VOKSHORI LAW GROUP BANKRUPTCY ATTORNEY

PERSONAL HISTORY STATEMENT

INSTRUCTIONS: To be typewritten, printed or handwritten legibly with ink. If space

provided is inadequate, add another page and identify additional information by item
number. Read questionnaire completely before making entries.

POSITION APPLYING FOR _____________________________________________________

PERSONAL

1. Name (print)

___________________________________________________________________
First Middle Last

Give any other names you have used or have been known by, and attach statement-
giving reasons.
If none, so state.

_____________________________ _________________________________

_____________________________ _________________________________

2. Address (print) ________________________________________________________

No. Street

___________________________________________________________________
City State Zip

Phone number: Home ______________________ Business ______________________

E-Mail Address: __________________________________________________

3. Full Name, Birth Date and Relationship of all individuals with whom you reside.

________________________ ___________________________________________

___________________________________________________________________

4. Date of Birth: _________________________________

Month Day Year

5. Are you a citizen of the United States? ________ Yes ______ No

6. If married, are you living with your wife/husband? ____Yes ____ No

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 If not, provide name and state reasons:

___________________________________________________________________
REFERENCES

7. Fill in below the names of five persons not related to you, and not former employers,
who have known you intimately for at least 5 years. All persons to whom you
refer may be asked to appraise your character, ability, experience, personality and
other qualities. Please provide complete address, phone number and e-mail
information. Incomplete information will delay background process.

.....................................................................
.

Name ______________________________ Address ___________________________

Years
Business, Occupation or Profession _______________________ Known _________

Work/Home Phone Number ___________ E-Mail Address _________________________

.....................................................................
...

Name ______________________________ Address ___________________________

Years
Business, Occupation or Profession _______________________ Known _________

Work/Home Phone Number ___________ E-Mail Address _________________________

.....................................................................
...

Name ______________________________ Address ___________________________

Years
Business, Occupation or Profession _______________________ Known _________

Work/Home Phone Number ___________ E-Mail Address _________________________

.....................................................................
..

Name ______________________________ Address ___________________________

Years
Business, Occupation or Profession _______________________ Known _________

Work/Home Phone Number ___________ E-Mail Address _________________________

.....................................................................
..

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 Name ______________________________ Address ___________________________
Years
Business, Occupation or Profession _______________________ Known _________

Work/Home Phone Number ___________ E-Mail Address _________________________

.....................................................................
..

RESIDENCES

8. List address past 5 years starting with present address at top:

FROM TO ADDRESS OF CITY & STATE FROM WHOM RENTING

Mo. Yr. Mo. Yr. RESIDENCE INCLUDE ADDRESS

WORK HISTORY

9. What is your occupation or calling? _______________________________________

10. Social Security Number? ____________________

11. Were you ever discharged or forced to resign because of misconduct or

unsatisfactory service? ____ Yes ___ No. If yes, give details:

___________________________________________________________________

___________________________________________________________________

12. List all jobs you have held in the last ten years. Put your present or most recent
job first. If you need more space, you may attach additional sheets. Include
military service in proper time sequence and temporary part-time jobs.
.....................................................................
..

Beginning _________ Ending _________ Exact Title of Position __________________

Mo. & Yr. Mo. & Yr.

Name/Address of Employer:

Phone #

Duties:

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 Name/Address of Supervisor:

Reason for Leaving:

No. Supervised: Salary per Month:

.....................................................................
.

Beginning _________ Ending _________ Exact Title of Position __________________

Mo. & Yr. Mo. & Yr.

Name/Address of Employer:

Phone #

Duties:

Name/Address of Supervisor:

Reason for Leaving:

No. Supervised: Salary per Month:

.....................................................................
.

Beginning _________ Ending _________ Exact Title of Position __________________

Mo. & Yr. Mo. & Yr.

Name/Address of Employer:

Phone #

Duties:

Name/Address of Supervisor:

Reason for Leaving:

No. Supervised: Salary per Month:

.....................................................................
.

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 Beginning _________ Ending _________ Exact Title of Position __________________
Mo. & Yr. Mo. & Yr.

Name/Address of Employer:

Phone #

Duties:

Name/Address of Supervisor:

Reason for Leaving:

No. Supervised: Salary per Month:

.....................................................................
.

Beginning _________ Ending _________ Exact Title of Position __________________

Mo. & Yr. Mo. & Yr.

Name/Address of Employer:

Phone #

Duties:

Name/Address of Supervisor:

Reason for Leaving:

No. Supervised: Salary per Month:

.....................................................................
.

13. If you were ever placed on an eligibility list and were not hired, state why:
___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

14. Were you ever rejected for any civil service position? ________ Yes ________No

If yes, please state the reason.

___________________________________________________________________

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 ___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

15. In space provided below, list your reasons for applying for position:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

MILITARY

16. Have you ever served in a military or naval organization of the U.S.?

_________ Yes _________ No Branch of Service _________________________

17. Service Number: _______________________________________________________

18. Highest rank held: ______________________________________________________

19. Type of discharge: honorable, dishonorable, medical, honorable conditions, etc.?

Be exact: ____________________________________________________________

___________________________________________________________________

___________________________________________________________________

EDUCATION

20. Indicate below, schools attended and courses completed. If you cannot remember,
say so. Do not trouble to write school for information.
Name No. Full Yrs. Work When Graduate
Address (City & State) Completed Attended

Grammar:

Jr. High:

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 High School:

University/College:

Extension, Graduate,
Correspondence Courses:

21. Do you drink alcoholic beverages? __________ Yes __________ No If yes, to what
degree? ________________________________________________________

22. Have you ever used marijuana? ___________ Yes ____________ No If yes, what
were the circumstances? ___________________________________________

23. Have you ever used any other illegal drugs, opiates, pills, etc?

_________ Yes __________ No If yes, what were the circumstances? _______

___________________________________________________________________

___________________________________________________________________

ARREST AND MILITARY DISCIPLINARY ACTION

Answer all of the following questions completely and accurately. Any falsifications
or misstatements of fact may be sufficient to disqualify you. (Exclude Traffic
Citations) Please use other side of this paper if needed.

24. Have you or anyone in y0ur household ever been arrested or detained by Police?
________ Yes _______ No.

If yes, give details below:

Crime Charged ______________________ Police Agency _____________________

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 Date ___________________ Disposition of case _____________________________
.....................................................................
..

Crime Charged ______________________ Police Agency _____________________

Date ___________________ Disposition of case _____________________________

.....................................................................
..

25. Have you or anyone in your household ever been placed on probation?
______ Yes _______ No

If yes, give details:______________________________________________________

___________________________________________________________________

___________________________________________________________________

26. Have you ever been reported as a missing person or a runaway? ___ Yes __No

If yes, give complete details, including jurisdiction, dates and outcome:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

27. Do you possess a valid Driver’s license from the State of California? ____ Yes ____
No

License No. ________________ Year Issued ___________

28. Was your license ever suspended or revoked? _______ Yes ______ No

If yes, which and give reasons:

___________________________________________________________________

___________________________________________________________________

29. Do you type? ______ Yes _____ No Words per minute? _________________

I hereby certify that all statements made in this questionnaire are true and
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complete, and understand that any misstatements of material facts will subject
me to disqualification or dismissal.

____________________________________________________
(Signature in Full)

____________________________________________________
(Date Completed)

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