Attachment 18 - Bio Submission Form.pdf

Version 1.0 S-AQMMA-17-R-0163 Department of State Global Anti-Terrorism Assistance (GATA II)

Attachment 18 – Bio Submission Form

Instructor/Mentor/Advisor Biographic Application

Instructions:

Submittal of this BIO by the contractor indicates the contractor has reviewed and verified the below information for accuracy and relevance, and that the candidate meets the minimum qualifications for the position description (PD). An applicant can be submitted for multiple PDs.

All claims of Education/Training/Instruction on the BIO application must be accompanied with verifiable/substantiated proof of completion by the candidate. Examples of verifiable/substantiated proof include, but are not limited to, the following: certification cards, graduation/completion certificates, college transcripts, military DD-214, and/or Police SRB's. All attachments must be legible.

List only supporting information for the labor category - do not list experience not applicable to position applying for. If duration of employment for one organization includes multiple positions, roles or responsibilities separate them out by the duration of time within that role. If military service is listed as relevant experience, applicant must submit applicable DD-214s. The DD-214 must show character and type of discharge.

INSTRUCTOR/MENTOR BIO APPLICATION

Application Date: (mm/dd/yyyy)

Last Name: First Name: Middle Name:

NOTICE: Indicate submittal type: Initial 1st Rebuttal 2nd Rebuttal

Company:

Position:

Candidate Personal Information

Social Security Number/TCN-LN Number: (Full Social. Ex: xxxxxxxxx)

Citizenship:

Date of Birth: (mm/dd/yyyy)

Country of Birth:

Current Home Address:

Street Address:

City: US State: ZIP:

NON-US State/Province:

Country of Residence:

Contact Phone: E-mail:

Passport Number: Type: Issuing Office:

For ATA/TED Use only

Reviewer #1:

Name: Date of Review: (mm/dd/yyyy)

Approved: Disapproved:

Comments:

Reviewer #2:

Name: Date of Review: (mm/dd/yyyy)

Approved: Disapproved:

Comments:

Issuing Country:

Expiration Date: (mm/dd/yyyy)

Drivers License Number: State:

Expiration Date: (mm/dd/yyyy)

Have you ever worked on an ATA contract before? If yes, list employing company, dates and labor categories:

No Yes (mm/dd/yyyy) (mm/dd/yyyy)

Company: Labor Category: From: To:

Have you ever worked for the State Department before? If yes, list employing company, dates and position held:

No Yes

Company:

Labor Category:

From:

(mm/dd/yyyy) (mm/dd/yyyy)

To:

Have you worked on a contract with INL, USAID or similar agency in support of the State Department? If yes, list employing company, dates and position held:

Have you worked on a Department of Defense Iraq or Afghanistan security support or similar contract? If yes, list employing company, dates and position held.

No Yes

Are there any current criminal charges, current or past felony charges, such as DUI, or anything that may keep you from obtaining a security clearance? If yes, please explain:

Explanation:

Have you ever been removed from an ATA course training delivery or mentorship (domestic or overseas) in the past for performance or conduct? If yes, please explain:

Explanation:

Education/Training/Instruction Certifications:

(Name of School/Type of Training/Agency Name/Location/MMDDYY (From-To)/Duration of Training)

Course Name/Certification/Training: Date Graduated/Awarded: ATA/TED

(mm/dd/yyyy) Use Only

Course Name/Certification/Training: Date Graduated/Awarded: ATA/TED

(mm/dd/yyyy) Use Only

Course Name/Certification/Training: Date Graduated/Awarded: ATA/TED

(mm/dd/yyyy) Use Only

Course Name/Certification/Training: Date Graduated/Awarded: ATA/TED

(mm/dd/yyyy) Use Only

Course Name/Certification/Training: Date Graduated/Awarded: ATA/TED

(mm/dd/yyyy) Use Only

Supplementary Information/Certificate Number (Max. 250 chars)

Supplementary Information/Certificate Number (Max. 250 chars)

Supplementary Information/Certificate Number (Max. 250 chars)

Supplementary Information/Certificate Number (Max. 250 chars)

Course Name/Certification/Training: Date Graduated/Awarded: ATA/TED

(mm/dd/yyyy) Use Only

Course Name/Certification/Training: Date Graduated/Awarded: ATA/TED

(mm/dd/yyyy) Use Only

Relevant Experience:

Company Name: Dates of Employment:

(mm/dd/yy)

Duration of Employment:

Years/Months

From: To:

Position Held: Rank (Where applicable) Location/Duty Station:

Brief description supporting labor category applying for.

Duration of Employment:

Years/Months

From: To:

Duration of Employment:

Years/Months

From: To:

Duration of Employment:

Years/Months

From: To:

Duration of Employment:

Years/Months

From: To:

Position Held: Rank (Where applicable) Location/Duty Station:

Brief description supporting labor category applying for.

Company Name: Dates of Employment:

(mm/dd/yy)

Duration of Employment:

Years/Months

From: To:

Position Held: Rank (Where applicable) Location/Duty Station:

Brief description supporting labor category applying for.

Company Name: Dates of Employment:

(mm/dd/yy)

Duration of Employment:

Years/Months

From: To:

Position Held: Rank (Where applicable) Location/Duty Station:

Brief description supporting labor category applying for.

Company Name: Dates of Employment:

(mm/dd/yy)

Duration of Employment:

Years/Months

From: To:

Duration of Employment:

Years/Months

From: To: