DOJ-OGR-00023877.pdf

3. A. Present Residential Address: ____________________________________________________ B. Length of time at this address: ________________________ 11 months C. Home telephone number: _____________________________________________________ D. List all residential addresses (including street and number, city and state) for the last five (5) years and dates you resided at each address: Addresses Dates ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4. A. Present Place of Employment: Law Office of Marc Fernich I. Name of immediate supervisor: Marsha Fernich / Jonathan Savella II. Employer's business address: 810 Seventh Avenue, Ste 620 New York, NY 10019 III. Employer's telephone number: 212-446-___________ IIII. Dates of Employment: 7/2019 - Present B. List all previous employers for the past five (5) years, including employers' addresses and dates of your employment with each employer: EMPLOYER ADDRESS DATES OF EMPLOYMENT ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 5. A. List all schools, universities, or other educational institutions attended from grade Page 4 of 10 Revised 2/01/08 DOJ-OGR-00023877