[별지 제21호 서식] <개정 2010.6.30>

PERSONAL QUESTIONNAIRE (1st page)
※ THIS INFORMATION IS ONLY FOR OFFICIAL USE														【PHOTO】 (3㎝×4㎝)
FULL NAME		Last / First / Middle				DATE OF BIRTH				Month/Day/ Year
NATIONALITY (include any dual nationality)						PLACE OF BRITH				City/ Country
ALIEN REGISTRATION NUMBERS						DATE & PLACE YOU ENTERED KOREA				Month/ Day/ Year City/ County
ADDRESS										GENDER
WORK PLACE						JOB/ POSITION
TELEPHONE NUMBERS (Include Area Code)		HOME : WORK : MOBILE :
BLOOD TYPE		HEIGHT	㎝		WEIGHT		㎏		HAIR COLOR				EYE COLOR
EDUCATION		NAME Of SCHOOL		PERIOD (MM/YY- MM/YY)				DEGREE/ DIPLOMA			MONTH/YEAR AWARDED				LOCATION (Street Address & City/ Country)
		.

(2nd page)

EMPOLOYMENT ACTIVITES	EMPLOYER/ VERIFIER NAME	PREVIOUS PERIOD (MM/YY-MM/YY)		JOB/ POSITION		LOCATION (Street Address & City/Country)
FAMILY	RELATION	FULL NAME Last/First/Middle	DATE OF BIRTH		EDUCATION	OCCUPATION	ADDRESS
RELATIVES & ASSOCIATES IN KOREA	RELATION	FULL NAME Last/ First/Middle	DATES KNOW (MM/YY-MM/YY)		OCCUPATION	TITLE	TELEPHONE NUMBERS
I understand that this form may be submitted for checking against the records of police, security and credit agencies in accordance with security policy. I declare that the information I have given is true and complete to the best of my knowledge and belief. I understand that any false statement or deliberate omission in the information I have given in this questionnaire may disqualify me for employment or make me liable to disciplinary action which may include dismissal. DATE : SIGNATURE :

210㎜×297㎜ 일반용지 60g/㎡(재활용품)