DA Form 3433-1 Supplemental Employment Application Form Page 2

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20. REFERENCES (List two persons NOT RELATED to you who can furnish information on your qualifications and character. Do not repeat
names of supervisors.)
FULL NAME
ADDRESS (Complete with ZIP Code)
PHONE
OCCUPATION
21. WITHIN THE LAST 5 YEARS, HAVE YOU BEEN FIRED FROM ANY JOB FOR ANY REASON, OR RESIGNED FROM A JOB AFTER BEING
TOLD THAT YOU WOULD BE FIRED, OR DID YOU LEAVE ANY JOB BY MUTUAL AGREEMENT BECAUSE OF SPECIFIED PROBLEMS? If yes,
give details, e.g. employer, address, approximate date, and reason in each case.
YES
NO
22. HAVE YOU EVER BEEN CONVICTED OF ANY OFFENSE AGAINST THE LAW OR FORFEITED COLLATERAL OR ARE YOU NOW UNDER
CHARGES FOR ANY OFFENSE AGAINST THE LAW AS A CIVILIAN, OR DURING MILITARY SERVICE? You may omit: (1) Traffic Violations for
which you paid a fine, and (2) Any offense committed before your 21st birthday which was finally adjudicated in a juvenile court or under a
Youth Offender Law. If your answer to either question is "Yes," give details. Show for each offense: (1) Date, (2), Charge, (3) Place,
(4) Court, (5) Action Taken.
YES
NO
23. ARE ANY OF YOUR RELATIVES
a. EMPLOYED BY A NONAPPROPRIATED FUND ACTIVITY?
NO
YES
b. EMPLOYED BY THE FEDERAL GOVERNMENT?
YES
NO
c. MEMBERS OF THE MILITARY ASSIGNED?
YES
NO
d. IF YES, LIST NAMES, RELATIONSHIP, POSITION, AND ORGANIZATION:
24. DO YOU RECEIVE OR HAVE YOU APPLIED FOR RETIREMENT PAY, PENSION, OR OTHER COMPENSATION BASED ON
APPROPRIATED/NONAPPROPRIATED FUND SERVICE? DID YOU RECEIVE VOLUNTARY SEPARATED INCENTIVE PAY (VSIP)? If yes, give
details.
YES
NO
I certify that, to the best of my knowledge and belief, all of the information on and attached to this form or any
other documents with the application packet I submitted in connection with my application for NAF employment is
true, correct, complete and made in good faith. I understand that providing false or fraudulent information may be
grounds for not hiring me or for firing me after I begin work, and may be punishable by fine or imprisonment. I
understand that any information I give may be investigated.
25. SIGNATURE
26. DATE (YYYYMMDD)
DA FORM 3433-1, AUG 2002
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