1. Tk* $t*xrn &*m*rat[ng T**m
Jure 14,2002
To Whom It May Concern:
It has been my privilege to have Scott Boatman serve as a General Foreman for SGT during the
Calvert Cliffs Steam Generator Project. Scott has been very productive and always kept activities on
schedule and utilized his manpower in the most efftcient manner. He is very sound technically and has very
good troubleshooting skills. He is a very valuable asset and a pleasure to work with.
If there are any questions, please call me at (410) 495 -8102.
John D Byers
General Superintendent
2. n'
'./
@
Gonstellation
$grrwricrrfiCatuert Cliffs
Nuclear Power Plant
A Membar of lhs
Constellallon Energy G roup
MTUoRANDUM
Security Screening, Training & Support Unit
Welcome to the Calvert Cliffs Nuclear Power Plant. We would like to explain
some of the requirements established by the Nuclear Regulatory Commission and
CCNPP, Inc. which you will be required to satisfy within the next few days. These
requirements are not negotiable, they are mandatory.
Testing and information to be provided will include the following:
1. Pre-Access Drug and Alcohol Testing
2. Psychological Test
3. General Employee Training
4. Proof of Positive Identification - Valid Drivers License with photo, State
Issued ID card, Passport, etc. (ID cards such as check cashing cards,
school ID's etc. are not proof of positive identification.)
5. Completed Personal History Questionnaire to facilitate the Background
Investigation.
6. Fingerprints
Required components of the Background Investigation must be completed prior to
badging.
REVIEW YOUR PERSONAL HISTORY QUESTIONNAIRE PRIOR TO
SUBMISSION, FOR ACCURACY, COMPLETENESS AND LEGIBILITY!
Failune to do sowill resultin the reiection of yourapplication until ithas been
completed properly. and will delay the processing of vour case!
All the scheduled items of the In-Processing Procedure have been formulated to
prepare you for badging and access in the most expedient and efficient manner.
Please cooperate and get to your appointments and classes on time.
If you have any questions please contact our office on
.
4 /r; **q 5 * 2b4'7
This package effective as of 10/01
3. ^*{v
'l FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM
t-tt-l
SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE LAB ACCESSION NO.
Quest
Diagnostics
A. Employer Name, Address, l.D" No. B. MRO Name, Address, Phone and Fax No.
C. Donor SSN or Employee l.D. No
D. Heason forTest: E Pre-employment f] Random E Reasonable Suspicion/Cause E Post-Accident
I R"trrn to Duty E Follo*-rp E Othur (specify)
E. Drug Tests to be Performed: E fHC, COC, PCP, OPl, AMP E fHC & COC Only E Oth"r (specify)
F. Collection Site Name: Collection Site Code:
Address:
Collector Phone No.:
City, State and Zip: Collector Fax No.:
o
(!
z
P
O
@
o
o6
Read specimen temperature within 4 minutes. ls temperature
between 90'and 100'F? E Y". E ruo, Enter Remark
Specimen Collection:
E sptit E singte f] Non" Provided (Enter Remark) E Observed (Enter Remark)
REMARKS
STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy)
STEP 4: CHAIN OF CUSTODY - INITIATED BY COLLECTOR AND COMPLETED BY LABORATORY
Siq""**f C"il* Ti""
"f
C.il".il-,
1 certifythatthe specimen giveDto ne bythe danar identified inthe certification sectiDn an Capy2 ofthts fonnwas callected, labeled,
xiM
(Print) Collector s Name lFirsl. Ml. Last)
patpd at)d rplpaspo to rhe Dehvery Splvil p Folpd n accatdante w,h applicable Iederal tequ;tenpnts
SPECIMEN BOTTLE(S) RELEASED TO:
Name of Delivery Service Transferring Specimen to Lab
Signature of Accessioner
lPrint) Accessioner s Name {First. Ml. Last) --JtM"tD*r >
RECEIVED
AT LAB: x Primary Specimen
Bottle Seal lntact
! v..
l-l No, Enter Bemark Below
SPECIMEN BOTTLE(S) RELEASED TO:
STEP 5: COMPLETED BY DONOR
provided an this form and on the label affixed to each specinlen bottle is corrcct.
x
Signature of Donor (PqiNT) Donors Name (F rst, Ml, Last) Date (N4o./Dav/Yr.)
Daytime Phone evening enone t',1o.-( Date of Bidh
separatepieceofpaperoronthebackofyourcopy(Copv5).-DONOTPROVIDETHISINFORMATIONONTHEBACKOFANYOTHERCOPYOFTHEFORM. TAKECOPY5WITHYOU.
STEP 6: COMPLETED BY MEDICIIL REVIEW OFFICER - PRIMARY SPECIMEN
ln accordance with applicable Federal requirenents, my determination/verification is:
E ruEcarrvE fl posrrrvE E resr cANCELLED E nerusar ro rESr BECAUSE:
E ouure E aourreRareo E suBSTlrurED
REMARKS
x ttiqnature oI Medical Beview Officer (PR'NT) lvledical Review Officer's Name (F;rst, lMI, Last) Date (Mo./Dav/Yr.)
STEP 7: COMPLETED BY MEDICAL REVIEW OFFICER - SECONDARY SPECIMEN
ln accordance with applicable Federal requirements, my determination/verification for the split specimen (if tested) is:
n Recorurrnveo E FATLED To RECoNFTRM - BEASoN
x
Signature of Medica Beview Officer (PRINT) Medical Review Officer's Name lFirst. Ml. L6st) Date (lMo./Dav/Yr.)
4. Grr$i.r1ileltia$l
JuaiSar
caiver:t t;liils
Nui:ioar lbrver Plafii
Cur-!if,dlnlr ir{,1e , C:rrur}
ffimW wwffiffiffiffiffif;ffi
PERSONAL HISTORY UPDATE FOR UNESCORTED ACCESS
(To ire Llsed where an indiviciual has had unescofied access within the past 365 days)
FULL LEGAL NAME: {:ll,t:;,:iTtnl,t,,t S*, ,t-t-f Lc e:
Last
SOCIAL SLCUrltTy NO.: jl llc S"*: - C, B ./,A
CAUTION - FALSE
4.
OR OF FACT F
UNESCORTED ACCESS. Review att i
Please complete the following questions which are related to the fitness-for-duty policy requirements. (Check yes or No).
Failure to list reasons for denial, removal or revocation of unescorted access shall be sufficient cause for Denial of Unescorted
Access. since your last access at calvert cliffs or any other nuclear utility:
1. Have 'vou ever been denied unescorted access to any nuclear facility? Vf S E NO EIlf yes, name of facilily.
2.
.)
Haveyoueverhadapositivetestresultforillegal drugs/alcohol?- I h,tJ ,t il;.tj ,.ib,:,,t{'l ' i:f I .t /4'i, 'r:':.J,::rl !'..1;:'r, ,ii, J,. ,r,,ttt ..1 :.jti, 6ri, i', iq ,r,, lzis-i
Have you ever been cietermineci to be impaired on duty due to use of alcohol or legal drugs?
Have you ever been subject to a mandatory plan for treating abuse of legal or illegal substances?
lf yes, list enrployer at the lrme.
Have you ever been suspendecl from, removecl from or denied activities within the scope of part 26
(Fi:D ilule) i.e., activities within the protected area of a nuclear po*"r. plunt or assignment to a
licensee's -[echnicar
support center or Emergency operations Facirity?
l-lave yoi-r evei been clenied or removed from access to Safeguards lnformation or responsibilities to:
measure, transport, escort orguard formula quantities of stra'iegic special nuclear material (which is
useable in the manufacture of a nuclear explosive device)?
Ha';e ycit-, ever been removed from any responsibilities at any nuclear power plant in accordance with a
Fitrless ior Duty policy (i.e., possession of a controlled dangerous substance, refusal to test etc.)?
::./r'"i,t,IES I
YES E
YES r
NOE
NO EI
NO,N
YES I No.E
YES E No EJ
YES J No EIii'7oit i:rls'"4"+r'L:tj "Yes" to any oi tite aborre. you must attach a detailed written slatement providing full details.
A.niicipateci siari ciate at CCNpp:
Employer while working at CCNpp: Employer phone:
'/ /{/ ,/./: ?>ti
i_,I f-rom;
t-
Page 1 o{ B
I
From;
T--.
tu.
T
LJ
I-lL]
I t / ,,,,'..-1.-! l_i'..
=J--lr-_Seli Enrpioyecl
l_l res f]r r.t,
a-/
Y
tmltloyed
Uneirployed
Cornpany
i" r t ;h jr:+r- rr i t li ,,:r, ;^a
Job Site
r*t
ti-,:;t_.,4
Address
/ ',' / i t.
-
r -.'-, r ,"i-"{,-,{( { t
':r
t
Job Site Address
? , / ri,,'i l; lt ,:
"- {-
':l ],,1,., ].-,ll
urly
*ll i-
State
iiI L,t
! "rj
Zip
'.l,Ji:'/
l,/*" -:" t t,, - i'f.',,1
City State
r ,;i,
zip
.( { .('
...t ,
Company phone-T
( it ;) .i ji- I l,r> l:
Job I tlle
_ i- :::-..-.ii't.-..1 i.-t i1
Supervisor Beason for Leaving
Your FcsicJcnce I -'
t ',{
)ss I City
,") .i '::,:-,TrLl:.,;yt :..*t/l-d I flv.'a.rir,l"r:
State
1, tt t'l
Zip
'/c t o' ,l
G:NSSDS ECFORIVISPhQSGI. PNO-U PD,T.DOC
REV.07.10/02
5. st,!Lgi2An2 1L: 35 4t94952323 SECURITY SCREENING
m PA,GE 85/ 13
[,mr mmp fu;-, r/,fr I socrAr, sncrll .I lrg:, . egd - g,+-- d sc/+ I
ISEtrTION VII . EMPLOYilI ENTru NEilI PLOYM EHT AND HESI DET'ICE HISTO FY
ll in your employmant and unemployment history hcluding milirary services (& not indude reselye servb$ where ttxxe 'uras
r afithre duty). B:gin with the pre.sent and work bachrard for livp (5) Werc, Datee MUST contain mgtrttr, CeI and yggI.
lf you have been out af the muntry in the paEl live (5) ye€it you
uet ait*dr a soFy I,our pasEport (a copy oI avery pEge is required).
:lude thm lollowirrgrl
AII fu.ll tlme urcrk
AII par":time work
.Ani:ive rnilitary duty
AotM[:s in betvueen sehool semestars
lf you ruorked urrder a corrtracior name )&ur employer, not the Contractor; afid llst tho spedfic iob site.
It vou tuere selil-employed or your previous amployor iE out of business, under u$upervisor's Name' sp€srty ard nam6
Efln{(ne (do not use a epouse or oiher relative} wtro carr verity employment Under iJob Title" list }our activiti,as during
tlrki tirte period. Under "Job Site Phone' lisl a telephone number for tre hrdividual who can vertfy setf+mplo1,ment,
!]i.r9q1ug19.un,employed, under $upeMso/s Name'specrry and name someone who can verify unernployrnent. Uncer
lcb "Itleo list your actrtvities during this time period. Undar rJob $ite Phona' list a telophona ndmUer tir tre imlivrUuat
vyho can verify unemployment,
List yo.rr address(es) where pu resided tor every entry" If tou lived at more then one address durirrg tfe specitrcrl tirne
periolt - speaffythe dates at each address.
lf you were in schoolduring the Syear period d tlme liEt the school attended urder ",Compant'.
List yc.rr Eernester break$ ao employrnent/unemphymefit as applioable. Under lBupervisor,s Nam6" $pecrfy and name
somecne $fto can verify lhase breaks. Under i.fob Title" lirt ytur aoflvities during thh time pedod. Under "Jlb Site
Phone' list a telephone,number for the irrdivldualwho oan venfy yqur seme$ter $eafu.
r Allpaid work
.. Allpedods ol unernphyment
. Self employment
*= -&; l0;o"
, .!::Y),
CornpAny F r--"'r-"' Flraor * Nuclqg,r
Joh Slta
iol ter ct:ffs Fla,{f
Addres$
t b{o ral veif c lr+C PKU&
rlob EitE Addrcs8
f ,.r ^. lr'
l" t:rn,p,loyment
] {ielf Emphyment
] Un*mployrnent
GitY
LL{ q bw
Etrfi€
/11 D
Zp
frl157
** )Y_1{'t*
Slala tp
Oornpany Fhone
l4tol H q{- ,i g Lll Job $tta Phone
l{tot qq{- q#t<
JobTltle
€tec:rrir-ia/l(
SuneMsor
d,"i cn$C,u^
Reason for Leaving
S"fill HorKivr"l
ur Flesitlence
Skeet Address
38lso Eo;tr:no n LaAe-
ity
.Ve.nue-
l'np
I l,.oirb1
st*te
tt4D,
n, JglL r-?7
: ilJ-Lt-oa.
Company
vaLlnd €lee*ricial
Job Eite
tue i{a l' o e. Ekn srhoq i
Address / u
Qt3 dlnQv G,r,rJ.r qf/iflq Q.ooA
r Sits Adrlrcss
(l
[' timptoyment
I ,*tt Emplolrment
I Jnemploynrent
Ity
(.,.r,l-, rObtna
t,EfiS
/LlD
4p
*oguo
Gity
frrlinto,tan
Steta
r/f{
Ap
Company Fhone
(fl,Yd q0i- I s1 {
Job Site Phone
()
Job Title
Elu:ri-r,.,.
$upervisor
NdrL Sh, ffer
Rpason for Laalrtg
Lo.-k .r#' t uor14-
I $treet Adclr€6$
ur Residenoe I T p i qO Hn.,-fnn-^ I _nAtt
]iu
ll tli ,tlt-r a
State
lhD
Zp
1o(,8?
,lSSl)SECIFORIvIttFHe PaEo 5 of 1s I{ev'elon 13,gilB
6. 8r^t rn qn ADDtTtoNAL EMPLoYMENT/UNEMPLoYMENT
A2O - K2-A 3.lZ
t-l
u
tx
Yor"
Fr:>ul io -l_ll l op
ro: l-L,--h-J-A-g-
Company Job Site
Address
*
Job Site Address lJ
A
-] Self E:mployed
[Yes B*o
I Employdd
City State Zip City Siate zip
Company Phone
(3ot1 b3tr- oo'77
Job Site Phone
Got) l3g -oo-tZ
S Unemployec
our Residence I
Job Title
l1 orna worK.,-r^
Supervisor
Terrv Bn*fm*
Reason for Leaving
fleu' foh
Street Address ^
3* t;t: Boofrrt^^ la rt e-
ty
Av<11u4<-
State
rnD
zip
3o b c'1
Frotr 1 t9"f too
ro: lJt_t-3Jl_A_P
Comoanv
Dvnole.<-'Trir'
Job Site
EAutfi0x
Address t
----2Lq.O Sha',u PJ
Job Site Address
tl
r(
Self Employed
[Yes BNo
rmpnyJl
City
-S re" I i r't at
State
VN
zip
,,otbI
City
4sl, hr,'n
State
vt4
Zip
Company Phone -
Qo3) 7-/z- z f oo
Job Site Phone
()
t] Unemploye<
Your Residence
Job Title
E/e. f r; c i.a ,n
Supervisor Reason for Leaving
RedrtcT i oq i ,'t Purrn
Street Address
? f / {O .$ oot rTt ot n l-an< Av< ni.,t<-
City State
rYI D
zip
lc60rJ
r'om: cl t /{ too
ro: 3L!11p"
Company
-.n,-.n-
Job Site
----'
Address yV
A
Job Site Address y _-/
--.i
n
tl
DX
Self Employed
fl ves
B *o
rmptoylo
!,Jnemployed
City State zip City State zip
Company Phone
(3or ) L3 g- or'l )
Job Site Phone
(3ot) 639-oa-1 7
Job Title
llc rn< wa, Ke.
Supervisor
T<-rr^v &oofnqn
Reason for Leaving
Ml,r, J, b
Your llesidence
StregtAddress
^ lCity
37tso fln;fman Lqn<- I'nv<A.,t<
I state I zip
I frytl | .Lo 6t,'l
rrom: 5 tl{ toe
ro: 3-lhlpo
Comoanv
' Z he S'q Peq Ke e lec
Job Site'rv,,ottv,ryleTro
6qs forK;rict l;T
Address"-"'""4orz
Stsr Piqrz
Job Site Address
T Self Employed
EYes B*o
rmpnye%
Unemployed
E1
fl
City
cotln)aa'Po.k
State
rnD
zip
)o'/,-1o
City
Wq Shirt q*f oq
l3tate
Dr:-
zip
Company Phone
Got) l gl- 6771
Job Site Phone
()
Job Title
6lec Tri cio,,r
Supervisor
Dqn
Reason for Leaving
A,4 i't
your*esidence
I "T$itffi Ea,ir ma, / o^.--I*ttu"r"* I Tfta
zip
,'7c lro
G:I'ISSo'.SECFoRMSPHOSGT-PHo-UPDT. Doc Page 2 of 7 REV. 06, CB/01
7. {3o.iTtn ralt
ADDTT|oNAL EMPLOYMENTiUNEMPLOYMENT
, 2o - gl-o 3,i2
From. 5 t 2 tOa
ro: Lt_l:LtSg
Company Job Site
s'
Address
'-'6-'-
Job Site Address iV' __.(
-/t f4
-l Self Emptoyed
flyes I *o
l-l emptoylo I
lN Unemproyed
__l
Tstreet /'/or.rr'Residence I 'Z
X
City State zip
"L-'-t-' lsrate
I
''o
Company Phone
(3ot) 63e-oo7)
Job Site Phone
fJot ) (38-Do77
Job Title
f-lorn< UtocKe.
Suoervisor'. a)
'Te.rry 6u,-fmou
Reason for Leaving
A/eu-, {ob
l?oo-r'r--^ /ontt
,ddress
t50
'City
Elvenu.<-
State
ruo
zip
I c6orr'
1=rrtn11 ':-f t ? loo
5-*Lr-pp c:T't() rl
n Self Emptoyed
I Yes
9*o
tE empoylo
tf Unemployed
Your Residence
IiS fut'tcliort
Job Site Phone
()
Company Phone
Got) Z tl-
Reason for Leaving
Q"r it'
3g ts^o EaoTr,qqn lqne-
Fron': tl ,-S-r r,
To: h"t9 t()c)
Company Job Site
Address N A
Job Site Address
Y_
-A
n Self Employed
nYes B*o
employef,
Unemployed
tl
E
City State zip City State zip
Company Phone
(J.,t) 63V ^ ooa)
Job Site Phone
(3"1 ) 6'Sg -o0-77
Job Title
ilorrle tdorK<r-
Supervisor
'T<rry flarrTtuton
Reason for Leaving
Me-,rt f.rl:
I Street Address
vourResidence
J 3ylq7 8^nTmo^ lq-ne-
City
Ave A,4 ?
State
rvl O
zip
t?c 6o t
rro^ JJI,1_Q!
ro: !L_t-7tg:_
Comoanv
''flLtor M,.rcleq.
Job Site
c.(
Address"-"'7'[;" c',t,lwerT cl;l{s PXWy
Job Site Address
luio ca lv,z;i ei:-(4'< ( Kv'tY
Tl Setf Emptoyed
[ves B*o
Dl rmptoyJ'o
t] Unemptoyed
City
Lq s bvn
State
f'4D
zip
Cob57
City
Lqsby
State
frlc
Zip
fi1tt,.5'!
Company Phone
(3ol) 4qf- q8r/^ Job Site Phone
?//o) Llqf- qg./e
Job Title
E le-cT r iciq n
Supervisor
Gre.q Cop(ren
Reason for Leavinc
{e";i',,," ,, fsr-t:
R-ATrvtr,A l,>Ae
your r.esidence I :5"+1?8u'
Citv
'/1v
er'tq<-
State
uo
7in
'1.obat
G:NSSDSECFORMS]PHQSGT-PHQ.UPDT. DOC Page 2 of 7 REV. 06, 08/01
8. Bt /18i 2032 1L: 35 41"44952323
ffi FAGE E6i 13
' 4*tI LAST NAME
sEcrroN v[ . EMPLOYMENT/UNEMFLOYMENT AttD RESIDENCE HTSTOHY (Continrred]
SECURITY SCREENING
prorn: ..i*LlJklfr
'r'c,i ltU)!J-11 '
--
,t
[yf' Erttployrnent
fl $elf Employment
Lnriemployment
;fVl clr.*ofe(
Job
(6o{ 1 loLt *3* I I
l€cfricirtn
frve,fir,te-
L]
/cutr Rrixridenca
FJnlrn
Ih:
w{
n
rf
}1ru.
:-_l-rofi
l"tr:
"l'fu**J3g
Comoanv-' -Hich"rJt Ele.tr;c i e rn eh:f flq.x
lit-!li,t3E
ddrese
I n qn I fitr,K,t,r <free-i.
.tou Site Address
""" "''"#;';* *^Ju.j n Pri'rt
furploymeint
Self Emplrryrnent
Urremploymeril
ry
R," I-fq i illa_.
State
wtD
Zp
Ao-lai
City
TUqfiflq$$rr s
$trte
Llfr
Ap
! uilo
Company Phone
(3ot) z+* lzraCI
Jon SIte Phone
tgYo) 509 ^91a1
Job Titlo
EIa.rririafi
Supervisor
Kei+h Dov", ies
Reason for Ls*virtg
Lqat< o f, t*'or(
I StreetAddrEss a
Resrdence l Sg tqA BodTrmort Lonu
City
frVea,,*
Stais
yylD
Zp
l.ah,Aq
rofiid .ta-r-s9r-19
.LtlrJrsg(l;
Cornpanu
ferlec.T f ic
Johstte A nt(
Addr*Es
3 t qO (f,-ina .(f /s+rf
Job siteAflaea
;,U V L1
-J
E{ [i:rnphyment
i:_l $;{}lt Employmant
:] Ilttemployment
Gity
..r
[-- i n *'a,{
gtat8
Vo
ztp
If,,o3i
city -)
Ir $tate 4p
Oompany Fhona
(70ts) Bss,- S/-_st I
Job Sito Phoft€/
()
Job Title LV,+o.*-:
Fla,r-Tr,i ri,z,rr
Eupervieor/4iF
(bnn Dq
? wgf
,lV Lq,cF. o..F LY6e'tt
He*on for Laaving
Your Fleeidence
Str€et Address
3 Y tEo Erffyn*n l-aa<
Citv I Stata
ll ioaua I I4AD
llI
i o,:"CI1
rron, *9J-lt-l-%
rr:: L(t-t *|J-tg
Somoanv
I)vna eleotric
Joh Site
Saf**o, treslrih<Tl{
Mdress r
^
'I?eko dfio* Pa fl.nd f/ro,.
Job SIte Mdrdss ' i
:4 rinployment
f &rlf Employrnent
Gity
Qfp.rllrr q
Etate
{A
ztt
lot6[
City
C f,'ttTfr n
tlete
f{tD
Gompany Fhone -
(7oB 7tt!-- -r {Dd
Job Site Phone
f{a*) yzc- -
:] Unemploym Ent
Job rltle
Fla,ff.t!n:*,,t
Bupervisor
fravil {;tt-e.r
Beason
r.r/c f t{
You'Residenoe
Su€et
3K
ddress
/5O Ed".Afl,ta1 bae--
iE lstata..
Elr.r'en ut e L[YID,-
Zo
fiedaq,
i :NII$D$EOFQITMS'PHQ Pagia 6of 13 Hevis'ion ls. siga
9. 7
GmAT i LgT 2gA2 ],:1- : 35 4LA4g52323 SECURITY SCREENING PAGE A1 / 13
-
l*gltfot* f. 'qrryNo.'*+d"oj.Sg:.q, ./3 J
SEC'IION Vll - EMPLOYMENT/LNEMPLOYMENT AllD HESIDENCE HISTOHY (Continued]
r*€l
*lb
ficm "-ZJE-J-1{
rcr: -E)J-LI?t.
A c.larrJ -flqtr_rirlafiogalrs,
Job Blte
ArklreEs
I i7 Veap ntnE ilw'l
Job s,* rurdr€,
illlflfl_(_
[ff'Enrplo!/ment
il $ielf Ernptoyment
il Ltr:employrnent
City
Cdm rraack
6tate
NY
Ltp
lr?at
city jI! $tata Ap
Company Phona
{glL I gLLl *q 3a-
Job Site Phone
tFo,t'l 63i- SLLl*3r**7
Job TiUa
E[p-.friciqr"t
Supervi8or
chri stine
Roason for Leaving a
'1
fr,drt b€
..ffi d*.tif 1ftqv u.rhe.r h"
I StrugtAddress I citv I State I Ap
rcurH(rt,rderrce I 3yl5o .l1,,,6man Lntrc. lA-1yert*+- lmn l!.o6oq
F:r,lm
n
hrm;.,L--**-q8'
'c:
-7'-lA{t*3!
Sompany Job Site
c hai K ?" ;r'l*r
ss
tt^ A.rdmpt Arle-
Job Sitp rMdress---
Z.h-;;i;e counTf
Hinrplolmrent
'$elf Ernployrnent
Unernploymant
City
A,.J*r.,r
Stats
?k
Zp
liq""3
City
frlarqanfad n il{b
Zp
Gompany Phone
(6to ) Ltiq- g.g+a
Job Site Phone
(gtt) ?#-Cooo
Job nile
*ralv* yPfuafor
fupervisor( ri4t
fu gh xt,ar*Eist
Eeason hr L€avrng
Lar-t<, n-€ L/or H
I StrBet Addres$ I Citv ' I StatE I Zp
Yc'urRe$idence I _jgtqA Ro.;1*, ^^ l_nAa I rt44e.nua I fin lioiaa
rroffi AJ*J1!J q1
I'c,: lLlAltSE
Ro* t,/jyrrle
Job liite
Addre$$ t
l|q iL feoraues PnlaT iQ^oJ
Jobsite*T
^nA o
"t' E,nrploymrmt
::.1 $eff Ennployment
:] Unemployment
City
Li.ra h ax wi lle
State
{nD
Ap
0043?
c*v ("T1 t ' E:tde Ep
CompEny Phon€
(3ot ) ?Za- frg:gg
Job Site P,hfne
()
lohTitle
F la..fn".. ln-^
Superticor
Dqrrvl H*n Sert
Reason for Leavhg
L<aR o € udorE
I StreetAddress
/ourFlesiidencs I Z*tfO Bru,f*on f_nn*
City
aVeflue- C, oq
twn; 3 rlj} It?
fir: 52EJ&
Comoanv
' fi<t^hpr.H * ryl*'tc
Job Site-
*edrql +ria,naflt - Pf f/ J
Address
I 5.tL P- ;r Q. r.,r.roer,l Drlrfe.
Job Site Addrcss ,
iLlO o P.erta f,te-
TJr' Enrployment
:] S;rrlf Emptoyment
:] Llrremplolrnent
City
Land ovar
Stats
rl, D
Zp
1o?6(ri
City
Wa la)n4Tar't
Stat€
Dc.
Ap
?tto71
Company Phone I Job Site Phone
ffrs I sgl- fiso
Job Title
Elqcr
"IcJ
on
Suoewisor
8b.rni<*
I Reason for Lnfving
t rgsr-d.--s*C5
/our FlrrsidencE
l-city
jg lfla Rnarrn**t LaA€ I *V'
I Srate I Zip
nqe- la,'l-.-l-*o:r3{-
i:U{E$otiECFORMSPHCI Page 7 of 18 Fevi*krn 1& $rfla
10. mALIIAI2AA2 11:35 4ta4952323 SECURITY SCREEN]NG
Ir,lsrunlm 8r '-"IT'YNO.I lI!: #: s Jga
$ECTION Vll - EMPLOYIrIEHTruNEMPLCIYMENT AND RESIDHNCE HTSTOBY (Continud]
Front:. ,il1-l{{1f;i
:l Eiet,t Empkryment
,:l LJr+rnployment
frrur Reriidence
torn, --L-r_lfu ?3
:] $eH Employmenr
] Unemplorynrent
/our Hes,idence
Job Site
Federol
'a"e 'weldor4 g.0603,
(5ot ) gq 3*'?Lt 2
LaeK dS il/+rrt{
,5, 6cn loa ieal 9ldL f,rJA Ele
(p$ 76s- Ssop (?'E) 7bg- s500
L*cK o-F wir
:Iom: I I
o:
Company Job Site
Adtltess
I Eilployment
:l $etrEmptoyment
:1 Unemployment
City Stato zip CIty Statl Zp
Company Phone
()
Job Site Phone
()
JobTifls Supervisor Heason ior Leeving
bur Resldence
StrcetAddrcss Otty Stata Zp
iom: _J_J__
Comparry Job $lte
o: I
Job Site Addrsss
I Enrployrnent
] Self Employmant
I Urernploymant
ury Etats City State Zp
CIompany Fhone
()
Job Sita Phone
()
Job TiUe Reason for Leadng
Street Addres* eltv- lstEta lup'cur Reriidence
T,NSSDI$ECFORMEPHO Page I of 13 Rev'qif,fl'1,9, Sl98
