HCO ES Hat

HCO Area Sec Hat

Dept 1 Hat

I _______________________________ of _____________________________________

Block capitals Permanent Address

_____________________________________________________ do hereby apply for a post in

City State

the ___________________________________ Organization.

I understand that my signing a contract for 2 1/2 years beginning with the date of going on staff, any and all training and processing I will subsequently receive while on contract will be given without charge.

Mark One.

(a) I wish to go on staff now and sign the contract and a note now and do any further training part time.

(b) I wish to take my HDC Course first and will sign the staff contract and a note before enrollment understanding that if I break the contract the full fee becomes due and payable and I will be refused further training or processing in any org.

AS A CONTRACTED STAFF MEMBER I REALIZE I WILL RECEIVE MY POWER PROCESSING IN THIS ORG WHEN MY CASE IS FULLY PREPARED FOR IT.

I am male female __________________ years old, born in ____________________

Date

in _____________________________

Town, Country.

(If a minor, I will present written consent of parents or Guardian to work in the org with this application.)

I (have had) (have not had) (mark one out) psychiatric treatment. If so, give details __________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

I (take) (have taken) (have not been on) drugs. (Mark out 2.)

I am (married) (unmarried). (Mark out one.)

My (husband) (wife) (has) (does not have) any objection to my working in the org.

My parents (have) (do not have) any objections to my working in the org.

I (am) (am not) connected to persons hostile to Scientology. If so, give details

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

My education consists of (give details) ___________________________________________

___________________________________________________________________________

___________________________________________________________________________

I am particularly competent at (give special skills) __________________________________

___________________________________________________________________________

___________________________________________________________________________

If employed, I agree to receive pay proportionate to org income from week to week.

If employed, I agree to the usual rules and regulations that govern staff members.

___________________________________________________________________

Witness Signed

____________________________________

Witness

COMPLETE THIS FORM AND GIVE IT TO RECEPTION TO PLACE IN THE BASKET OF HCO DEPT 1.

CS-1

for