A. Personal/Contact Information
1.
Last name:
First name:
Middle name:
Birthday
Month
---
January
February
March
April
May
June
July
August
September
October
November
December
Day
---
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
---
1985
1986
1987
1989
2080
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Primary address
Secondary address
Address:
Address:
City:
City:
State/province:
State/province:
Zip code:
Zip code:
Home Phone:
Other Phone:
Cell
Work
Fax:
Personal website:
2. What type of assignment would you consider? (check all that apply)
Short-term assignments
Long-term assignments(greater than 1year)
Volunteer assignments
3. How did you hear Midwest Assistance Program
B. Background information
4. Are you a U.S citizen
Yes
No
5. List countries where you have residency status
a.
b.
6. Are you a Midwest Assistance Program board member, current or former employee or retiree?
MAP board member
Current MAP employee
Former MAP emplyee
MAP retiree
none of the above
7. Check each educational/certification level attained and write in your major area of study
Technical
Associates
Bachelors of Arts and Sciences
Masters
Doctorate/Juris Doctorate
Certification please verify: