APPLICANT/EMPLOYEE BIOGRAPHICAL DATA SHEET 1. Applicant/Employee Name 2. Contractor's Name (Last, Middle) FHI 360 3. Applicant/Employee Address 4. Project ID No. 5. Position Under Project (include ZIP Code) 6. Proposed Salary 7. Duration of Assignment 8. Telephone Number 10. Citizenship (if U.S citizen give Social Security Number; 9. Place of Birth If non-U.S. citizen, give visa status) (include area code) 11. Education 12. Language Proficiency (include all college or university degrees) (see instructions on reverse) Proficiency Proficiency Name & Location of Institution Major Degree Year Language Speaking Reading 13. Employment History Employment Period Salary (most recent first) Give last three (3) years. List salaries separate for each year. Continue on separate page if necessary. Employer Name & Address U.S. Position Title From To Point of Contact & Telephone # Dollars 14. Specific Consultant Services (give last (3) years) Dates of Service Company’s Name & Address Daily Rate Days at Services Performed (MM/DD/YY) Point of Contact & Telephone # Rate From To U.S. Dollars 15. Applicant/Employee Certification Applicant/Employee certifies in submitting this form that applicant has reasonable steps to ensure the accuracy of the information contained in this form and understands that FHI 360 will make necessary contacts to verify the information. Applicant/Employee understands that FHI 360 may rely on the accuracy of such information in negotiating a rates and/or salary with the applicant. Applicant/Employee understands that the making of certifications that are false, fictitious, or fraudulent may result in appropriate remedial action by FHI 360, taking into consideration all of the pertinent facts and circumstances, which may include immediate termination of any relationship with FHI 360. Signature of Applicant/Employee: Date
APPLICANT/EMPLOYEE BIOGRAPHICAL DATA SHEET 1. Applicant/Employee Name (Last, Middle) 2. Contractor's Name FHI 360 3. Applicant/Employee Address (include ZIP Code) 4. Project ID No. 5. Position Under Project 6. Proposed Salary 7. Duration of Assignment 8. Telephone Number (include area code) 9. Place of Birth 10. Citizenship (if U.S citizen give Social Security Number; If non-U.S. citizen, give visa status) 11. Education (include all college or university degrees) 12. Language Proficiency (see instructions on reverse) Name & Location of Institution Major Degree Year Language Proficiency Speaking Proficiency Reading 13. Employment History Give last three (3) years. List salaries separate for each year. Continue on separate page if necessary. Employment Period (most recent first) Salary Position Title Employer Name & Address Point of Contact & Telephone # From To U.S. Dollars 14. Specific Consultant Services (give last (3) years) Services Performed Company’s Name & Address Point of Contact & Telephone # Dates of Service (MM/DD/YY) Daily Rate Days at Rate From To U.S. Dollars 15. Applicant/Employee Certification Applicant/Employee certifies in submitting this form that applicant has reasonable steps to ensure the accuracy of the information contained in this form and understands that FHI 360 will make necessary contacts to verify the information. Applicant/Employee understands that FHI 360 may rely on the accuracy of such information in negotiating a rates and/or salary with the applicant. Applicant/Employee understands that the making of certifications that are false, fictitious, or fraudulent may result in appropriate remedial action by FHI 360, taking into consideration all of the pertinent facts and circumstances, which may include immediate termination of any relationship with FHI 360. Signature of Applicant/Employee: Date
Annex-3-fhi-360-biodata-form.docx