Please, take few minutes to fill out this inventory to help us gather substantial information on our database. We appreciate
very much your effort in this endeavor.

DEPARTMENT OF HUMAN RESOURCES

Inventory of Professionals & Human Resources of Haitians in Diaspora
Inventaires des Ressources Humaines & Professionnels des Haïtiens à l’Étranger

PERSONAL INFORMATION/INFORMATION PERSONNELLE

1.  Last Name _________________________________                2. First name
__________________________________       Nom                                                          Prénom
3.  Address____________________________________ 4. __________ 5. City __________________________________
                                          Rue/Boite Postale                        Apt. #                             Ville
6.  State __________________ 7.  Zip Code ________________ 8.  Telephone __________________________________
                  État                                Code Postale                        Code Régionale/Area code
9.  Place of Birth _____________________________        10. Date of Birth (m/d)_____________________11. Sex.  M   F
                                    Lieu de Naissance                                        Date de Naissance (Jour/mois)
12. Nationality ______________________         13. Occupation__________________14. Business #: ________________
                   Nationalité                                    Occupation                              Téléphone du travail
15. E-mail address __________________________________________ 16. Cell #: _______________________________
                                  Adresse Electronique                                                                           Téléphone portable
17. Religion _____________________________                18. Church ____________________________________
                      Religion                                                                               Eglise
19. Children: ______________________        ________________________        ________________________________
                  Noms des Enfants
              ______________________                ________________________        ________________________________
SPOUSE INFORMATION/INFORMATION DU/DE LA CONJOINT (E)

20. Spouse First Name ________________________________                 21. Maiden Name ________________________
                              Prénom du conjoint                                                              Nom de jeune fille
22. Place of Birth _____________________________        23. Date of birth (mm/dd) _______________________________
                        Lieu de Naissance                                             Date de Naissance
24. Nationality__________________________                 25. Occupation  _______________________________________
                           Nationalité                                        Occupation Personnelle
26. Religion _______________________________         27. Church  __________________________________________
                              Religion                                                Église
EDUCATION/FORMATION ACADEMIQUE ET PROFESSIONNELLE (OPTIONAL)
28. Education: a) Secondary ______ b) College ______________ c) Professional Training _________________________
                                                   1    2    3    4
   d) Master’s _____________________ Other  ___________          29. Institution  
_________________________________
                              Maîtrise                        autres
30. Date attended ____________________         31. Diploma ________________        Degree ______________________
                                           Dâte                                                            Diplôme                                                 Titre
33. Bus. Address _____________________        34.  City _____________ 35. State _________          36. Zip
____________
                      Adresse de Travail                      Ville                            Ètat                Code Postale
37. Today’s Date _____________________________
                                    Dâte du Jour
712 East 27th Street Suite 1-F
Brooklyn, New York 11210

Telephone: ( 718) 421-5760
CLF Ministries
Center For the Less Fortunate, Inc.
CLF Ministries - Jean-Claude Blaise, President
© 2008 CLF Ministries All rights reserved