Attachment 1 - Recruitment usm235-20220805.pdf

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Form USM-235 Est. [TBD] Page of Form USM-235 Est. [TBD Page of U.S. Department of Justice United States Marshals Service Protective Services Officers (PSO) Personal Qualifications Statement OMB Number [TBD] (Exp. [TBD])

GENERAL INFORMATION

3. Social Security Number:

9a. Are you a citizen of the United States?

10c. Days of the week that you can work:

10d. Are you available to perform PSO duties in other cities?

EDUCATION AND TRAINING

12. Foreign Language Proficiency Proficiency Proficiency

14. List any special training you have received in law enforcement that would qualify you for a contract guard position:

COURSE OR TYPE

OF TRAINING

SCHOOL/PLACE

OF TRAINING

DATES OF TRAINING

CERTIFICATE/COURSE

CREDIT RECEIVED

PERSONAL BACKGROUND DATA

15. Within the past ten years have you:

YES NO

a. Been fired from any job for any reason or quit after being notified you would be fired?

b. Have you ever been arrested, charged, cited, or held by Local, State, Federal (include military), or Foreign authorities, regardless of whether the citation was dropped or dismissed or you were found not guilty? Note: Exclude minor traffic violations for which a fine or forfeiture of $200 or less was imposed.

c. Have you ever been convicted, fined by or forfeited bond to a local, state, federal (include military), and foreign judicial authority or adjudicated a youthful offender or juvenile delinquent (regardless of whether the record in your case has been "sealed" or expunged?)

d. Have you ever detained, held in, or served time in any jail or prison, or reform or industrial school or any juvenile facility or institution under the jurisdiction of any local, state, federal (include military), or foreign authority?

e. Have you ever been awarded, or are you now under suspended sentence, parole or probation, or awaiting any action on charges against you?

f. Have you filed for bankruptcy?

16. Are you now or have you ever been affiliated with any organization, association, movement, group, gang or combination of persons that advocates violence or the overthrow of our constitutional form of government or that has adopted a policy of advocating or approving the commission of acts or force or violence to deny other persons their rights under the Constitution of the United States or that seeks to alter the form of government of the United States by unconstitutional means?

17. To the best of your knowledge, have you been the subject of a background investigation (by either local, state, federal (include military), or private industry) or been given a security clearance?

Agency Requiring the Clearance Type of Clearance/Investigation Date Clearance Issued/Investigation Completed

EMPLOYMENT HISTORY

If you are currently employed, complete Section A below. Please provide the additional work experience information under 'Space for detailed answers and continuation of information' (#20) below. Also list in any other work experience in the law enforcement area that would qualify you for a contract guard position.

18. Current work status (check one):

18a. EMPLOYMENT HISTORY (Note: Start with most recent and include past 10 years.)

May inquiry be made of your present employer?

18b. PREVIOUS EMPLOYMENT Name and address of employer's organization:

Title of your Position:

Dates Employed (Month/Year - Month/Year):

Name of Immediate Supervisor:

Supervisor Phone:

Business Type (i.e., LE, Government, Private) If Federal service, list series, grade or rank:

Description of Work (Describe your specific duties, responsibilities and accomplishments in this job):

Reason for Leaving:

MILITARY SERVICE

19. List the dates, branch, and date of discharge for all active service (enter 'N/A' if none):

INCLUSIVE DATES

(mm/yyyy)

BRANCH OF SERVICE

DATE OF DISCHARGE (mm/yyyy)

SIGNATURE AND CERTIFICATION STATEMENT

Read the following carefully before signing this certification. A false answer to any question in this statement may be grounds for not contracting with you or invalidating your contract after you begin work and may be punishable by fine or imprisonment (U.S. Code Title 18, Section 1001).

CERTIFICATION: I have completed this statement with the knowledge and understanding that any items contained herein may be subject to investigation and I consent to the release of information concerning my capacity and fitness by employers, educational institutions, law enforcement agencies, and other individuals and agencies, to duly accredited investigators, and other authorized employees of the Federal Government for that purpose.

I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

Applicant: Attach documentation as requested in the instructions.

INSTRUCTIONS FOR COMPLETION OF THIS FORM

1. Complete all fields. Incomplete forms will not be accepted.

2. Type or print legibly in blue or black ink. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."

3. You must use U.S. Postal Service 2-letter state abbreviations when you fill out this form. Do not abbreviate the names of cities or foreign countries.

4. All telephone numbers must include area codes.

5. All dates provided on this form must be in Month/Day/Year (mm/dd/yyyy) or Month/Year (mm/yyyy) format. Use numbers (1-12) to indicate months. For example, August 15, 2017 should be shown as 08/15/2017.

6. If you need additional space to complete this form, please use a separate blank sheet of paper. Include the applicant's name and Social Security number on each sheet. Specify the question number for which you are providing additional details.

7. Documentation: Provide documentation to verify any significant claims or activities, such as:

- naturalization certificate;

- originals or certified copies of college transcripts or degree;

- high school diploma;

- professional license(s) or certificate(s);

- military discharge certificate(s) (DD Form 214);

- marriage certificate(s);

- divorce papers;

- tax returns;

- passport; and/or

- business license(s).

8. NAME CHANGES: If you have had a name change from that indicated on the form, you must provide a copy of the documentation of any legal name change. If the name you are currently using is not a legal name, please use your official name as indicated on your birth certificate or marriage license.

9. EMPLOYMENT: Ensure that you list previous law enforcement related employment, including military (e.g., Military Police).

PURPOSE OF THIS FORM

This form is the basis for an initial background investigation that will be used to determine your qualifications (to include law enforcement qualifications) and suitability to work for the U.S. Government under contract.

AUTHORITY TO REQUEST THIS INFORMATION

The U.S. Government is authorized to ask for this information under 5 U.S.C. 3301 and 28 U.S.C. 561. Your Social Security number is needed to keep records accurate, because other people may have the same name and birth date. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

THE BACKGROUND CHECK PROCESS

The U.S. Marshals Service (USMS) inputs the information from this completed form into the NCIC Database and conducts a pre-employment name check through the National Crime Information Center (NCIC). The system will produce a criminal history report that is reviewed by designated USMS personnel. The designated USMS personnel will determine the eligibility of the temporary contractor based upon the information provided by the check.

FINAL DETERMINATION ON YOUR ELIGIBILITY

Final determination on your eligibility for a position is the responsibility of the USMS. You may be provided the opportunity personally to explain, refute, or clarify any information before a final decision is made.

AUTHORIZATION AND RELEASE

I hereby authorize the USMS and other authorized Federal agencies to obtain any information required from the Federal government and/or state agencies, including but not limited to, the Federal Bureau of Investigation (FBI), the Defense Investigation Service (DIS), the U.S. Office of Personnel Management (OPM), the U.S. Department of Homeland Security (DHS), (if applicable). This authorization is valid for one year from the date this form was signed.

I have been notified of any employer’s right to require a criminal history records check as a condition of employment. I understand that I may request a copy of such records as may be available to me under the law. I understand that I have a right to challenge the accuracy and competencies of any information contained in the report. I also understand that this information will be treated as privileged and confidential information. Case files are handled under the procedures for safeguarding records.

I release any individual, including records custodians, any component of the U.S. Government or the individual State Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION

Providing the information on this form is voluntary, however, failure to furnish the requested information may delay or prevent action on your employment. In addition, incomplete, misleading, or untruthful information provided on the form may result in delays in processing the form for employment, termination of employment, or criminal sanction.

PRIVACY ACT ROUTINE USES

This form or information contained therein may be disclosed in accordance with the routine disclosures set forth in the Office of Personnel Management government-wide system of records, OPM/Govt-1, General Personnel Records, 76 Fed. Reg. 32997 (June 7, 2011), including but not limited to:

1. The disclosure of pertinent information to the appropriate Federal, State, or local agency responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order, when the disclosing agency becomes aware of an indication of a violation or potential violation or potential violation of civil or criminal law or regulation.

2. The disclosure of information to any source from which additional information is requested (to the extent necessary to identify the individual inform the source of the purpose(s) of the request, and to identify the type of information requested), when necessary to obtain information relevant to an agency decision to hire or retain an employee, issue a security clearance, conduct a security or suitability investigation of an individual, classify jobs, let a contract, or issue a license, grant, or other benefits.

3. The disclosure to a Federal agency in the executive, legislative, or judicial branch of Government, in response to its request, or at the initiation of the agency maintaining the records, information in connection with the hiring of an employee, the issuance of a security clearance or determination concerning eligibility to hold a sensitive position, the conducting of an investigation for purposes of a credentialing, national security, fitness, or suitability adjudication concerning an individual, the classifying or designation of jobs, the letting of a contract, the issuance of a license, grant, or other benefit by the requesting agency, or the lawful statutory, administrative, or investigative purpose of the agency to the extent that the information is relevant and necessary to the requesting agency's decision.

PUBLIC REPORTING BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this to Prisoner Operations Division, CG-3, Rm #3008A, U.S. Marshals Service, Washington, DC 20530-0001. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

9.0.0.2.20120627.2.874785