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[[[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]]
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