I made this and figured i would post it sense i used other peoples items to get this working. [file name=myapplication___Copy.zip size=11083]http://www.chronoengine.com/images/fbfiles/files/myapplication___Copy.zip[/file]
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<html> <style type="text/css"> <!-- .style1 {font-size: small} .style2 {color: #22165e} .style10 {color: #22165e; font-size: small; } #apDiv1 { position:absolute; left:206px; top:138px; width:129px; height:17px; z-index:1; } .style11 {color: #FFFFFF} .style13 {font-size: 18px} .style14 {font-size: 18px; font-weight: bold; } .style16 {font-size: 24px; font-weight: bold; } .style17 {color: #000000} --> </style> </head> <body> <p><strong>Personal Information</strong></p> <table width="750" border="0"> <tr> <td width="49">Name:</td> <td width="150"><form name="form1" method="post" action=""> <input name="lname" type="text" id="lname" size="20" maxlength="50"> </form></td> <td width="158"><form name="form2" method="post" action=""> <input name="fname" type="text" id="fname" size="20" maxlength="50"> </form></td> <td width="158"><form name="form3" method="post" action=""> <input name="mname" type="text" id="mname" size="15" maxlength="50"> </form></td> <td width="80">Date of Birth</td> <td width="115"><form name="form4" method="post" action=""> <input name="dob" type="text" id="dob" size="15"> </form></td> </tr> <tr> <td> </td> <td>Last</td> <td>First</td> <td>Middle</td> <td> </td> <td>(MM/DD/YYYY)</td> </tr> </table> <table width="750" border="0"> <tr> <td width="118">Home Address</td> <td width="235"><form name="form5" method="post" action=""> <input name="homeaddress" type="text" id="homeaddress" size="30" maxlength="50"> </form></td> <td width="82"><form name="form6" method="post" action=""> <input name="homeapt" type="text" id="homeapt" size="10"> </form></td> <td width="158"><form name="form7" method="post" action=""> <input name="homecity" type="text" id="homecity" size="20" maxlength="50"> </form></td> <td width="45"><form name="form8" method="post" action=""> <input name="homestate" type="text" id="homestate" size="5" maxlength="25"> </form></td> <td width="86"><form name="form9" method="post" action=""> <input name="homezip" type="text" id="homezip" size="10"> </form></td> </tr> <tr> <td> </td> <td>Street Number</td> <td>Apt#</td> <td>City </td> <td>State</td> <td>Zip Code</td> </tr> </table> <table width="750" border="0"> <tr> <td>Home Phone</td> <td><form name="form10" method="post" action=""> <input name="homephone" type="text" id="homephone" size="25"> </form></td> <td>E-Mail Addtress</td> <td><form name="form11" method="post" action=""> <input name="homeemail" type="text" id="homeemail" size="25" maxlength="50"> </form></td> </tr> </table> <p><strong>Current Employment </strong></p> <table width="750" border="0"> <tr> <td width="74" scope="col"><div class="style10">Employer:</div></td> <th width="204" scope="col"> <label> <input name="cemployer" type="text" id="empname43" size="34" maxlength="100"> </label> </th> <td width="137" scope="col"> </td> <th width="92" scope="col"> </th> <th width="50" scope="col"> </th> <td width="167"> </td> </tr> <tr> <td scope="col"><div class="style10">Title:</div></td> <th scope="col"><input name="cmtitle" type="text" id="jobtitle42" size="34" maxlength="50"></th> <td scope="col">Date(s) of Service</td> <th colspan="3" scope="col"><form name="form12" method="post" action=""> <div align="left"> <input name="cmdos" type="text" id="cmdos" size="35"> </div> </form></th> </tr> <tr> <td height="2" colspan="6" scope="col"> <div class="style10"></div> <div align="left"></div></td> </tr> </table> <table width="750" border="0"> <tr> <td width="97">Work Address</td> <td width="256"><form name="form5" method="post" action=""> <input name="cmaddress" type="text" id="cmaddress" size="30" maxlength="50"> </form></td> <td width="82"><form name="form6" method="post" action=""> <input name="cmsuite" type="text" id="cmsuite" size="10"> </form></td> <td width="159"><form name="form7" method="post" action=""> <input name="cmcity" type="text" id="cmcity" size="20" maxlength="50"> </form></td> <td width="44"><form name="form8" method="post" action=""> <input name="cmstate" type="text" id="cmstate" size="5" maxlength="25"> </form></td> <td width="86"><form name="form9" method="post" action=""> <input name="cmzip" type="text" id="cmzip" size="10"> </form></td> </tr> <tr> <td> </td> <td>Street Number</td> <td>Suite#</td> <td>City </td> <td>State</td> <td>Zip Code</td> </tr> </table> <table width="750" border="0"> <tr> <td>Work Phone</td> <td><form name="form13" method="post" action=""> <input name="cmphone" type="text" id="cmphone" size="25"> </form></td> <td>Work Fax</td> <td><form name="form15" method="post" action=""> <input name="cmfax" type="text" id="cmfax" size="25"> </form></td> <td>Mobile Phone</td> <td><form name="form14" method="post" action=""> <input name="cmmobile" type="text" id="cmmobile"> </form></td> </tr> </table> <table width="750" border="0"> <tr> <td>Work E-mail</td> <td><form name="form16" method="post" action=""> <input name="cmemail" type="text" id="cmemail" size="25" maxlength="50"> </form></td> <td>Work Hours</td> <td><form name="form17" method="post" action=""> <input name="cmhours" type="text" id="cmhours" size="25"> </form></td> </tr> </table> <table width="750" border="0"> <tr> <td>Duties and Responsibilities</td> </tr> <tr> <td><form name="form18" method="post" action=""> <textarea name="cmdr" cols="80" id="cmdr"></textarea> </form></td> </tr> </table> <p><br> <span class="style14"> Previous Corrections Experience</span><br> <em>Please provide information about your other corrections experience. Include any specialization (eg, juvenile justice, gang intervention, sunstance abuse, etc)</em><br> <br> </p> <table width="750" border="0"> <tr> <td>Employer</td> <td>Title</td> <td>Duties and Responsibilities</td> <td>Date(s) of Service</td> </tr> <tr> <td><form name="form19" method="post" action=""> <input name="pceemployer1" type="text" id="pceemployer1" size="25" maxlength="50"> </form></td> <td><form name="form22" method="post" action=""> <input name="pcetitle1" type="text" id="pcetitle1" size="25" maxlength="50"> </form></td> <td><form name="form25" method="post" action=""> <textarea name="pcmdr1" cols="25" id="pcmdr1"></textarea> </form></td> <td><form name="form28" method="post" action=""> <input name="pcmdos1" type="text" id="pcmdos1" size="20"> </form></td> </tr> <tr> <td><form name="form20" method="post" action=""> <input name="pceemployer2" type="text" id="pceemployer2" size="25" maxlength="50"> </form></td> <td><form name="form23" method="post" action=""> <input name="pcetitle2" type="text" id="pcetitle2" size="25" maxlength="50"> </form></td> <td><form name="form26" method="post" action=""> <textarea name="pcmdr2" cols="25" id="pcmdr2"></textarea> </form></td> <td><form name="form29" method="post" action=""> <input name="pcmdos2" type="text" id="pcmdos2" size="20"> </form></td> </tr> <tr> <td><form name="form21" method="post" action=""> <input name="pceemployer3" type="text" id="pceemployer3" size="25" maxlength="50"> </form></td> <td><form name="form24" method="post" action=""> <input name="pcetitle3" type="text" id="pcetitle3" size="25" maxlength="50"> </form></td> <td><form name="form27" method="post" action=""> <textarea name="pcmdr3" cols="25" id="pcmdr3"></textarea> </form></td> <td><form name="form30" method="post" action=""> <input name="pcmdos3" type="text" id="pcmdos3" size="20"> </form></td> </tr> </table> <p>Education<br> Please check highest level attained.<br> </p> <table width="750" border="0"> <tr> <td width="21"> <form action="" method="post" name="ged" id="ged"> <input name="eged" type="checkbox" id="eged" value="checkbox"> </form></td> <td width="926">GED</td> <td width="96"> <form name="form34" method="post" action=""> <input name="eaa" type="checkbox" id="eaa" value="checkbox"> </form></td> <td width="888">Associate of Arts (2years)</td> <td width="96"> <form name="form35" method="post" action=""> <input name="emaster" type="checkbox" id="emaster" value="checkbox"> </form></td> <td width="952">Master's Degree</td> </tr> <tr> <td><form name="form32" method="post" action=""> <input name="ehcd" type="checkbox" id="ehcd" value="checkbox"> </form></td> <td>High School Diploma</td> <td><form name="form36" method="post" action=""> <input name="ebd" type="checkbox" id="ebd" value="checkbox"> </form></td> <td>Bachelor's Degree</td> <td><form name="form37" method="post" action=""> <input name="epd" type="checkbox" id="epd" value="checkbox"> </form></td> <td>Professional Degree</td> </tr> <tr> <td><form name="form33" method="post" action=""> <input name="esc" type="checkbox" id="esc" value="checkbox"> </form></td> <td>Some College</td> <td><form name="form38" method="post" action=""> <input name="esgw" type="checkbox" id="esgw" value="checkbox"> </form></td> <td>Some Graduate Work</td> <td><form name="form39" method="post" action=""> <input name="eo" type="checkbox" id="eo5" value="checkbox"> </form></td> <td>Other (Specify Below): </td> </tr> <tr> <td colspan="6"><form name="form31" method="post" action=""> <input name="eod" type="text" id="eod" size="120"> </form></td> </tr> </table> <br> <br> <br> <br> <br> <em>Please provide specific information about institutions of higher education and/or specialized training programs attended, beginning with the most recent.</em><br> <br> <table width="750" bordercolor="#000000"> <tr> <td width="20"> </td> <td width="160"> <div class="style10">Name</div></td> <td width="150"><div class="style10">Area of Concentration</div></td> <td width="160"><div class="style10">Dates(s) Attended</div></td> <td width="256"><div class="style10">Certificate or Degree</div></td> </tr> <tr> <td width="20">1.</td> <td><form name="form40" method="post" action=""> <input name="hgname1" type="text" id="hgname1" size="25" maxlength="50"> </form></td> <td><input name="hgaoc1" type="text" id="hgaoc1" size="25" maxlength="50"> </label> </td> <td> <label> <input name="hgdates1" type="text" id="hgdates1" size="25"> </label> </td> <td> <label> <input name="hgcod1" type="text" id="hgcod1" size="25" maxlength="50"> </label> </td> </tr> <tr> <td width="20">2.</td> <td><form name="form41" method="post" action=""> <input name="hgname2" type="text" id="hgname2" size="25" maxlength="50"> </form></td> <td><input name="hgaoc2" type="text" id="hgaoc2" size="25" maxlength="50"></td> <td><input name="hgdates2" type="text" id="hgdates2" size="25"></td> <td><input name="hgcod2" type="text" id="hgcod2" size="25" maxlength="50"></td> </tr> <tr> <td width="20">3.</td> <td> <form name="form42" method="post" action=""> <input name="hgname3" type="text" id="hgname3" size="25" maxlength="50"> </form></td> <td><input name="hgaoc1" type="text" id="hgaoc1" size="25" maxlength="50"></td> <td><input name="hgdates3" type="text" id="hgdates3" size="25"></td> <td><input name="hgcod3" type="text" id="hgcod3" size="25" maxlength="50"></td> </tr> </table> <p> </p> <table width="750" border="0"> <tr> <td colspan="6">Have you ever recieved academic credit for any course in the University of Southern California's School of Public </td> </tr> <tr> <td colspan="2">Administration; School of Policy, Planning, and Development; or School of Social Work? </td> <td width="26"> <form name="form43" method="post" action=""> <input type="radio" name="racy" value="radiobutton"> </form></td> <td width="33">YES</td> <td width="20"> <form name="form44" method="post" action=""> <input type="radio" name="racn" value="radiobutton"> </form></td> <td width="107">NO</td> </tr> <tr> <td colspan="6">If yes, indicate course(s), credit hours, where taken, and dates:</td> </tr> <tr> <td colspan="6"><form name="form45" method="post" action=""> <textarea name="racd" cols="80" id="racd"></textarea> </form></td> </tr> <tr> <td colspan="2">Have you ever participated in any DCI program?</td> <td> <form name="form43" method="post" action=""> <input type="radio" name="racdciy" value="radiobutton"> </form></td> <td>YES</td> <td> <form name="form44" method="post" action=""> <input type="radio" name="racdcin" value="radiobutton"> </form></td> <td>NO</td> </tr> <tr> <td width="121">If yes, give dates: </td> <td width="417"><form name="form46" method="post" action=""> <input name="textfield" type="text" size="50"> </form></td> <td colspan="4"> </td> </tr> </table> <p><strong>Organization and Leadership Activities</strong><br> <em>Please list your current participation in political, community, professional, social, religious and/or other activities.</em></p> <table width="750" border="0"> <tr> <td>Orgization</td> <td>Role</td> <td>Monthly Time Commitment</td> </tr> <tr> <td><form name="form47" method="post" action=""> <input name="olaorg1" type="text" id="olaorg1" size="35" maxlength="50"> </form></td> <td><form name="form48" method="post" action=""> <input name="olarole1" type="text" id="olarole1" size="30" maxlength="50"> </form></td> <td><form name="form49" method="post" action=""> <input name="olamtc1" type="text" id="olamtc1" size="30" maxlength="50"> </form></td> </tr> <tr> <td><form name="form50" method="post" action=""> <input name="olaorg2" type="text" id="olaorg2" size="35" maxlength="50"> </form></td> <td><form name="form51" method="post" action=""> <input name="olarole2" type="text" id="olarole2" size="30" maxlength="50"> </form></td> <td><form name="form52" method="post" action=""> <input name="olamtc2" type="text" id="olamtc2" size="30" maxlength="50"> </form></td> </tr> <tr> <td><form name="form53" method="post" action=""> <input name="olaorg3" type="text" id="olaorg3" size="35" maxlength="50"> </form></td> <td><form name="form54" method="post" action=""> <input name="olarole3" type="text" id="olarole3" size="30" maxlength="50"> </form></td> <td><form name="form55" method="post" action=""> <input name="olamtc3" type="text" id="olamtc3" size="30" maxlength="50"> </form></td> </tr> </table> <p><em>Please attach a statement of note more then two pages articulating your personal reasons and goals for participating in the CCLD Program. Discuss highlights of recent responsibilities and achievements: What was/were the greatest challenge(s) and what steps did you take to overcome it/them? What outcomes do you anticipate as a result of your participation in the CCLD Program? (Please double space your remarks.)</em></p> <form name="form56" enctype="multipart/form-data" method="post" action=""> <input name="file_name_1" type="file" id="file_name_1"> </form> <table width="750" border="0"> <tr> <td><em>Please provide contact information for two people who will evaluate your leadership potential. (Professional references preferred. You should inform them that we may be contacting them via phone or e-mail in connection with this program)</em></td> </tr> <tr> <td><form name="form57" method="post" action=""> <textarea name="prrd" cols="100" id="prrd"></textarea> </form></td> </tr> </table> <p> </p> <table width="750" border="0"> <tr> <td>How did you learn about the CCLD Program?</td> </tr> <tr> <td><form name="form58" method="post" action=""> <input name="ccldpd" type="text" id="ccldpd" size="105"> </form></td> </tr> </table> <br> <br> <table width="750" border="0"> <tr> <td colspan="2">I hereby verify that the above information is true and correct to the best of my knowledge.</td> </tr> <tr> <td width="139"><form name="form59" method="post" action=""> <input name="ccldai" type="text" id="ccldai" size="20"> </form></td> <td width="601"><form name="form60" method="post" action=""> <input name="ccldasd" type="text" id="ccldasd"> </form></td> </tr> <tr> <td>Initials </td> <td>DATE : </td> </tr> </table> <br> <table width="750" border="0"> <tr> <td width="199"><input type="submit" name="submit" id="submit2" value="Submit"></td> <td width="541"> </td> </tr> </table> <p> </p> <p> </p> <p><br> </p> <div align="left"></div> <p> </p> <p> </p> <p> </p> <p> </p> </body> </html>
<html> <style type="text/css"> <!-- .style1 {font-size: small} .style2 {color: #22165e} .style10 {color: #22165e; font-size: small; } #apDiv1 { position:absolute; left:206px; top:138px; width:129px; height:17px; z-index:1; } .style11 {color: #FFFFFF} .style13 {font-size: 18px} .style14 {font-size: 18px; font-weight: bold; } .style16 {font-size: 24px; font-weight: bold; } .style17 {color: #000000} --> </style> </head> <body> <p><strong>Personal Information</strong></p> <table width="750" border="0"> <tr> <td width="49">Name:</td> <td width="150"> {lname}</td> <td width="158">{fname}</td> <td width="158">{mname}</td> <td width="80">Date of Birth</td> <td width="115">{dob}</td> </tr> <tr> <td> </td> <td>Last</td> <td>First</td> <td>Middle</td> <td> </td> <td>(MM/DD/YYYY)</td> </tr> </table> <table width="750" border="0"> <tr> <td width="118">Home Address</td> <td width="235">{homeaddress}</td> <td width="82">{homeapt}</td> <td width="158">{homecity}</td> <td width="45">{homestate}</td> <td width="86">{homezip}</td> </tr> <tr> <td> </td> <td>Street Number</td> <td>Apt#</td> <td>City </td> <td>State</td> <td>Zip Code</td> </tr> </table> <table width="750" border="0"> <tr> <td>Home Phone</td> <td>{homephone}</td> <td>E-Mail Addtress</td> <td>{homeemail}</td> </tr> </table> <p><strong>Current Employment </strong></p> <table width="750" border="0"> <tr> <td width="74" scope="col">Employer:</td> <th colspan="5" scope="col"><div align="left">{cemployer}</div></tr> <tr> <td scope="col"><div class="style10">Title:</div></td> <th width="204" scope="col"><div align="left">{cmtitle}</div></th> <td width="137" scope="col">Date(s) of Service</td> <th colspan="3" scope="col">{cmdos}</td> </tr> <tr> <td height="2" colspan="6" scope="col"> <div class="style10"></div> <div align="left"></div></td> </tr> </table> <table width="750" border="0"> <tr> <td width="97">Work Address</td> <td width="256">{cmaddress}</td> <td width="82">{cmsuite}</td> <td width="159">{cmcity}</td> <td width="44">{cmstate}</td> <td width="86">{cmzip}</td> </tr> <tr> <td> </td> <td>Street Number</td> <td>Suite#</td> <td>City </td> <td>State</td> <td>Zip Code</td> </tr> </table> <table width="750" border="0"> <tr> <td width="123">Work Phone</td> <td width="131">{cmphone}</td> <td width="108">Work Fax</td> <td width="88">{cmfax}</td> <td width="145">Mobile Phone</td> <td width="129">{cmmobile}</td> </tr> </table> <table width="750" border="0"> <tr> <td width="124">Work E-mail</td> <td width="129">{cmemail}</td> <td width="109">Work Hours</td> <td width="370">{cmhours}</td> </tr> </table> <table width="750" border="0"> <tr> <td>Duties and Responsibilities</td> </tr> <tr> <td>{cmdr}</td> </tr> </table> <p><br> <span class="style14"> Previous Corrections Experience</span><br> <em>Please provide information about your other corrections experience. Include any specialization (eg, juvenile justice, gang intervention, sunstance abuse, etc)</em><br> <br> </p> <table width="750" border="0"> <tr> <td>Employer</td> <td>Title</td> <td>Duties and Responsibilities</td> <td>Date(s) of Service</td> </tr> <tr> <td>{pceemployer1}</td> <td>{pcetitle1}</td> <td>{pcmdr1}</td> <td>{pcmdos1}</td> </tr> <tr> <td>{pceemployer2}</td> <td>{pcetitle2}</td> <td>{pcmdr2}</td> <td>{pcmdos2}</td> </tr> <tr> <td>{pceemployer3}</td> <td>{pcetitle3}</td> <td>{pcmdr3}</td> <td>{pcmdos3}</td> </tr> </table> <p>Education<br> Please check highest level attained.<br> </p> <table width="750" border="0"> <tr> <td width="21">{eged} </td> <td width="926">GED</td> <td width="96">{eaa} </td> <td width="888">Associate of Arts (2years)</td> <td width="96">{emaster} </td> <td width="952">Master's Degree</td> </tr> <tr> <td>{ehcd}</td> <td>High School Diploma</td> <td>{ebd}</td> <td>Bachelor's Degree</td> <td>{epd}</td> <td>Professional Degree</td> </tr> <tr> <td>{esc}</td> <td>Some College</td> <td>{esgw}</td> <td>Some Graduate Work</td> <td>{eo}</td> <td>Other (Specify Below): </td> </tr> <tr> <td colspan="6">{eod}</td> </tr> </table> <br> <br> <br> <br> <br> <em>Please provide specific information about institutions of higher education and/or specialized training programs attended, beginning with the most recent.</em><br> <br> <table width="750" bordercolor="#000000"> <tr> <td width="20"> </td> <td width="160"> <div class="style10">Name</div></td> <td width="150"><div class="style10">Area of Concentration</div></td> <td width="160"><div class="style10">Dates(s) Attended</div></td> <td width="256"><div class="style10">Certificate or Degree</div></td> </tr> <tr> <td width="20">1.</td> <td>{hgname1}</td> <td>{hgaoc1}</td> <td> <label>{hgdates1} </label> </td> <td> <label>{hgcod1} </label> </td> </tr> <tr> <td width="20">2.</td> <td>{hgname2}</td> <td>{hgaoc2}</td> <td>{hgdates2}</td> <td>{hgcod2}</td> </tr> <tr> <td width="20">3.</td> <td>{hgname3}</td> <td>{hgaoc3}</td> <td>{hgdates3}</td> <td>{hgcod}</td> </tr> </table> <br> <br> <table width="750" border="0"> <tr> <td colspan="6">Have you ever recieved academic credit for any course in the University of Southern California's School of Public </td> </tr> <tr> <td colspan="2">Administration; School of Policy, Planning, and Development; or School of Social Work? </td> <td width="26">{racy} </td> <td width="33">YES</td> <td width="20">{racn} </td> <td width="107">NO</td> </tr> <tr> <td colspan="6">If yes, indicate course(s), credit hours, where taken, and dates:</td> </tr> <tr> <td colspan="6">{racd}</td> </tr> <tr> <td colspan="2">Have you ever participated in any DCI program?</td> <td>{racdciy} </td> <td>YES</td> <td>{racdcin} </td> <td>NO</td> </tr> <tr> <td width="121">If yes, give dates: </td> <td width="417">{racdcid}</td> <td colspan="4"> </td> </tr> </table> <p><strong>Organization and Leadership Activities</strong><br> <em>Please list your current participation in political, community, professional, social, religious and/or other activities.</em></p> <table width="750" border="0"> <tr> <td>Orgization</td> <td>Role</td> <td>Monthly Time Commitment</td> </tr> <tr> <td>{olaorg1}</td> <td>{olarole1}</td> <td>{olamtc1}</td> </tr> <tr> <td>{olaorg2}</td> <td>{olarole2}</td> <td>{olamtc2}</td> </tr> <tr> <td>{olaorg3}</td> <td>{olarole3}</td> <td>{olamtc1}</td> </tr> </table> <p><em>Please attach a statement of note more then two pages articulating your personal reasons and goals for participating in the CCLD Program. Discuss highlights of recent responsibilities and achievements: What was/were the greatest challenge(s) and what steps did you take to overcome it/them? What outcomes do you anticipate as a result of your participation in the CCLD Program? (Please double space your remarks.)</em></p> <form name="form56" enctype="multipart/form-data" method="post" action=""> <input name="file_name_1" type="file" id="file_name_1"> </form> <table width="750" border="0"> <tr> <td><em>Please provide contact information for two people who will evaluate your leadership potential. (Professional references preferred. You should inform them that we may be contacting them via phone or e-mail in connection with this program)</em></td> </tr> <tr> <td>{prrd}</td> </tr> </table> <p> </p> <table width="750" border="0"> <tr> <td>How did you learn about the CCLD Program?</td> </tr> <tr> <td>{ccldpd}</td> </tr> </table> <br> <br> <table width="750" border="0"> <tr> <td colspan="2">I hereby verify that the above information is true and correct to the best of my knowledge.</td> </tr> <tr> <td width="139">{ccldai}</td> <td width="601">{ccldasd}</td> </tr> <tr> <td>Initials </td> <td>DATE : </td> </tr> </table> <br> <table width="750" border="0"> <tr> <td width="199"><input type="submit" name="submit" id="submit2" value="Submit"></td> <td width="541"> </td> </tr> </table> <p> </p> <p> </p> <p><br> </p> <div align="left"></div> <p> </p> <p> </p> <p> </p> <p> </p> </body> </html>
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<html> <style type="text/css"> <!-- .style1 {font-size: small} .style2 {color: #22165e} .style10 {color: #22165e; font-size: small; } #apDiv1 { position:absolute; left:206px; top:138px; width:129px; height:17px; z-index:1; } .style11 {color: #FFFFFF} .style13 {font-size: 18px} .style14 {font-size: 18px; font-weight: bold; } .style16 {font-size: 24px; font-weight: bold; } .style17 {color: #000000} --> </style> </head> <body> <p><strong>Personal Information</strong></p> <table width="750" border="0"> <tr> <td width="49">Name:</td> <td width="150"><input name="lname" type="text" id="lname" size="20" maxlength="50"></td> <td width="158"><input name="fname" type="text" id="fname" size="20" maxlength="50"></td> <td width="158"><input name="mname" type="text" id="mname" size="15" maxlength="50"></td> <td width="80">Date of Birth</td> <td width="115"><input name="dob" type="text" id="dob" size="15"></td> </tr> <tr> <td> </td> <td>Last</td> <td>First</td> <td>Middle</td> <td> </td> <td>(MM/DD/YYYY)</td> </tr> </table> <table width="750" border="0"> <tr> <td width="118">Home Address</td> <td width="235"><input name="homeaddress" type="text" id="homeaddress" size="30" maxlength="50"></td> <td width="82"><input name="homeapt" type="text" id="homeapt" size="10"></td> <td width="158"><input name="homecity" type="text" id="homecity" size="20" maxlength="50"></td> <td width="45"><input name="homestate" type="text" id="homestate" size="5" maxlength="25"></td> <td width="86"><input name="homezip" type="text" id="homezip" size="10"></td> </tr> <tr> <td> </td> <td>Street Number</td> <td>Apt#</td> <td>City </td> <td>State</td> <td>Zip Code</td> </tr> </table> <table width="750" border="0"> <tr> <td>Home Phone</td> <td><input name="homephone" type="text" id="homephone" size="25"></td> <td>E-Mail Addtress</td> <td><input name="homeemail" type="text" id="homeemail" size="25" maxlength="50"></td> </tr> </table> <p><strong>Current Employment </strong></p> <table width="750" border="0"> <tr> <td width="74" scope="col"><div class="style10">Employer:</div></td> <th width="204" scope="col"><input name="cemployer" type="text" id="empname43" size="34" maxlength="100"></th> <td width="137" scope="col"> </td> <th width="92" scope="col"> </th> <th width="50" scope="col"> </th> <td width="167"> </td> </tr> <tr> <td scope="col"><div class="style10">Title:</div></td> <th scope="col"><input name="cmtitle" type="text" id="jobtitle42" size="34" maxlength="50"></th> <td scope="col">Date(s) of Service</td> <th colspan="3" scope="col"> <div align="left"><input name="cmdos" type="text" id="cmdos" size="35"> </div></th> </tr> <tr> <td height="2" colspan="6" scope="col"> <div class="style10"></div> <div align="left"></div></td> </tr> </table> <table width="750" border="0"> <tr> <td width="97">Work Address</td> <td width="256"><input name="cmaddress" type="text" id="cmaddress" size="30" maxlength="50"></td> <td width="82"><input name="cmsuite" type="text" id="cmsuite" size="10"></td> <td width="159"><input name="cmcity" type="text" id="cmcity" size="20" maxlength="50"></td> <td width="44"><input name="cmstate" type="text" id="cmstate" size="5" maxlength="25"></td> <td width="86"><input name="cmzip" type="text" id="cmzip" size="10"></td> </tr> <tr> <td> </td> <td>Street Number</td> <td>Suite#</td> <td>City </td> <td>State</td> <td>Zip Code</td> </tr> </table> <table width="750" border="0"> <tr> <td>Work Phone</td> <td><input name="cmphone" type="text" id="cmphone" size="25"></td> <td>Work Fax</td> <td><input name="cmfax" type="text" id="cmfax" size="25"></td> <td>Mobile Phone</td> <td><input name="cmmobile" type="text" id="cmmobile"></td> </tr> </table> <table width="750" border="0"> <tr> <td>Work E-mail</td> <td><input name="cmemail" type="text" id="cmemail" size="25" maxlength="50"></td> <td>Work Hours</td> <td><input name="cmhours" type="text" id="cmhours" size="25"></td> </tr> </table> <table width="750" border="0"> <tr> <td>Duties and Responsibilities</td> </tr> <tr> <td><textarea name="cmdr" cols="80" id="cmdr"></textarea></td> </tr> </table> <p><br> <span class="style14"> Previous Corrections Experience</span><br> <em>Please provide information about your other corrections experience. Include any specialization (eg, juvenile justice, gang intervention, sunstance abuse, etc)</em><br> <br> </p> <table width="750" border="0"> <tr> <td>Employer</td> <td>Title</td> <td>Duties and Responsibilities</td> <td>Date(s) of Service</td> </tr> <tr> <td><input name="pceemployer1" type="text" id="pceemployer1" size="25" maxlength="50"></td> <td><input name="pcetitle1" type="text" id="pcetitle1" size="25" maxlength="50"></td> <td><textarea name="pcmdr1" cols="25" id="pcmdr1"></textarea></td> <td><input name="pcmdos1" type="text" id="pcmdos1" size="20"></td> </tr> <tr> <td><input name="pceemployer2" type="text" id="pceemployer2" size="25" maxlength="50"></td> <td><input name="pcetitle2" type="text" id="pcetitle2" size="25" maxlength="50"></td> <td><textarea name="pcmdr2" cols="25" id="pcmdr2"></textarea></td> <td><input name="pcmdos2" type="text" id="pcmdos2" size="20"></td> </tr> <tr> <td><input name="pceemployer3" type="text" id="pceemployer3" size="25" maxlength="50"></td> <td><input name="pcetitle3" type="text" id="pcetitle3" size="25" maxlength="50"></td> <td><textarea name="pcmdr3" cols="25" id="pcmdr3"></textarea></td> <td><input name="pcmdos3" type="text" id="pcmdos3" size="20"></td> </tr> </table> <p>Education<br> Please check highest level attained.<br> </p> <table width="750" border="0"> <tr> <td width="21"><input name="eged" type="checkbox" id="eged" value="checkbox"></td> <td width="926">GED</td> <td width="96"><input name="eaa" type="checkbox" id="eaa" value="checkbox"></td> <td width="888">Associate of Arts (2years)</td> <td width="96"><input name="emaster" type="checkbox" id="emaster" value="checkbox"></td> <td width="952">Master's Degree</td> </tr> <tr> <td><input name="ehcd" type="checkbox" id="ehcd" value="checkbox"></td> <td>High School Diploma</td> <td><input name="ebd" type="checkbox" id="ebd" value="checkbox"></td> <td>Bachelor's Degree</td> <td><input name="epd" type="checkbox" id="epd" value="checkbox"></td> <td>Professional Degree</td> </tr> <tr> <td><input name="esc" type="checkbox" id="esc" value="checkbox"></td> <td>Some College</td> <td><input name="esgw" type="checkbox" id="esgw" value="checkbox"></td> <td>Some Graduate Work</td> <td><input name="eo" type="checkbox" id="eo5" value="checkbox"></td> <td>Other (Specify Below): </td> </tr> <tr> <td colspan="6"><input name="eod" type="text" id="eod" size="120"></td> </tr> </table> <br> <br> <br> <br> <br> <em>Please provide specific information about institutions of higher education and/or specialized training programs attended, beginning with the most recent.</em><br> <br> <table width="750" bordercolor="#000000"> <tr> <td width="20"> </td> <td width="160"> <div class="style10">Name</div></td> <td width="150"><div class="style10">Area of Concentration</div></td> <td width="160"><div class="style10">Dates(s) Attended</div></td> <td width="256"><div class="style10">Certificate or Degree</div></td> </tr> <tr> <td width="20">1.</td> <td><input name="hgname1" type="text" id="hgname1" size="25" maxlength="50"></td> <td><input name="hgaoc1" type="text" id="hgaoc1" size="25" maxlength="50"></td> <td><input name="hgdates1" type="text" id="hgdates1" size="25"></td> <td><input name="hgcod1" type="text" id="hgcod1" size="25" maxlength="50"></td> </tr> <tr> <td width="20">2.</td> <td><input name="hgname2" type="text" id="hgname2" size="25" maxlength="50"></td> <td><input name="hgaoc2" type="text" id="hgaoc2" size="25" maxlength="50"></td> <td><input name="hgdates2" type="text" id="hgdates2" size="25"></td> <td><input name="hgcod2" type="text" id="hgcod2" size="25" maxlength="50"></td> </tr> <tr> <td width="20">3.</td> <td><input name="hgname3" type="text" id="hgname3" size="25" maxlength="50"></td> <td><input name="hgaoc1" type="text" id="hgaoc1" size="25" maxlength="50"></td> <td><input name="hgdates3" type="text" id="hgdates3" size="25"></td> <td><input name="hgcod3" type="text" id="hgcod3" size="25" maxlength="50"></td> </tr> </table> <p> </p> <table width="750" border="0"> <tr> <td colspan="6">Have you ever recieved academic credit for any course in the University of Southern California's School of Public </td> </tr> <tr> <td colspan="2">Administration; School of Policy, Planning, and Development; or School of Social Work? </td> <td width="26"><input type="radio" name="racy" value="radiobutton"></td> <td width="33">YES</td> <td width="20"><input type="radio" name="racn" value="radiobutton"></td> <td width="107">NO</td> </tr> <tr> <td colspan="6">If yes, indicate course(s), credit hours, where taken, and dates:</td> </tr> <tr> <td colspan="6"><textarea name="racd" cols="80" id="racd"></textarea></td> </tr> <tr> <td colspan="2">Have you ever participated in any DCI program?</td> <td><input type="radio" name="racdciy" value="radiobutton"></td> <td>YES</td> <td><input type="radio" name="racdcin" value="radiobutton"></td> <td>NO</td> </tr> <tr> <td width="121">If yes, give dates: </td> <td width="417"><input name="textfield" type="text" size="50"></td> <td colspan="4"> </td> </tr> </table> <p><strong>Organization and Leadership Activities</strong><br> <em>Please list your current participation in political, community, professional, social, religious and/or other activities.</em></p> <table width="750" border="0"> <tr> <td>Orgization</td> <td>Role</td> <td>Monthly Time Commitment</td> </tr> <tr> <td><input name="olaorg1" type="text" id="olaorg1" size="35" maxlength="50"></td> <td><input name="olarole1" type="text" id="olarole1" size="30" maxlength="50"></td> <td><input name="olamtc1" type="text" id="olamtc1" size="30" maxlength="50"></td> </tr> <tr> <td><input name="olaorg2" type="text" id="olaorg2" size="35" maxlength="50"></td> <td><input name="olarole2" type="text" id="olarole2" size="30" maxlength="50"></td> <td><input name="olamtc2" type="text" id="olamtc2" size="30" maxlength="50"></td> </tr> <tr> <td><input name="olaorg3" type="text" id="olaorg3" size="35" maxlength="50"></td> <td><input name="olarole3" type="text" id="olarole3" size="30" maxlength="50"></td> <td><input name="olamtc3" type="text" id="olamtc3" size="30" maxlength="50"></td> </tr> </table> <p><em>Please attach a statement of note more then two pages articulating your personal reasons and goals for participating in the CCLD Program. Discuss highlights of recent responsibilities and achievements: What was/were the greatest challenge(s) and what steps did you take to overcome it/them? What outcomes do you anticipate as a result of your participation in the CCLD Program? (Please double space your remarks.)</em></p> <input name="file_name_1" type="file" id="file_name_1"> <table width="750" border="0"> <tr> <td><em>Please provide contact information for two people who will evaluate your leadership potential. (Professional references preferred. You should inform them that we may be contacting them via phone or e-mail in connection with this program)</em></td> </tr> <tr> <td><textarea name="prrd" cols="100" id="prrd"></textarea></td> </tr> </table> <p> </p> <table width="750" border="0"> <tr> <td>How did you learn about the CCLD Program?</td> </tr> <tr> <td><input name="ccldpd" type="text" id="ccldpd" size="105"></td> </tr> </table> <br> <br> <table width="750" border="0"> <tr> <td colspan="2">I hereby verify that the above information is true and correct to the best of my knowledge.</td> </tr> <tr> <td width="139"><input name="ccldai" type="text" id="ccldai" size="20"></td> <td width="601"><input name="ccldasd" type="text" id="ccldasd"></td> </tr> <tr> <td>Initials </td> <td>DATE : </td> </tr> </table> <br> <table width="750" border="0"> <tr> <td width="199"><input type="submit" name="submit" id="submit2" value="Submit"></td> <td width="541"> </td> </tr> </table> <p> </p> <p> </p> <p><br> </p> <div align="left"></div> <p> </p> <p> </p> <p> </p> <p> </p> </body> </html>
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