Technical Assistant, Lab Assistant, Master Craftsman, Etc.

Please note that ONLY the German version of this document is legally binding and has to be signed! The English translation is provided to help you fill out the original German document!

Personnel Factsheet Photograph (please write clearly and fill out in full) Mark with a cross where applicable please write your name

1. Surname: on the reverse Maiden name: - First name:

2. Born on: Do not stick it on! Place of birth: Nationality:

3. Marital status: Single Married Widowed Divorced

4. Permanent address: (Postcode and place) (Street) Telephone:

5. Do you have a serious disability or the like? Yes No

If yes, please state the type and level of (Replies can be submitted in a sealed envelope -> R12) the disability:

6. Profession: School education: Examinations taken: (Technical assistant, lab assistant, master craftsman, etc.)

7. Do you have a Yes No (Replies can be submitted in a sealed envelope -> R12) criminal record?

8. Periods of public service (including military or civil service) after your 18th birthday:

Reason for leaving a) from to b) from to c) from to d) from to

9. Children entitled to maintenance (with surnames, if these differ to your own):

1. First name: DOB: 2. First name: DOB: 3. First name: DOB: 4. First name: DOB: 5. First name: DOB:

I hereby declare that my details are complete and correct. I am aware that by intentionally providing false information, I may expect instant dismissal from service. I am obliged to inform Human Resources immediately of any changes which may occur at a later date in writing.

(Date) (Signature) Date 05/2014