LOCAL APPLICANT QUESTIONNAIRE

LOCAL APPLICANT QUESTIONNAIRE

(This form is subject to the Privacy Act of 1974)

AUTHORITY: Title 5, Code of Federal Regulat= ions, Sections 5.2 and 5.3, Title 5, USC, Sections 1303, 1304 and 3301; Sections 8(b), (c) and 9(c) of Executive order 10450, Title 42, USC, Sections 1434= and 2685. PRINCIPAL PURPOSE: Used by civilian personnel speci= alists to make determinations regarding eligibility for employment with the US F= orces and for employment referrals. ROUTINE USES: Record= s from this system may be disclosed for any of the blanket routine uses publishe= d by the Department of Defense. = Furnishing the information is volun= tary. If you do not give the requested information or give erroneous information, it may result in erroneous employment determinations and may be grounds for not employing you or dismissal after you begin work.

Name: (Last, First & Mi= ddle)

Social Security Numbe= r:

Place of Birth (City & State or Country)

Date of Birth (Day/Month/Year)

SECTION A: TO BE COMPLETED BY ALL APPLICANTS

1. STATUS AND REASONS FOR BEING IN = THE OVERSEAS AREA ( Mark “X” and complete information where applicable).

a. ( ) SPOUSE OF ACTIVE DUTY MILI= TARY MEMBER ASSIGNED TO ______________________________________________________= ____________

&nbs= p; (Attach = copy of sponsor’s PCS orders, or agency documentation showing command sponsorship. Complete Section B)

b. ( ) SPOUSE OF DOD CIVILIAN EMP= LOYEE ASSIGNED TO _____________________________________________________________= _____________

c. ( ) CHILD OF ACTIVE DUTY MILIT= ARY OR DOD CIVILIAN EMPLOYEE ASSIGNED TO________________________________________= _________

&nbs= p; (Attach copy of sponsor’s orders, or agency documentation showing command sponsorship. Complete Section B)

d. ( ) ACTIVE DUTY MILITARY MEMBER SEEKING EMPLOYMENT DURING OFF DUTY TIME.= (Complete Section C)

e. ( ) OTHER (Explain, e.g., student, employed by private company, etcetera. If employed by a private company= or a dependent of a person employed by a

&nbs= p; private company, be sure to include the company name, including address. Complete Section E= .)

&nbs= p;

2. US CITIZEN BY (<= span style=3D'mso-spacerun:yes'> ) BIRTH ( ) NATURALIZATION (Give original citizenship)_____= __________________________________________________

3. PASSPORT NUMBER AND DATE OF ISSU= E:

4. IF YOU ARE NOT A U.S. CITIZEN, LIST THE COUNTR= Y(S) OF WHICH YOU CLAIM CITIZENSHIP AND IDENTIFY WHETHER OR NOT YOU HAVE A PASSPORT FOR THAT COUNTRY(S). (Give details in Section F= )

SECTION B. TO BE COMPLETED BY SPOUSES AND CHILDREN OF MILITARY AND GOVERNMENT EMPLOYEES

5. SPONSOR’S NAME AND GRADE:<= o:p>

6. SPONSOR’S CURRENT ORGANIZA= TION:

7. SPONSOR’S CURRENT DUTY PHO= NE

8. SPONSOR’S DEROS:

9. ARE YOU CURRENTLY RESIDING WITH = YOUR SPONSOR?

&nbs= p; ( ) YES &nbs= p; ( &n= bsp; ) NO

10. YOUR ID CARD NUMBER:<= /span>

SECTION C. TO BE COMPLETED BY ACTIVE DUTY MILITARY MEMBERS SEEKING EMPLOYMENT IN OFF DUTY = TIME

11. ORGANIZATION TO WHICH YOU ARE CURRENTLY ASSIGNED

12. DEROS

13. I UNDERSTAND THAT UNDER THE JOINT REGULATION, MY MILITARY DUTIES TAKE PRIORITY OVER OTHER EMPLOYMENT: (Initials)

SECTION D. TO BE COMPLETED BY FORMER MILITARY MEMBERS

14. DATE OF SEPARATION:

WAS________________ = WILL BE______________________

15. PLACE OF SEPARATION:<= /span>

WAS_____________________ WILL BE_____________________

16. REASON FOR SEPARATION:

WAS_____________________ WILL BE____________________

17. MILITARY TRANSPORATION ENTITLEME= NT:

( ) WAS USED ( ) WILL BE USED= ( ) WILL NOT BE = USED

Updated 9 Nov 98

SECTION E TO BE COM= PLETED BY ALL APPLICANTS OTHER THAN DOD DEPENDENTS OR OFF DUTY MILITARY

18. LIST DATE OF ORIGINAL ARRIVAL IN KOREA AND OF = ALL ENTRANCES AND EXITS FROM KOREA FOR THE LAST FIVE YEARS.=

19. CURRENT RESIDENCE:

(<= span style=3D'mso-spacerun:yes'> ) OWNED HOUSE, APT, ETC (By applicant or family members, including in-laws)

(<= span style=3D'mso-spacerun:yes'> ) RENTED HOUSE, APT, ETC., SINCE___________________________CURRENT LEASE EXPIRES____________________= __

( ) OTHER <= /span>(Give details in Section F)

20. DO YOU HAVE A PLACE OF RESIDENCE= IN THE US? (= ) NO ( ) YES (Give full street address including zip code and who is living th= ere now.)

21. LOCAL RESIDENT:

&nbs= p; &= nbsp; &nbs= p; PERMIT TYPE AND EXPIRATION__________________________________________________________=

&nbs= p; &= nbsp;

&nbs= p; &= nbsp; &nbs= p; VISA TYPE AND DATE OF EXPIRATION__________________________________= __________________

&nbs= p; &= nbsp;

22. DO YOU HAVE, OR HAVE EVER HAD, A= LOCAL WORK PERMIT? &nbs= p; ( = ) NO &nbs= p; ( = ) YES (If YES, give details in Section F)

23. HAVE YOU WORKED ON THE LOCAL ECONOMY? &nbs= p; &= nbsp; ( ) NO &nbs= p; ( = ) YES (If YES, give details in Section F)

24. ARE YOUR HOUSEHOLD GOODS IN STORAGE? &nbs= p; &= nbsp; &nbs= p; ( = ) NO &nbs= p; ( = ) YES (If YES, give details in Section F)

25. WHO IS PAYING FOR YOUR HOUSE HOLD GOODS IN STORAGE?

26. ( ) I AM NOT MARRIED ( = ) I AM MARRIED AND MY SPOUSE= &nbs= p; ( = ) IS ( ) IS NOT WORKING ON THE LOCAL ECON= OMY

27. DO YOU OR YOUR SPOUSE OWN REAL PROPERTY OR AN INTEREST IN A BUSINESS IN KOREA?

(<= span style=3D'mso-spacerun:yes'> ) NO &nbs= p; ( = ) YES (If YES, explain in Section F)

28. DO YOU HAVE A DRIVER’S LIC= ENSE ISSUED BY KOREAN AUTHORITIES? ( = ) NO &nbs= p; ( = ) YES

29. DO YOU HAVE A CURRENT US OR THIRD COUNTRY VOTER’S REGISTRATION? ( = ) NO &nbs= p; ( = ) YES

STATE/COUNTY OF REGISTRATION___________________________________ REGISTRATION NUMBER__________________________________

30. HAS YOUR INCOME EVER BEEN TAXED = BY KOREAN AUTHORITIES? &nbs= p; ( ) NO &nbs= p; ( = ) YES

31. DO YOU HAVE A RETURN TICKET TO THE US?

(<= span style=3D'mso-spacerun:yes'> ) NO ( ) YES (Give date of fligh= t) ________________________________ IF OPEN, TICKET EXPIRES(Give date)_____________________= _______

F: REMARKS=

APPLICANT’S NAME (Printed):

SIGNATURE:

DATE:

Updated 9 Nov 98