AMEDDApplicantWorksheet-July2012-3.doc

Include question number and explain all yes answers

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Include question number and explain all ‘YES’ answers that apply to include the following information: From-To Date(s) (dd-MMM-yyyy), Organization Name and Group/Member Association Information (Street address, City, State, County, Zip Code, Country). 17
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CONTACT INFORMATION AND METHOD 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). Type Country Code Telephone No. Ext. Best time to contact (Day, Night or Both) Permanent ( ) - Home/Current ( ) - Business ( ) - Mobile/Cell ( ) - DSN ( ) - Pager ( ) - Temporary ( ) - EMAIL Home Email: School Email: Work Email: Which is your primary email? (Home, School or Work) ALIAS 18
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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 (Maiden, Former Marriage, Nickname, Alias, etc.) Other #1 Last Name Other #1 First Name Other #1 Middle Name Suffix (Jr., II, etc.) From (dd-MMM-yyyy): To (dd-MMM-yyyy): Reason(s) why the name changed: Name Type (Maiden, Former Marriage, Nickname, Alias, etc.) Other #2 Last Name Other #2 First Name Other #2 Middle Name Suffix (Jr., II, etc.) From (dd-MMM-yyyy): To (dd-MMM-yyyy): Reason(s) why the name changed: Name Type (Maiden, Former Marriage, Nickname, Alias, etc.) Other #3 Last Name Other #3 First Name Other #3 Middle Name Suffix (Jr., II, etc.) From (dd-MMM-yyyy): To (dd-MMM-yyyy): Reason(s) why the name changed: RESIDENCES 19
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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’ 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 20
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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
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