DISCLOSURE FORM - INDIVIDUAL (Complete in Duplicate. Forward one (1) copy with the required attachments to the financial Services Unit) GENERAL INSTRUCTIONS ‘TYPE OR PRINT AS LEGIBLY AS POSSIBLE. AN ANSWER TO EVERY QUESTION IS REQUIRED. 1H A QUESTION DOES NOT APPLY TO YOU INDICATE WITH "N/A". IF SPACE IS INSUFFICIENT, USE A SEPARATE SHEET. ALL INDIVIDUALS ARE ADVISED THAT THIS PERSONAL HISTORY RECORD IS AN OFFICIAL DOCUMENT AND ANY MISREPRESENTATION OR FAILURE TO REVEAL INFORMATION REQUESTED MAY BE DEEMED TO BE SUFFICIENT CAUSE FOR THE REFUSAL OR REVOCATION OF HIS/HER APPLICATION/LICENCR, LAST NAME" Ujipricht FIRSTNAME Rogg MIDDLE NAME(S) william ALIASES (Maiden or other name changes - Include date of change) SOCIAL SECURITY NO. or . NATIONAL ID NO. 828 | * Provide a copy of your bitth certificate, passport, Social Security/National ID, and Driver's license. 1Additional Personal Information: Date of Binh OSM 984 Place of Birth Austin, TX Country of Citizenship_USA Passport No, 46S Mother's Maiden Name _LaCava Drivers License No. 19MM State Issued Texas Color of Bye Hazel Color of Hair BTOWN _ Complexion White Weight Ibs Height _6'2" Build _thin Distinguishing Marks _MON€ Curre i Address: Date Since 05/fff2012 a Apiouse No,_5802 City_Austin State_Texas Country USA Zip Code 78749 ‘Communication Numbers: Residence Telephone (____), Cell Phone _(717)650- Business Telephone (__) Fax No. ( Email Address _fossulbricht@ gmail.com RESIDENCES (List all residences (other than current) you have had for the last ten (10) years) 09/2009 po_95/16/2012 — 05/16/2012 Street] ApvHouse No. A City Austin sas Texas Country USA ip Code 78703 From 07/2006 9 09/2009 ApdHouse No. City_State College State Pennsylvania Country USA Zip Code_16801 From 05/2002 ty 07/2006 »sve I prio.se vo A city Richardson State Texas Country USA Zip Code 75080 Marital Information: Single [X] Married [_] Separated [] Divorced [] Widowed (] Engaged Current Marriage’: Date, Place/City State County Country Spouse's Full Name (Maiden) Spouse's Place of Birth Spouse's Residence (if different) Street, Apt/House No. City State Country Zip Code. Spouse's Residence Telephone (if different) Spouse's Business Telephone Cell Phone, Spouse's Employer Occupation Address of Spouse's Employer Street, City State Country Zip Code Previous Marriages/Engagement ever legally separated, divorce or annulled diate below) Name of Spouse | Date of Order/Decree | Nature of Action | City/Sate/Country List the names, birth dates, and addroses of previous spouses, [Fengaged, enter future spouse with nota * Please provide a copy of your marriage certificateName Birth Date ‘Address | Family Information Children and Dependents: List all children, including stepchildren and adopted children and provide the following: Name Birth Date ‘Address Occupation List parents, parents-in-law, or legal guardian and provided the following:Name Birth Date ‘Address ‘Occupation Father: . ji 94: FC Retired uct [re ‘ie: : tmp utricht | M949 | EE perarag | Retired Fatherin-Law: Mother-in-Law: Brothers and Sisters: List all brothers and sisters and provide the following: Name Birth Date ‘Address ‘Occupation CEBU bricht M979 yaney, NSW | 526sEDUCATION List all academic and trade schools attended: ‘School Name ‘Address | Dates Attended | Graduated High School Westlake [4100 Westbank Or. | o@/t99@ - Yes bk] No [] High Scoo! Austin, rx 78746 | 05/2002 University of Texas | 800 Campbell Rd. | 08/2002 - Yes BJ No 0 at Dallas ponents 05/2006 Pennsylvania 417 Old Main 07/2006 - Yes EX] No 1 State Universiy | UVES Park PA | esracqg College/University Yes] No Trade Yes] No TJ List all Academic Degrees Conferred: [ Degree College/University Date B.S. Physics UT Dallas, 05/2008 M.S. Materials Science Penn State University 05/2009 EMPLOYMENT HISTORY: Beginning with your current employment, list your work history, all business with which you have been involved, and/or all periods of unemployment for the past 10 years. Also, list all corporations, partnerships or any other business ventures with which your have been associated as an officer, director, stockholder, or related capacity. (If self-employed provide the name, address and nature of Business) Note: May we contact your current employer? YesName of Employer Address of Position Held Dates Reason for Employer (Include (Month and Leaving _ Tel. No.) Year) Lemar! From Te NA Austin, TX 78749 03/2011 Soit . , 717) 660) Supervisor's . current trconsuingy — | SMM | Name proce From To Good Wagon Books ganenmanager | 41/2008 Business was ‘Auslin, TX 78754 isor' Supervisor's | gsor1 liquidated (512) 522 | Name: NVA — From To Doctoral Employer moved Instituto University Park, PA | Supervisor's ~ oav2008 oe [Ne See Darrali sf a fen Moved to a Assistant Richardson, TX Supervisor's o2re004 Pennsylvania Institute 75080 Noon ~08/2008 for Grad School MILITARY INFORMATION Have you ever served in any armed fore Yes’ [] No Bl A yes, answer the following questions) Branch Date of entry active service Date of separation Type of Discharge Rating at separation Serial Number * Provide a copy of your USA military record, (DD214) or discharge papers from country of military serviceWhile in the Military service were you ever arrested for an offense, which resulted in summary action, a trial, or special or general court martial? Yes [J] No []__ (ifyes, furnish details.) ARRESTS, DETENTIONS, AND LITIGATIONS (include those arrests in which your were not convicted. Have you ever been arrested, detained, charged, indicted, or summoned to answer for any criminal offense or violation for any reason whatsoever, regardless of the disposition of the event? (Except Minor traffic citations.) Have you ever testified before a grand jury or investigative hearing or probe? If so give details, List all cases without exception, No Have you ever been subpoenaed to appear to testify before a federal, state, or county grand! jury, board or commission? Yes No kk] (If yes give details) Has a criminal indictment, information, or complaint ever been returned against you, but for which you were not arrested or in which you were named as an un-indicted co-party? Yes [] No [XJ __ Ifyes, furnish details. Have you ever received a pardon for any criminal offense? Ys [ No B&H If yes, note Date, City, County, State and Country. 8Have you ever had a civil or criminal record expunged or sealed by a court order? Yes [] No &] __Ifyes, give details. Have you, as an individual, or as an owner, partner, director or officer of any partnership, corporation or other entity, ever been a party to a lawsuit as either plaintiff or defendant? (Other than divorces). Yes [] No If yes, give details. List all cases without exception, including bankruptcies: Plaintiff/Defendant Court & Case No. City/County/State Disposition CountryCHARACTER REFERENCES, Complete the following tables by listing three (3) character references who have known you for five (5) years or more. DO NOT include relatives, present employer, or employees: irst Name/Middle Initial | Last Name ‘Years Known Alden L = 20 ‘Address City/State/Zip Code Occupation Employer ~ | Werk Phone Home Phone First Name/Middle Initial | Last Name Years Known Mirza A S| 5 Address City/State/Zip Code ‘Occupation Employer Work Phone Home Phone First Name/Middle Initial [ Last Name ‘Years Known Rene J = 7 Address CigState/Zip Code ‘Occupation Employer Work Phone ‘Home Phone Have you ever held a privileged or professional license in any state, including but not limited to the following: Liquor Boxing Promoter oO Real Estate Broker or Salesman. (1 __ Race Horse/Race Dog Owner Oo Accountant 1 dJockey Oo Lawyer (_ Trainer or Manager oO 10Doctor 1 Securities Dealer Oo Casino Operator oO If yes to the previous question, state type of license, where held, years held, and the nature of any disciplinary actions taken against you with respect to these licenses. ‘Have you ever applied for citizenship of any other country? Yess [1 No Bf (f yes give details) Have you ever been the subject of any order, judgment or decree of any federal or state authority barring, suspending, or otherwise limiting your right to engage in any professional or business |! practice or activity? Ye [| No (if yes give details) I certify that the facts contained in this disclosure are true and complete to the best of my knowledge and I further understand that any false statements on this form shall be grounds for rejection. 1 authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company conducting the investigation and the Government of Dominica from all liability for any damage that may result from utilization of such informa SIGNATURE DATE Subscribed and sworn to before me this day of, 5200 Notary Public Commission Expiration Date SEAL ilBie View Mode Hel Evidence Tree | File List x © mile ESI Fe i Size | Type [Dete Modifica [ © kde Z 7 $KB_ Director (9/5/20121:10:48 AM . accounting irectory 130 . 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