<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 />
|