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Level III Sample Form

Print in CAPITAL or BLOCK or UPPERCASE letters.

Title:

Mr c Mrs [ü] Miss c Ms c Dr c Other……………………….

Family/Last name/Surname:……………SIU……………………………….

Maiden/Former Surname:………………WONG……………………………

Given/First/Christian name:……………CATHERINE…………………..…

Initials of other given names:……………E………………………………….

Sex: Male c Female [ü]

Birth date/Date of birth/D.O.B.: Day [06] Month [04] Year [1951]

Home address:………103 SUNBURST CRESCENT……………………

Postcode:……4059…………Phone/Tel.:….(07)…2657 1642………….

Facsimile/Fax: ….(07)…2657 1483…………….

Postal address:…………AS ABOVE………………………………………..

Postcode:……………………E-mail:…[email protected]……………..

Have you ever been convicted by the police? Yes c No [ü]

Country of birth:……………CHINA…………………………………………

Language spoken at home:……MANDARIN……...……………………

Disabilities:…………………ASTHMA………………………………………..

Type of employment preferred:

Casual c Part time/PT c Full time/FT [ü]

Most recent occupation:…VOLUNTEER TEACHER AIDE…………...

 Educational background:

Academic background:

Employment history:

Three referees:

Printed name of applicant:……CATHERINE SIU……………………….

Signature of applicant:……Catherine Siu……Date:…11/04/98…..

Printed name of witness:………ANDREW JONES………………………

Signature of witness:………Andrew Jones.……..Date:…11/04/98…..

"Click" on the Blank Form III Employment

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