DOJ-OGR-00023770.tif

3. A. Present Residential Address: B. Length of time at this address: C. Home telephone number: D. List all residentia] addresses (including street and number, city and state) for the last five (5) years and dates you resided at each address: Addresses Dates 4, A. Present Place of Employment: IL Name of immediate supervisor: II. Employer’s business address: UI. Employer’s telephone number: III. Dates of Employment: B. List all previous employers for the past five (5) years, including employers’ addresses and dates of your employment with each employer: EMPLOYER ADDRESS DATES OF EMPLOYMENT 5. A. List all schools, universities, or other educational Institutions attended from grade Page 4 of 10 Revised 2/01/08 DOJ-OGR-00023770