day K Socially 21. Current work status: K Occasionally 0 Working full duty K Working restricted duty (Since ) K Retired K Disabled (Since ) K Student K Homemaker Company: Occupation: Title: K Unemployed 6 EFTA00307794 22. Have you ever had a problem with drug dependence? El Yes K No 23

on No: 314643 Person Number: 73274 Campus Activity Blom NOT • student employ**, or volunteer at a university or Institution of higher turning. 1. K Student K Employes O Volunteer Start Date: End Date Uriversity/School Name: Campus: — Address: ' (Stint AddrodS) (CPT) County: Employer. Contact: