Name __________________________________________
first middle last
Sex M F
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Birth date ___/___/______
MM/DD/YYYY
Hair color Brown Black Red Blonde Gray Other ______
Eye color Brown Hazel Gray Blue Black Other ______
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Height ___'___"
Weight _____lbs.
Marital status Single Married Divorced Widowed
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Sexual preference Heterosexual Homosexual Bisexual
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Do you suffer from any illnesses/diseases? YES NO
If yes, please list them below.
_____________________________________________________________________________________
Do any illnesses/diseases run in your family? YES NO
If yes, please list them below.
_____________________________________________________________________________________
Please list any allergies you may have
_____________________________________________________
Have you ever been convicted of a felony? YES NO
If yes, please explain and tell when.
_____________________________________________________________________________________
High school attended _______________________________________________
College/university attended __________________________________________
Year last attended Freshman Sophomore Junior Senior
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Major ___________________________
Degree earned ____________________
Employment
List the past three jobs you have had. List the most recent first.
Company ____________________________________
Position held __________________________________
List duties ____________________________________________________________________________________
Starting date __________
Ending date __________
Reason for leaving __________________________
Company ____________________________________
Position held __________________________________
List duties ____________________________________________________________________________________
Starting date __________
Ending date __________
Reason for leaving __________________________
Company ____________________________________
Position held __________________________________
List duties ____________________________________________________________________________________
Starting date __________
Ending date __________
Reason for leaving __________________________
What type of occupations would you be interested in having? ______________________________________________________________________________________________________________________________________
What skills do you posses? ______________________________________________________________________
List any community service projects you are involved in/have done _______________________________________________________________________________________________________________________________________
Religion _____________________
How often to you attend religious services? ____________________
Would you be interested in playing on/coaching a community sports team? YES NO
If yes, which sport would you be interested in playing/coaching? ______________________________________
Do you wear glasses or contact lenses? YES NO
Do you have any body piercings? YES NO
If yes, do you have any in places other than your ears? YES NO
Favorite foods _________________________________________
Least favorite foods _____________________________________
Favorite types of music __________________________________
Favorite movies ________________________________________
Favorite tv shows _______________________________________
Favorite types of books ___________________________________
Favorite magazines ______________________________________
Hobbies ___________________________________________________________________________________________________________________________________________________________________________________
Please list positive qualities you may have ______________________________________________________________________________________________________________________________________________________
Please list any negative qualities you may have _____________________________________________________
_____________________________________________________________________________________________
What are your reasons for wanting to go on this journey?
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Would you have any concerns with being on a space ship for several years? If yes, please list.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
References please list people who you have known for at least 2 years and are not related to
Name _______________________________________
Relationship _____________________
Occupation ___________________________
How long have they known you for? __________
Phone number _____________________
Name _______________________________________
Relationship _____________________
Occupation ___________________________
How long have they known you for? __________
Phone number _____________________
Name _______________________________________
Relationship _____________________
Occupation ___________________________
How long have they known you for? __________
Phone number _____________________
Contact information
Street ____________________________ City ___________________________
State ______ Zip code ________ Country _______________
Phone numbers __________________ ___________________ ___________________
E-mail address __________________________________
