Viewing page 22 of 23

This transcription has been completed. Contact us with corrections.

[[[preprinted blank form]]

29. PERMANENT MAILING ADDRESS (No., Street, City and State)
30. BIRTH PLACE (City, State, Foreign Country)
31. EMERGENCY ADDRESS (Name, Relationship, Number, Street, City, State)
32. MARITAL STATUS
33. NO. OF DEPENDENTS
34. PARENTS' BIRTHPLACE
    PARENT | COUNTRY OF BIRTH | CITIZENSHIP STATUS
FATHER |   |   |
MOTHER |   |   |
35. FOREIGN LANGUAGES
[[7 columns]]
LANGUAGE | DIALECT | SPEAK | READ | WRITE | INTERPRETER | TRANSLATOR
[[3 columns]]
36. EDUCATION | NAME AND LOCATION |MAJOR SUBJECT
HIGH SCHOOL
COLLEGE OR UNIVERSITY
POSTGRADUATE
OTHER
37. CIVILIAN OCCUPAIONAL EXPERIENCE (Main and secondary)
TITLE OR POSITION
CODE
CODE
NAME AND ADDRESS OF EMPLOYER
DATES EMPLOYED   FROM   TO   FROM   TO
DUTIES PERFORMED
DUTIES PERFORMED
38. SPORTS
    PARTICIPATE
    EXCEL
    COACH (School, etc.)
39. AVOCATIONS
40. QUALIFICATION IN ARMS
WEAPON | COURSE | QUALIFIED | SCORE | DATE
41. AWARDS, DECORATIONS, AND CITATIONS
TYPE | AUTHORITY AND DATE | PRESENTED (Yes or No)
42. REMARKS
PAGE 3
43. FLYING STATUS
AUTHORITY | DATE | RESTRICTIONS
44. RATINGS, SPECIALTIES, AND DESIGNATIONS
RATING, SPECIALTY OR DESIGNATION | EFFECTIVE DATE | AUTHORITY
45. AIRPLANE QUALIFICATIONS (Military)
NO. OF ENGINES | TYPE OF PLANE
CONVENTIONAL
1
2
OVER 2
"JET"
1
2 
OVER 2
OTHER
46. FLYING HOURS
HOURS | MONTH AND YEAR
250
500
750
1000
1500
2000
3000
5000
47. CIVILIAN FLYING EXPERIENCE (Nature, type equipment, no. hrs., last date flown, licenses)
48. COMBAT DATA (AAF only)
49. INTERNSHIP
    HOSPITAL (Location)| TYPE | TOTAL MONTHS | YEARS COMPLETED
50. PRIVATE PRACTICE
    LOCATION AND TYPE | % OF TIME | FROM TO|
51. RESIDENCIES AND FELLOWSHIPS
    HOSPIAL (location) | SERVICE | TOTAL MONTHS | YEAR COMPLETED
[/preprinted blank form]]