3. EMPLOYER ___________________________________________________________________________

DATE OF EMPLOYMENT ______________________________________________________________

TYPE OF WORK _______________________________________________________________________

REASON FOR LEAVING _______________________________________________________________

WIFE EMPLOYMENT

1. EMPLOYER ___________________________________________________________________________

DATE OF EMPLOYMENT ______________________________________________________________

TYPE OF WORK _______________________________________________________________________

REASON FOR LEAVING _______________________________________________________________

2. EMPLOYER ___________________________________________________________________________

DATE OF EMPLOYMENT ______________________________________________________________

TYPE OF WORK _______________________________________________________________________

REASON FOR LEAVING _______________________________________________________________

DO YOU HAVE A VALID DRIVER’S LICENSE (H) YES NO (W) YES NO

DO YOU OWN AN AUTOMOBILE? YES NO IF YES, HOW MANY? ____________

INSURANCE COMPANY NAME ________________________________________________________________

TYPE OF INSURANCE COVERAGE _____________________________________________________________

PLEASE LIST ANY CRIMINAL CHARGES, FINES OR CONVICTIONS FOR ANY MEMBER OF THE

HOUSEHOLD. INCLUDE DATES AND DISPOSITION.

LIST ANY HOUSEHOLD MEMBERS CHARGED OR CONVICTED OR SPOUSE OR CHILD ABUSE/NEGLECT AND THE DISPOSITION.

All information in this profile is true and complete to the best of my knowledge. We consent to the agency verifying our information. We are aware that should investigation disclose misrepresentations or falsifications, our application will be rejected.

________________________________________________________ ________________________________

HUSBAND SIGNATURE DATE

________________________________________________________ ________________________________

WIFE SIGNATURE DATE

9/23/98 PMHC-329