AMEDDApplicantWorksheet-July2012-3.doc

Reference who knew you at that time period do not

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reference who knew you at that time period (do not list spouse, former spouses, or other relatives and use each “person who knew you” only ONCE in the entire application. Time at Residence: Reference Information: From Date ( dd-MMM-yyyy ): Last Name: To Date ( dd-MMM-yyyy ): First Name: Middle Name: Residence Information: (Mark ‘X’ to one that applies) Suffix: Date of last contact: Status: Military Housing Owned by you Rented or leased by you Other Explanation: Relationship: (Mark ‘X’ to one that applies) Business Associate Friend Landlord Neighbor Other Explanation: Address Type: Previous Reference Address: Street: Street: City: City: State: State: County: Zip Code: Zip Code: Country: Country: Reference Daytime Phone Number: [‘X’ here if unknown ] Set as Mailing Address? Y/N: Country Code: Set as Permanent Address? Y/N: Telephone No.: ( ) - Extension: Reference Evening Phone Number: [‘X’ here if unknown ] Country Code: Telephone No.: ( ) - Reference Cell/Mobile Phone Number: [‘X’ here if unknown ] Country Code: Telephone No.: ( ) - Reference Email Address: [‘X’ here if unknown ] Email address: RESIDENCES 21
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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, list a reference who knew you at that time period (do not list spouse, former spouses, or other relatives and use each “person who knew you” only ONCE in the entire application. Time at Residence: Reference Information: From Date ( dd-MMM-yyyy ): Last Name: To Date ( dd-MMM-yyyy ): First Name: Middle Name: Residence Information: (Mark ‘X’ to one that applies) Suffix: Date of last contact: Status: Military Housing Owned by you Rented or leased by you Other Explanation: Relationship: (Mark ‘X’ to one that applies) Business Associate Friend Landlord Neighbor Other Explanation: Address Type: Current Reference Address: Street: Street: City: City: State: State: County: Zip Code: Zip Code: Country: Country: Reference Daytime Phone Number: [‘X’ if unknown ] Set as Mailing Address? Y/N: Country Code: Set as Permanent Address? Y/N: Telephone No.: ( ) - Extension: Reference Evening Phone Number: [‘X’ here if unknown ] Country Code: Telephone No.: ( ) - Reference Cell/Mobile Phone Number: [‘X’ here if unknown ] Country Code: Telephone No.: ( ) - Reference Email Address: [‘X’ here if unknown ] Email address: 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 FOREIGN LANGUAGES Primary Foreign Language: Secondary Foreign Language : 22
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Proficiency: [Mark ‘X’ to those that apply] Read Speak Understand Write Proficiency: [Mark ‘X’ to those that apply] Read Speak Understand Write EMPLOYMENT SCREENING/MILITARY SERVICE HISTORY Complete all questions. If additional information is required for ‘YES’ answers given, additional Y/N 23
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information will be specified. Refer to the end of the Employment Screening section for additional space if
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