Form F-3(Le) - Personal History Statement Page 7
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1628. Have you ever been discharged, requested to resign, or allowed to resign in lieu of termination, from any position
because of criminal or personal misconduct or rules violations?
Yes
No
If yes, list organization name and give details: ___________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
__________________________________________________________________________________
29. Do you object to wearing a uniform?
Yes
No
30. Do you object to working nights?
Yes
No
31. Do you object to working rotating shifts?
Yes
No
32. Do you object to occasionally being away from home overnight and for other periods of time attending meetings,
acquiring training and otherwise performing official duties?
Yes
No
33. List ALL jobs, positions or appointments you have held in the last ten years to include temporary, part-time, paid or
not paid employment, active or inactive reserve, and internships. Put your present or most recent job first. List a
Reason for Leaving for each job. Include military service in proper time sequence and temporary part-time jobs. If
there are gaps in your employment please provide an explanation for each period of unemployment.
A. 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: __________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
F-3(LE) Rev. 12.2.13
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