ASTRONAUT CANDIDATE PROGRAM APPLICATION/UPDATE

New Application Update to Application on File

Please complete all items on this form if this is a new application. If this is an update, complete only your name, address, and the information that has changed since your last update. You may attach additional sheets of paper if more space is needed. 1. LAST NAME FIRST AND MIDDLE NAMES . SOCIAL SECURIT! NUM"ER

#. MAILING ADDRESS

$. DATE OF "IRT%

&. PLACE OF "IRT%

'. P%ONE NUM"ERS (include area code)

(Daytime) Yes

(Evening) No Contact me first

(. MA! )E CONTACT !OUR CURRENT SUPER*ISOR+

,. )OR- E.PERIENCE Describe your paid and non-paid work e perience in the blocks below. You may attach a resume or C! or additional sheets of paper if more space is needed. a. "ob #itle (if Federal or Military, include series and grade, or rank)

$rom% (mm/yy)

#o% Present

&alary%

per%

'ours per week%

(mployer)s name and address%

&uper*isor)s name and phone number%

Describe your duties and accomplishments.

b. "ob #itle (if Federal or Military, include series and grade, or rank)

$rom% (mm/yy)

#o% (mm/yy)

&alary%

per%

'ours per week%

+eason for ,ea*ing

(mployer)s name and address%

&uper*isor)s name and phone number%

Describe your duties and accomplishments.

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,. )OR- E.PERIENCE (continued) c. "ob #itle (if Federal or Military, include series and grade, or rank)

$rom% (mm/yy)

#o% (mm/yy)

&alary%

per%

'ours per week%

+eason for ,ea*ing

(mployer)s name and address%

&uper*isor)s name and phone number%

Describe your duties and accomplishments.

d. "ob #itle (if Federal, include series and grade)

$rom% (mm/yy)

#o% (mm/yy)

&alary%

per%

'ours per week%

+eason for ,ea*ing

(mployer)s name and address%

&uper*isor)s name and phone number%

Describe your duties and accomplishments.

/. EDUCATION (Mark the highest level completed) '&78(D 1ssociate 9achelor 4aster Doctoral

10. COLLEGES OR UNI*ERSITIES ATTENDED (Provide a copy of your final transcript for degrees received, do not send copies of diplomas) Name, City, and &tate Dates 1ttended #otal Credits (arned 4a:or0s3 #ype7Date Degree $rom #o &emester ;uarter +ecei*ed (mm/yy)

a. b. c. d.
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11. TRAINING COURSES (list title and year completed, do not send copies of certificates)

1 . %ONORS AND A)ARDS (publications, memberships, public speaking, performance a ards, etc!"do not send copies of documents or certificates)

1#. OT%ER S-ILLS AND ACTI*ITIES (#$%&', sports, music, languages, computer soft are/hard are tools, machinery, volunteer ork, etc!)

1$. CITI1ENS%IP 1re you a =nited &tates citi>en?

Y(&

N@A8i*e country of your citi>enship

1&. MILITAR! SER*ICE2 'a*e you e*er ser*ed in the military ser*ice? If yes, gi*e dates and branch of ser*ice. 1ttach a copy of your DD<B-. Y(& N@

1'. PROFESSIONAL/TEC%NICAL REFERENCES2 ,ist C indi*iduals who are not related to you and are not listed as a super*isor in block /. Name a. b. c. 1(. APPLICANT CERTIFICATION 4ailing 1ddress Phone Number

I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete and made in good faith. I understand that false or fraudulent information on or attached to this application 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 gi*e may be in*estigated. Si3nat45e Date Si3ned

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