Form F-3(Le) - Personal History Statement Page 10
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16F. Title of present or last position _______________________________________________________________
Employer Address and Phone Number _________________________________________________________
Name
Phone Number
________________________________________________________________________________________
Street
City
State
Zip Code
Date Employed _______________ Starting Salary ____________ Last Salary
_____________________
Date Separated _______________ Name/Title of Supervisor ______________________________________
Full Time ___ Yrs _____ Mos
Part Time ____ Yrs ____ Mos
If part time, number of hours worked per week _________ No. employees supervised by you ___________
Duties: __________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Reason for leaving: ________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
G. Explain Periods of unemployment of three months or more. _________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
MILITARY SERVICE
34. Were you ever in the U.S. Military Service or any other military organization?
Yes
No
Were you ever denied entrance into the military?
Yes
No If yes, why?__________________________
____________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
QUESTIONS 35 THROUGH 43 ARE APPLICABLE ONLY TO VETERANS
35. What is your service number?
_______________________________________________________________
36. What was the highest rank that you held? _______________________________________________________
37. What was the last rank that you held? __________________________________________________________
38. What was the date and location of your first enlistment or commission? Date: ___________________________
F-3(LE) Rev. 12.2.13
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