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Name

Date of Birth

Country of Birth

Street Address

City

State

Postal Zip Code

Age

Sex

Height

Weight

Eye Color

Hair Color

Eyeglasses Worn?

What Type of Vision Impairment?

Religious Preference

Current Country of Citizenship

Any Other Countries of Citizenship Please List

Name of Elementary School/Schools

City of Elementary School/Schools

State of Elementary School/Schools

Years Attended

Name Of Jr High/Middle School/Schools

City of Jr High/Middle School/Schools

State of Jr High/Middle School/Schools

Years Attended

Name of High School/Schools

City of High School/Schools

State of High School/Schools

Years Attended

Graduated High School or Equivalency?

Date

Trade or Technical School Name

Dates From and To

Program Studied

Program Completed

Date Completed

College Attended

Dates From and To

Major/Minor Studied

Degree Completed

Date Completed

University Attended

Dates From and To

Major/Minor Studied

Degree Completed

Date Completed

Single, Married, Divorced, or Widowed

Number of Children

Current Employer

Current Position

Brief Description of Duties

Industry (Agriculture, Steel, Manufacturing, Etc.)

Division (Production, Distribution, Etc.)

Profession

Field Of Specialization

Recent Past Employment Positions (List past 4)

Fields of Occupation

Employer's Name

Dates Employeed

Are you affiliated with a labor union?

Name

Local

Are you currently serving?

Branch

Unit

Rank

Military Reserve

Branch

Unit

Rank

National Guard

Branch

Unit

Rank

State Militia

Branch

Unit

Rank

Veteran's Organization

Name

Fraternal Society

Name

Parent Teacher Association

Name

American Radio Relay League

Volunteer Organization

Name

Do you have a driver license?

Class License and Expiration Date

Do you own a motor vehicle?

Year, Make, and Model

What athletics and/or hobbies do you engage in?

Do you have additional remarks?

Terms and Conditions

I certify that the knowledge given herein by me, is to the best of my knowledge, correct.
I herby attest that the following information is correct and I give full permission for the applicant’s participation in the activities of Technocracy Inc.

Print Name of Applicant/Guardian

Signature of Applicant/Guardian (Type your Full Name)

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