Form F-3(Le) - Personal History Statement Page 9

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Reason for leaving: ____ ___________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
D. 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: _______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
E. 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: _______________________________________________________________________
__________________________________________________________________________________
F-3(LE) Rev. 12.2.13
9

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