarian Reason Promotion Transferred Other Personal Reasons Brief Explanation: Did any of the following happen to you: fired from a job, laid off from job by employer, left a job by mutual agreement following allegations of misconduct, quit a job after being told you'd be fired, left a job by mutual agreement following allegations of unsatisfactory performance or left a job for other reason under unfavorable circumstance? If Yes, list the Type of Termination and Reason for Termination below. Termination Type: Reason for Termination:

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EMPLOYMENT HISTORY DETAIL (U.S. Military) Unit: Position: Unit Name: Rank: Employment Code: (Mark X to one that applies) Full Time: Part Time: Active Military Duty Stations National Guard/Reserve U.S.P.H.S. Commissioned Corps Date Range of Employment Supervisor/Verifier Information From Date (DDMMMYYYY): Last Name: To Date (DDMMMYYYY): First Name: Unit Address and Phone No.: Middle Name: Street: Suffix: City: Title: State: County: Zip Code: Country: Country Code: Telephone No.: () - Extension: Applicant work address same as Unit? Supervisor work address same as Unit? If No, provide address and phone number. If No, provide address and phone number. Street: Street: City: City: State: State: County: County: Zip Code: Zip Code: Country: Country: Country Code: Country Code: Telephone No.: () - Telephone No.: () - Extension: Extension: Did you leave this position for favorable reasons (such as to pursue education, transfer to another job, promotion, FMLA, humanitarian reason, or other)? If Yes, complete information below. If No, continue to the next question. Favorable Reason for Leaving: ( Mark X to one that applies) Family Medical Leave Act Further Education Humanitarian Reason Promotion Transferred Other Personal Reasons Brief Explanation: Did any of the following happen to you: fired from a job, laid off from job by employer, left a job by mutual agreement following allegations of misconduct, quit a job after being told you'd be fired, left a job by mutual agreement following allegations of unsatisfactory performance or left a job for other reason under unfavorable circumstance? If Yes, list the Type of Termination and Reason for Termination below. Termination Type: Reason for Termination:

**More employment to be added? Continue on blank sheet providing the above information.

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MILITARY SERVICE HISTORY List ALL military service history below, beginning from current and working back to include service in Active Duty, Reserves (Inactive Reserve/Delayed Entry Program/Unit Member), National Guard, U.S. Merchant Marine and Foreign Military Service. If there was a break in service, each separate period should be listed. Complete all entries blocks that may apply. All Non-Commissioned Officer Evaluation Reports and/or all Officer Evaluation Reports covering service periods will need to be submitted. Type: (Mark X to one that applies) Enlisted Officer Warrant Officer Service: (Mark X to one that applies) Air Force Marine Corps Army Merchant Marines Coast Guard Navy U.S. Public Health Service From Date (DDMMMYYYY): To Date (DDMMMYYYY): Present SSN/Service #: Service Status: (Mark X to one that applies) Active Inactive Reserve Active Reserve Unit Member

Rank: Current/Highest Grade: Effective Date of Grade (DDMMMYYYY): Date Active Tour Terminates (DDMMMYYYY): NG State: Country:

DISCHARGE INFORMATION Discharge Type: (Mark X to one that applies) Bad Conduct Discharge None Dishonorable Other Than Honorable Honorable Uncharacterized Honorable Conditions Separation Code: (From DD 214/NGB 22) RE Code: (From DD 214/NGB 22) MILITARY SPECIALITY INFORMATION Primary Military Occupation (PMOS) Additional Skill Identifier 1 (ASI1) Skilled Qualification Identifier 1 (SQI1) Secondary Military Occupation (SMOS) Additional Skill Identifier 2 (ASI2) Skilled Qualification Identifier 2 (SQI2) Alternate Military Occupation (AMOS) Additional Skill Identifier (ADI3) Skilled Qualification Identifier 3 (SQI3) UNIT INFORMATION Unit Name: Unit Street: Unit Zip Code: Last Name: Suffix: Title/Rank/Grade: Lost Time (DDMMMYYYY): Reason: Unit City: Unit State: Unit Country: SUPERVISOR INFORMATION First Name: Middle Name:

From Date:

To Date:

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MILITARY SERVICE HISTORY Type: (Mark X to one that applies) Enlisted Officer Warrant Officer Service: (Mark X to one that applies) Air Force Marine Corps Army Merchant Marines Coast Guard Navy U.S. Public Health Service From Date (DDMMMYYYY): To Date (DDMMMYYYY): SSN/Service #: Service Status: (Mark X to one that applies) Active Inactive Reserve Active Reserve Unit Member

Rank: Current/Highest Grade: Effective Date of Grade (DDMMMYYYY): Date Active Tour Terminates (DDMMMYYYY): NG State: Country:

DISCHARGE INFORMATION Discharge Type: (Mark X to one that applies) Bad Conduct Discharge None Dishonorable Other Than Honorable Honorable Uncharacterized Honorable Conditions Separation Code: (From DD 214/NGB 22) RE Code: (From DD 214/NGB 22) MILITARY SPECIALITY INFORMATION Primary Military Occupation (PMOS) Additional Skill Identifier 1 (ASI1) Skilled Qualification Identifier 1 (SQI1) Secondary Military Occupation (SMOS) Additional Skill Identifier 2 (ASI2) Skilled Qualification Identifier 2 (SQI2) Alternate Military Occupation (AMOS) Additional Skill Identifier (ADI3) Skilled Qualification Identifier 3 (SQI3) UNIT INFORMATION Unit Name: Unit Street: Unit Zip Code: Last Name: Suffix: Title/Rank/Grade: Lost Time (DDMMMYYYY): Reason: Unit City: Unit State: Unit Country: SUPERVISOR INFORMATION First Name: Middle Name:

From Date:

To Date:

MILITARY SERVICE HISTORY Type: (Mark X to one that applies) Enlisted Officer Service Status: (Mark X to one that applies) 24 Active Active

DISCHARGE INFORMATION Discharge Type: (Mark X to one that applies) Bad Conduct Discharge None Dishonorable Other Than Honorable Honorable Uncharacterized Honorable Conditions Separation Code: (From DD 214/NGB 22) RE Code: (From DD 214/NGB 22) MILITARY SPECIALITY INFORMATION Primary Military Occupation (PMOS) Additional Skill Identifier 1 (ASI1) Skilled Qualification Identifier 1 (SQI1) Secondary Military Occupation (SMOS) Additional Skill Identifier 2 (ASI2) Skilled Qualification Identifier 2 (SQI2) Alternate Military Occupation (AMOS) Additional Skill Identifier (ADI3) Skilled Qualification Identifier 3 (SQI3) Lost Name: Unit Time (DDMMMYYYY): Reason: Unit Street: Unit Zip Code: Last Name: Suffix: Title/Rank/Grade: UNIT INFORMATION From Date: To Date: Unit City: Unit State: Unit Country: SUPERVISOR INFORMATION First Name: Middle Name:

**More Military History to be added? Continue on blank sheet providing the above information.

MILITARY SERVICE SCHOOLS Enter ALL Military Schools attended. From Date: (DDMMMYYYY) School Name: To Date: (DDMMMYYYY) 25

Course Name: Is this the Highest Level service school attended? Y/N

Completed? Y/N

MILITARY SERVICE SCHOOLS From Date: (DDMMMYYYY) To Date: (DDMMMYYYY) School Name: Course Name: Is this the Highest Level service school attended? Y/N Completed? Y/N

From Date: (DDMMMYYYY) Installation: Type: (Mark X to one that applies) Advanced Basic Ranger

ROTC SCHOOL To Date: (DDMMMYYYY)

Completed? Y/N

**More Military schools to be added? Continue on blank sheet providing the above information.

FOREIGN HISTORY QUESTIONNAIRE Complete all questions. If additional information is required for YES answers given, additional information will be specified. Refer to the end of the Foreign History section for additional space if needed. 26

Y/N

1. Do you have or have you EVER had any foreign financial business, foreign bank accounts, or other foreign financial interests of which you have direct control or direct ownership? Type (Bank Accounts, Financial Business, Other): Explanation: Amount: (USD) $ 2. Do you have or have you had any foreign financial interests that someone controls on your behalf? Type (Bank Accounts, Financial Business, Other): Explanation: Amount: (USD) $ 3. Do you own or have you owned real estate in a foreign country? From-To Dates (DDMMMYYYY): Amount: (USD) $ Property Type (Business, Land, Rental Property, Vacation Home, Other): Explanation:
Foreign Owned Real Estate Information (Street address, City, Country, Zip Code):

4. Do you receive or have you received any educational, medical, retirement, social welfare, or other such benefits from a foreign country? Type of benefit (Educational, Medical, Retirement, Social Welfare, Other): Amount: (USD) $ Explanation: 5. Have you provided advice or support to anyone associated with a foreign business or other foreign organization that you have not previously listed as a former employer regarding any of the following: management, strategy, financing, or technology? If answer is Yes, Official Government business? Y/N: . If No, complete below. From-To Dates (DDMMMYYYY): Country: Name of Foreign National or Organization: Description of advice or support given: Explanation: Was Compensation Provided? Y/N: If Yes, provide Amount: (USD) $ 6. Have you attended any international conferences, trade shows, seminars, or other meetings outside of the US? If Yes, Official Government business? Y/N: . If No, complete below. From-To Dates (DDMMMYYYY):
Foreign Conference Information (Street address, City, Country):

Purpose of Event: Name of Sponsoring Organization: Explanation:

7. Have you or any of your immediate family members been asked to provide advice or serve as a consultant, even informally, by any foreign government official or agency? If Yes, Official Government business? Y/N: . If No, complete below. From-To Dates (DDMMMYYYY): Parties Involved: Foreign Country: Circumstances:
Foreign Advice/Contact Information (Street Address, City, State, County, Zip Code Country):

8. Are you now or have you ever been employed by or acted as a consultant for a foreign government, firm, or agency? From-To Dates (DDMMMYYYY): Firm: Government: Explanation:

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9. Have you or any of your immediate family had any contact with a foreign government, its establishment (embassies, consulates, agencies, or military services), or its representatives, whether inside or outside of the US? If Yes, Official Government business? Y/N: . If No, complete below. From-To Dates (DDMMMYYYY): Parties Involved: Foreign Country: Circumstances:
Foreign Advice/Contact Information (Street Address, City, State, County, Zip Code Country):

10. Have you sponsored any foreign citizen to come to the U.S. as a student, for work, or for permanent residence? If Yes, Official Government business? Y/N: . If No, complete below. Last name, First name, Middle name, Suffix of Foreign Sponsored Citizen: Purpose of Stay: Purpose Explanation: From-To Dates (DDMMMYYYY): Country of Citizenship:
Foreign Sponsored Citizen Street Address, City, State, County, Zip Code, Country:

11. Have you EVER held or do you now hold a passport that was issued by a foreign government? If Yes, Official Government business? Y/N: . If No, complete below. Last name, First name, Middle name, Suffix: Issuing Country: Passport No.: Issue Date (DDMMMYYYY): Expiration Date (DDMMMYYYY): Status of Foreign Passport (Active, Expired, Relinquished, Other): Explanation: 12. Have you traveled outside the US in the last 10 years?
IF YES: Respond for foreign countries you have visited in the last 10 years, beginning with the most current and working back. If you have lived near a border and have made short (one day or less) trips to the neighboring country (e.g. Canada or Mexico), you do not need to list each trip. Instead, provide the time period, purpose of visit, the country, and indicate that Many Short Trips were taken. Do not list travel under official U.S. Government travel business, but you must include any personal trips made in conjunction with the official U.S. Government travel.

From Date (DDMMMYYYY): To Date (DDMMMYYYY): Purpose of Visit: Business/Professional Conference Education Other Tourism Visit family or friends Volunteer Activities Country Visited: Many short trips: Y/N Number of days outside the US: Explanation: From Date (DDMMMYYYY): To Date (DDMMMYYYY): Purpose of Visit: Business/Professional Conference Education Other Tourism Visit family or friends Volunteer Activities Country Visited: Many short trips: Y/N Number of days outside the US: Explanation:

28

13. Do you have or have you had close continuing contact with foreign nationals within the last 10 years with whom you, your spouse, or your cohabitant are bound by affection, influence, and/or obligation? Include associates, as well as relatives, not already listed. (A foreign national is defined as any person who is not a citizen or national of the U.S.) From-To Dates (DDMMMYYYY): Last name, First name, Middle name, Suffix: Country(ies) of Citizenship: Country of Residence: Nature of Relationship (Business, Personal, Other): Relationship Explanation: Type of Contact (Telephone, In Person, Electronic or Written Correspondence, Other) : Contact Explanation: Number of Contacts per Year: Include question number and continue explanations below for all YES answers that may apply:

AWARD INFORMATION 29

List military awards received. Do not list theater or service medals. Award: Award: Award: Award: Award: Award: Award: Award: Award: Award: GOVERNMENT AND MILITARY Complete all questions. If additional information is required for YES answers given, the question requiring additional information will be specified. Refer to the end of the Government and Military section for further information needed for all other YES answers provided. 1. Have you EVER served in the U.S. military or the U.S. Merchant Marines? 2. Have you EVER served in a foreign country's military, security forces, merchant marine, militia, or other defense forces? 3. Have you EVER received a discharge that was not honorable? 4. Have you ever been subject to court martial or other disciplinary proceedings under the Uniform Code of Military Justice? (Include non-judicial, Captain's mast, etc.) Offense Date (DDMMMYYYY): Offense Action: Action Taken: Explanation:
Court Information (Name, Street address, City, State, County, Zip Code, Country:

Y/N

5. Are you now or have you ever been a deserter from any branch of the armed forces of the United States? 6. Have you ever been employed by the United States Government? 7. Are you now drawing, or do you have an application pending, or approval for: retired pay, disability allowance, severance pay, or pension from any agency of the government of the United States? 8. Are you now or have you ever been a conscientious objector? (That is, do you have, or have you ever had, a firm, fixed, and sincere objection to participation in war in any form or to the bearing of arms because of religious belief or training?) 9. Is there anything which would preclude you from performing military duties or participating in military activities whenever necessary (i.e., do you have any personal restrictions or religious practices which would restrict your availability?) 10. Have you ever been discharged by any branch of the Armed Forces of the United States for reasons pertaining to being a conscientious objector? 11. Have you ever been an officer or a member or made a contribution to an organization dedicated to the violent overthrow of the United States Government and which engages in illegal activities to that end, knowing that the organization engages in such activities with the specific intent to further such activities? 12. Have you ever knowingly engaged in any acts or activities designed to overthrow the United States Government by force? 13. Have you ever applied and not been selected for appointment in Regular Army as a commissioned officer? Date (DDMMMYYYY): Explanation: 14. Have you ever applied and not been selected for appointment in Regular Army as a warrant officer? Date (DDMMMYYYY): Explanation: 15. Have you ever applied and not been selected for appointment in Reserve component (USAR/ARNG) as a commissioned officer? Date (DDMMMYYYY): Explanation: 16. Have you ever applied and not been selected for appointment in Reserve component (USAR/ARNG) as a warrant officer? Date (DDMMMYYYY): Explanation: 30

17. Have you ever applied and not been selected for OCS? 18. Have you ever applied and not been selected for ROTC? 19. Have you ever resigned or been asked to resign in lieu of elimination proceedings; been discharged in lieu of elimination, furloughed, or placed on inactive status while serving in the US Armed Forces; or, have you ever resigned or been asked to resign from position while in government or private employment? Date (DDMMMYYYY): Explanation: 20. Have you been employed by the US Army as a Dietitian, Occupational or Physical Therapist? From-To Dates (DDMMYYYY): Explanation: 21. Are you in a promotable status and on a published promotion list? I understand that, if I am selected for appointment, I will be expected to accept such assignments as are in 22. the best interest of the service regardless of my marital status and/or responsibility for dependents; and it is my responsibility to make appropriate arrangements for the care of my dependents should I be required to perform duty in an area where dependents are not permitted. Do you have an ADL Promotion Date? 23. 24. Have you ever been passed over for a military promotion? If Yes, how many times? 25. Do you have a current commission? If Yes, give source: ARNGUS (Direct Appointment, OCS, Other): USAR (Direct Appointment, OCS, ROTC, ROTC (ECP), ROTC (SMP), Other: 26. To your knowledge, have you EVER had a clearance or access authorization denied, suspended, or revoked; or been debarred from government employment? [If "Yes," give the action(s) date(s), of action(s), agency (ies), and circumstances.] Note: An administrative downgrade or termination of a security clearance is not a revocation. Date (DDMMMYYYY): Department/Agency taking Action: Circumstances: 27. Has the U.S. Government or a foreign government EVER investigated your background and/or granted you a security clearance? Date (DDMMMYYYY): Agency Name: Explanation: Clearance: Clearance Explanation: 28. Are you a male born after December 31, 1959? If Yes, complete the following information below: Have you registered with the Selective Service System? If Yes, provide Registration Number. If No, provide Legal Exception Explanation. Registration Number: Legal Exception Explanation: Include question number and explain all YES answers that apply to include the following information: Explanation.

EDUCATION QUESTIONNAIRE Complete all questions. Additional information is required for YES answers given. Refer to the end of 31 the Education Questionnaire section for additional information.

Y/N

EDUCATION 32 List ALL education received starting from high school and working forward to the most current education history School Information: to include certificate, undergraduate, graduate and doctorate programs. Complete all entries that may apply. All Name: From Date: (DDMMMYYYY)

EDUCATION School Information: Name: Education Type: (Mark X to one that applies) 33 From Date: (DDMMMYYYY) To Date: (DDMMMYYYY)

EDUCATION School Information: Name: Education Type: (Mark X to one that applies) 34 From Date: (DDMMMYYYY) To Date: (DDMMMYYYY)

EDUCATION School Information: Name: Education Type: (Mark X to one that applies) 35 From Date: (DDMMMYYYY) To Date: (DDMMMYYYY)

36

ADVANCED EDUCATION List ALL education/training received to include fellowship, internship, residency and specialty training. Complete all entries that may apply. All information must match professional certificate(s) and verification letters submitted. Hospital/School Information: (Mark X to one that applies) Fellowship Residency From Date: (DDMMMYYYY) Internship Specialty Training To Date: (DDMMMYYYY) Hospital/School Name: Specialty: Hospital/School Location Information: Street: State: Zip Code: City: Country: Phone No.: Questions About School (If answering Yes, provide detailed explanation below). Board Eligible? Y/N: If Yes, Specialty Board Name: Board Certified? Y/N: Certification Date (DDMMMYYYY): ADVANCED EDUCATION Hospital/School Information: (Mark X to one that applies) Fellowship Residency From Date: (DDMMMYYYY) Internship Specialty Training Date: (DDMMMYYYY) To Hospital/School Name: Specialty: Hospital/School Location Information: Street: State: Zip Code: City: Country: Phone No.: Questions About School (If answering Yes, provide detailed explanation below). Board Eligible? Y/N: If Yes, Specialty Board Name: Board Certified? Y/N: Certification Date (DDMMMYYYY): ADVANCED EDUCATION Hospital/School Information: (Mark X to one that applies) Fellowship Residency From Date: (DDMMMYYYY) Internship Specialty Training Date: (DDMMMYYYY) To Hospital/School Name: Specialty: Hospital/School Location Information: Street: State: Zip Code: City: Country: Phone No.: Questions About School (If answering Yes, provide detailed explanation below). Board Eligible? Y/N: If Yes, Specialty Board Name: Board Certified? Y/N: Certification Date (DDMMMYYYY):

**More education to be added? Continue on blank sheet providing the above information

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FINANCIAL HISTORY QUESTIONNAIRE Complete all questions. Additional information is required for YES answers given. Refer to the end of the Financial History Questionnaire section for additional information. Y/N 1. Have you filed a petition under any chapter of the bankruptcy code? If "Yes," indicate Chapter 7, 11, or 13? Have you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? 2. 3. Have you failed to pay Federal, state, or other taxes, or to file a tax return, when required by law or ordinance? 4. Have you had a lien placed against your property for failing to pay taxes or other debts? 5. Have you had a judgment entered against you? 6. Have you defaulted on any type of loan? 7. Have you had bills or debts turned over to a collection agency? 8. Have you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? 9. Have you been evicted for non-payment of financial obligations? 10. Have you been delinquent on court-imposed alimony or child support payments? 11. Have you had your wages, benefits, or assets garnished or attached for any reason? 12. Have you been counseled, warned, or disciplined for violating terms of agreement for a travel or credit card provided by your employer? 13. Have you EVER experienced financial problems due to gambling? 14. Are you currently delinquent on any Federal debt? 15. Have you been over 180 days delinquent on any debt(s)? 16. Are you currently over 90 days delinquent on any debt(s)? Include question number and explain all YES answers that apply to include the following information: Date (DDMMMYYYY), Type of Action, Amount (USD), Account Number, Name of Agency/Organization/Individual to whom Debt is/was owed, Name Action Occurred Under, Status of Action, Explanation, Court/Agency Name and Address.

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FAMILY & ASSOCIATES Complete all entries that apply to the best of your knowledge. Mother and Father information is required. If married, provide Spouse, Mother in Law and Father in Law information. If divorced, Former Spouse information is required. For any family member that is deceased, provide only name, birth date and place of birth information. SSNs are required for those you will list as beneficiaries. If anyone was not born in the U.S., but currently reside in the U.S., provide citizenship information. Relationship: (Mark X to one that applies) Adult Living w/ you Associate Brother Cohabitant Child (custody) Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother in X Mother Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Maiden Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (DDMMMYYYY) Approximate DOB? Social Security No.: City: Use Applicants Current Address? Y/N Street: Use Applicants Home of Record? Y/N State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued (DDMMMYYY): City/State: Court:

Relationship: (Mark X to one that applies) Adult Living w/ you Associate Brother Cohabitant Child (custody) X Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother in Mother Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (DDMMMYYYY) Approximate DOB? Social Security No.: City: Use Applicants Current Address? Y/N Street: Use Applicants Home of Record? Y/N State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued (DDMMMYYY): City/State: Court:

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Relationship: (Mark X to one that applies) Adult Living w/ you Associate Brother Cohabitant Child (custody) Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother in Mother Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (DDMMMYYYY) Approximate DOB? Social Security No.: City: Use Applicants Current Address? Y/N Street: Use Applicants Home of Record? Y/N State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued: (DDMMMYYY): City/State: Court:

Relationship: (Mark X to one that applies) Adult Living w/ you Associate Brother Cohabitant Child (custody) Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother in Mother Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (DDMMMYYYY) Approximate DOB? Social Security No.: City: Use Applicants Current Address? Y/N Street: Use Applicants Home of Record? Y/N State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued: (DDMMMYYY): City/State: Court:

40

Relationship: (Mark X to one that applies) Adult Living w/ you Associate Brother Cohabitant Child (custody) Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother in Mother Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (DDMMMYYYY) Approximate DOB? Social Security No.: City: Use Applicants Current Address? Y/N Street: Use Applicants Home of Record? Y/N State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued: (DDMMMYYY): City/State: Court:

Relationship: (Mark X to one that applies) Adult Living w/ you Associate Brother Cohabitant Child (custody) Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother in Mother Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (DDMMMYYYY) Approximate DOB? Social Security No.: City: Use Applicants Current Address? Y/N Street: Use Applicants Home of Record? Y/N State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued: (DDMMMYYY): City/State: Court:

41

Relationship: (Mark X to one that applies) Adult Living w/ you Associate Brother Cohabitant Child (custody) Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother in Mother Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (DDMMMYYYY) Approximate DOB? Social Security No.: City: Use Applicants Current Address? Y/N Street: Use Applicants Home of Record? Y/N State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued: (DDMMMYYY): City/State: Court:

Relationship: (Mark X to one that applies) Adult Living w/ you Associate Brother Cohabitant Child (custody) Father Father in Law Former Spouse Foster Parent Guardian Half Brother Half Sister Mother in Mother Law Other Relative Sister Stepbrother Stepchild Stepfather Stepmother Stepsister Last Name: Deceased? Y/N First Name: Dependent? Y/N Gender: Middle Name: Suffix: Adopted? Y/N Date of Birth: (DDMMMYYYY) Approximate DOB? Social Security No.: City: Use Applicants Current Address? Y/N Street: Use Applicants Home of Record? Y/N State: Zip Code: Country: Place of Birth: City: State: Country: Country(ies) of Citizenship: Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.) Certificate/Registration No.: Date Issued: (DDMMMYYY): City/State: Court:

**More Family and Associates to be added? Continue on blank sheet providing the above information.

Last Name:

SPOUSE INFORMATION 42 Current Spouse? Y/N

Last Name:

43 FORMER SPOUSE INFORMATION Deceased? Y/N

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CITIZENSHIP Complete all sections that apply. If additional information is required for YES answers given, additional information will be specified. Country(ies)of Citizenship (if applicable): Citizenship: (Mark X to one that applies) US Citizen at Birth, Native Born US Citizen Born Abroad of US Parents US Citizen Naturalized Immigrant Alien US Passport Number (if applicable) : Date Issued: (DDMMMYYYY) Expiration Date: (DDMMMYYYY) Documentation of US Citizens Born Aboard (if applicable): (FS 240, DS 1350, FS 545 etc.) Form Completed Date: Document Number: Place of Issuance: Place: City: Country: Explanation: Do you now hold or have you EVER held multiple citizenships?
If Yes, answer the following questions below.

Is your non-U.S. citizenship based on your birth in a foreign country or the citizenship of your parents? Have you renounced or attempted to renounce your foreign citizenship(s)? If Yes, Explain:

PROFESSIONAL REFERENCES List a minimum of three people who know your work. They should be supervisors or peers you have worked with during the last year and who are in a position to know the quality of your work and your work habits and ethics. At 45 least one reference must be in a supervisory position and you must have reported to that person. The supervisory positions have a Reference Type of Supervisor, Instructor or Dean. Persons listed below should be the same people

#2 Reference Information: First Name: Middle Name: Last Name: Suffix: Reference Address: Street: City: Home Phone: Available Day or Night? Day Night Country Code: Telephone No.: () - Extension: #3 Reference Information: First Name: Middle Name: Last Name: Suffix: Reference Address: Street: City: Home Phone: Available Day or Night? Day Night Country Code: Telephone No.: () - Extension:

From Date: (yyyymmdd) To Date: (yyyymmdd) Reference Type: (Mark X to one that applies) Dean Instructor Pee r Supervisor Unit Commander State: Zip Code: Country: Work Phone: Available Day or Night? Day Night Country Code: Telephone No.: () - Extension:

From Date: (yyyymmdd) To Date: (yyyymmdd) Reference Type: (Mark X to one that applies) Dean Instructor Pee r Supervisor Unit Commander State: Zip Code: Country: Work Phone: Available Day or Night? Day Night Country Code: Telephone No.: () - Extension:

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CHARACTER REFERENCES List a minimum of three people you know well and preferably live in the United States. They should be good friends, peers, colleagues, college roommates,etc., whose combined association with you covers, as well as possible, the last 7 years. Do not list your spouse, former spouse, other relatives or anyone listed elsewhere as a reference. The individual(s) you list as your supervisor(s) under the Employment Section cannot be used as a Character Reference. #1 Reference Information: From Date: (DDMMMYYYY) Last Name: To Date: (DDMMMYYYY) First Name: Reference Type: (Mark X to one that applies) Middle Name: Friend Neighbor Schoolmate Suffix: Work Associate Other: Reference Address: Street: State: Zip Code: City: Country: Home Phone: Work Phone: Available Day or Night? Day Night Available Day or Night? Day Night Country Code: Country Code: Telephone No.: () - Telephone No.: () - Extension: Extension: #2 Reference Information: Last Name: First Name: Middle Name: Suffix: Reference Address: Street: City: Home Phone: Available Day or Night? Day Night Country Code: Telephone No.: () - Extension: #3 Reference Information: Last Name: First Name: Middle Name: Suffix: Reference Address: Street: City: Home Phone: Available Day or Night? Day Night Country Code: Telephone No.: () - Extension: From Date: (DDMMMYYYY) To Date: (DDMMMYYYY) Reference Type: (Mark X to one that applies) Friend Neighbor Schoolmate Work Associate Other: State: Zip Code: Country: Work Phone: Available Day or Night? Day Night Country Code: Telephone No.: () - Extension: From Date: (DDMMMYYYY) To Date: (DDMMMYYYY) Reference Type: (Mark X to one that applies) Friend Neighbor Schoolmate Work Associate Other: State: Zip Code: Country: Work Phone: Available Day or Night? Day Night Country Code: Telephone No.: () - Extension:

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Organization Name (i.e. Am. Medical Assoc.)

PROFESSIONAL ORGANIZATION(S) From Date To Date (yyyymmdd) (yyyymmdd)

Status (i.e. Current unrestricted)

PROFESSIONAL LICENSE(S) List all professional licenses/certifications ever held, even if expired. National License Type State License? License No. (i.e. Registered Initial Issue Date (i.e. HI) Y/N (i.e. 01234) Nurse) (yyyymmdd)

Expiration Date (yyyymmdd)

Status (i.e. Current Unrestricted)

PROFESSIONAL PRIVILEGE(S) All information must match professional privilege(s) verification letter(s) submitted. Facility Name: From Date: (yyyymmdd) To Date: (yyyymmdd) Status: Facility Address: Street: State: Zip Code: City: Country: Facility Phone No.: Country Code: Telephone No.: () - Extension: PROFESSIONAL PRIVILEGE(S) Facility Name: From Date: (yyyymmdd) From Date: (yyyymmdd) Status: Facility Address: Street: State: Zip Code: City: City: Facility Phone No.: Country Code: Telephone No.: () - PROVIDER Extension: MALPRACTICE INSURANCE Provide information for Malpractice Insurance Provider(s) within the past 7 years. Information must match Malpractice Insurance verification letter submitted. Carrier Name: Policy No.: Street Address: City: State: Zip Code: Telephone No.:() - Time of Provider Coverage: From Date: (yyyymmdd) To Date: (yyyymmdd) 48

MALPRACTICE INSURANCE PROVIDER Carrier Name: Policy No.: Street Address: City: State: Zip Code: Telephone No.:() - Time of Provider Coverage: From Date: (yyyymmdd) To Date: (yyyymmdd)

Case No.: Suit Filed? Y/N:

MALPRACTICE CLAIM Allegation: Court Date: (yyyymmdd):

Claim Status (Closed, Open, Settled or Suit Withdrawn): Disposition Favored: Payment Required? Y/N: Payment Amount: $ Detailed Medical Facts: Associated Carrier(s):

Payment Type (Award or Settlement):

Case No.: Suit Filed? Y/N:

MALPRACTICE CLAIM Allegation: Court Date: (yyyymmdd):

Claim Status (Closed, Open, Settled or Suit Withdrawn): Disposition Favored: Payment Required? Y/N: Payment Amount: $ Detailed Medical Facts: Associated Carrier(s):

Payment Type (Award or Settlement):

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ACTIVE DUTY ASSIGNMENT PREFERENCES Complete the information below regarding active duty preferences. First Assignment Preference: Duty Assignment (Location): Area Assignment (AOC): Second Assignment Preference: Duty Assignment (Location): Area Assignment (AOC): Third Assignment Preference: Duty Assignment (Location): Area Assignment (AOC):

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EXPLANATIONS Additional space for explanations to YES answers (include section title and question number).

51