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<br />._.............~-~...._......__....._.....REQUIREO iNFORM A TION...m..-...----........ <br /> <br />...--...................--............................... ; <br /> <br />-.......'o.......'..____~....._ .....~_..._~...................._~.._... <br />or:CLWATrON {PRh.'SENTRM.f'LO'lIvfRNT _ PAlD<"!F,llNf'MD) t":"" ~..." ......m._....;,~ 'm....... <br />l I . --, .~;;,,-J}...;') \ <br />y\{j(fV\~J {(C'::::,..,z:x)f\:.c:S O).kS'l.i\::q~-.JT t JA.:"7'~6/",; f::::([i, t.:'~4,.tTS ) <br />.)~ ./ <br /> <br />'n___~''''''''''''h_....",.......'': <br /> <br />l OCCUP.ATIONAL BACKC,1~{JUND (FREVlOUS RMPLO\'1,1EN1' - f'AtpOR lJN'PA1D) <br />; '"'\ ", - ,/." . '. .",., h- t,l;.).. ll.., f:)J l" <<l" "'. <br />j ~ (.. /~,,''\,ntd h\oU\'-\M-'j../ t?f\pte"H:-:.v.:::> n(f~v\.rh '~i"'\ <.t':h,~,t- <br />, \') '::...A '<. \l ',~ ',. ., " C/' I . i <br /> <br />.....~n....~_..._.-,-,.'......,........,."............."..__~....._ <br /> <br />..._~....._....._---.................._--...................- <br /> <br />.._.._--~..,................_~.-:. <br /> <br /> <br /> <br />I <br /> <br />E6l1CA TIONiCBACKGROUi:<JD l.ti:HDOI~C\fi'ENDE6:'u.>'Jl;l aitilclm.1eut if n(.~ded) <br /> <br />"'---~.._------.-.~...._-...............o'a"'_""""""", <br /> <br />1 [(:~;;~Pi~l~ ~~;. m sdwof~nQ.~!!rQ.l'l'rm;--....m <br /> <br />..._-~..._---~............"....._---,..~.._.-.... -.._--- <br />,$ ~ --:: t'../...-...... " ~r'" .~:. . <br />J/nL0t~{ .) d'S::aJ.d~\rtl~:!.~?Q, ~i, S "nm.. <br />I ,- , /'''' r U' <br />~V,:, 'J ('C'!?~ .f C<~jR', 1...1, <le'i_ <br /> <br />, C " ~ ,. ~ - <br />~:~ \ ';. ...., ~ ". " -0.... .". ". I L. y .......... ~. _'\ <br />.,l '<:':~.L.?~,.,{,l.h. )C l;!t>:::..:~~~.".~.~:!h f-ift/ <br /> <br />()th;;-i.~'~'-"'''..,m <br /> <br />~:;d ~~"~i::~'::C ,~="'~;;'dy "'l"~>> .1 <br />.~ .,. t) l . <br />j ,Y',;, " ';>.<c~Dk:..:-:: . ",.. <br />'" l i ...n(":;.~(;:...m:rr~_"~'::'~' j':i :tu...... ;/\~, l-"~'l <br />. '<<::L^ !ff.f?\.Q\" ,.,:t"~~'..m ".2:~:/l~?~:~'--<:.._ U\V.;Ai'"' ~..:::~:~:=/~A'<~?mJ <br />124-\ . <br /> <br />. .......__.=I.......u_~__...:.....-=__~.__.. ...-=.~__=--=__.~..... <br /> <br />.._-~.......,~._------..................-......._-----~.......n...___.................__...._ <br /> <br />..................................--.....uo__.........................__u_u........................... <br /> <br />.......uu................__....__uu_..................__...____o <br /> <br />. PlUOR GO'lERNl'.1f-.NTAL EXPERlENCH (Hr.-BeTED OR APPOlNTED) ._. '\ <br />i ("\...L (.:. 'h ..<; ..t /\. t:1 (\l....."- ';'~/l.y>",. i ,. ( k(.;(;...).t',,::::\ <br />{t ..i :t""" n~'" ~~ <.)) fflt /-~A.t:.~se.-~ l.;j,Y7l ~1\ ~,. f'C(;; ^~_~'\\ UfO \, h u-A..:.hv l'l ;.: ~J./ :~) <br /> <br />~ ! ~,;~; (&~f\ i:{, fff\P; ~ ;;^t) \0" (LTn "\<,, 4\ ( ? 1 q <11- Z<<;; \ <br /> <br />~ v' . < .... .w' ,,' \..J ~ >. ,. .."". \...... ...-/' <br /> <br />.---...............-n.....____~............n.._______...............___.......___............................____...... <br /> <br />NOTE: nUs Illfmmauon ls a m.aUef of puMk xecom and may be pU:hH~hed or reprodueed. <br /> <br />~hm <br />1 By gjgll:ing this do<;&u:mmt, J hf:t<:'hy Ji:tat~; <br />! THA'fl ~fh,n a'OI.,<;,pt fu~ nnmlnati".>.n h>r fu.-, nffk~ uldb,t<2'd :'}x.",~; <br />1'H/\ l' r shall <{llil:1ify fox w.id offu-s:- .if>:le;;~.l>i; and <br />THAT all. it\lo,matio:n pr;)vid~ctby n',ll on tlus f<<un, indudil\~ my ()":'1::I}~ltion, ~dtl<:iliiona.! ,',nJ t"_'wpatiDnai ba<:kgr.nund., ;;md prim <br />g<.,v<:".'J:lm~nta1l'(.~pe:rif.'nc~, :is true to tl.'t be,i: of r.ny kn<~wk'dg~. <br /> <br />. /\ /'< '1 ' U l <br />i < d~"'/ .v..\ ''''l-''i..,.'-'' <br />_...L::f....f.t'2x:.~ I ./ / :11~r it-/" ~.muu__m......u._....um. <br />Caw,hkre'l> signature ,/ , <br /> <br /> <br />l <br />, <br /> <br />l~'W A.R.l\ii'Nl;: s<lppiy'i;;g fa1&e inf;;;;;ti.on on ti;i.~'f~:'rm mi',y ;;~it'l; COl-lvktk;;';'-;Yil.fuJo.ny wtth';'Mf: (ff <o/t~~"$-H'j(j,(l(l(l ~d!~'lr p~1s.;)n ft'r'~r t;'flv;' <br />YNms, {ORS 26fi.715). . . <br />No p~rson shl.lll ilk a 1'l01Xunating pehtion <), d0Clarahon of nmclkh,<:y tOt mm:1~ than tme iucr<,Uv,..~ oflki: bdor~ If!fZ dat~ of th~: pdmary d~:tio~_ Ul~ <br />the p<.m>nn first m~"f a wntl,m. withdraw,3.\ >.vUh the office, WX!i.l accl2:pted thie fiiint \ORS 249.l'l.3{2}}, . <br />.~,..,..,....,..,........_---....................._._---~.......__._--~-....._-........................-----.......................n._____~ ..,.....~._--~-......._--"""'~......n...__ ......__................~_ <br />31'1- 1:':(' llll\'. Hi<ll Gl'J; :M'!.<l3; <br />