SF-171 - Fillable.pdf

Application for Federal Employment - SF 171 Read the instructions before you complete this application. Type or print clearly in dark ink.

Electronic Approved 08/31/1999 Form Approved:

OMB No. 3206-0012

GENERAL INFORMATION DO NOT WRITE IN THIS AREA

1 What kind of job are you applying for? Give title/announcement no. (If any) FOR USE OF EXAMINING OFFICE ONLY Date entered register Form reviewed:

Form approved:

Social Security Number 3 Sex

Option Grade

Earned Rating

Veteran Preference

Augmented Rating

Male

Female No Preference

4 Birth date (MM,DD,YY) 5 Birthplace (City, State, Country)

Claimed

5 Points (Tentative)

Name (Last, First, Middle) 10 Pt.(30%) Or More

Comp. Dis.)

Mailing address (Include apartment number, if any) 10 Pt. (Less Than

30% Comp. Dis.)

City State ZIP Code Other

10 Pt.

Being

Other names ever used (e.g., maiden name, nickname, etc.)

Initials and Date

Dis-allowed Investigated 7

FOR USE OF APPOINTING OFFICE ONLY

Home Phone 9 Work Phone

Area Code Number Area Code Number Ext.

Preference has been verified through proof that the separation was under honorable conditions, and other proof as required.

5-Point 10-Pt--30% or More Comp. Disability

10-Pt--Less Than 30% Comp. Disability

10-Point-- Other

Were you ever employed as a civilian by the Federal Government? If "NO", go to Item 11. If "YES", mark each type of job you held with an "X".

Temporary

Career-Conditional

Career

Excepted

Signature and Title

What is your highest grade, classification series and job title?

Agency Date

Dates at highest grade: FROM TO

AVAILABILITY MILITARY SERVICE AND VETERAN PREFERENCE (Cont.)

11 When can you start work? (MM,YY) (4-Digits)

12 What is the lowest pay you will accept? (You will not be considered for jobs which pay less than you indicate.)

Were you discharged from the military service under honorable conditions? (If your discharge was changed to "honorable" or "general" by a Discharge Review Board, answer "YES". If you

YES

NO

Pay $ per

OR

Grade received a clemency discharge, answer "NO".) If "NO", provide below the date and type of discharge you received.

13 In what geographic area(s) are you willing to work? Discharge Date (MM/DD/YY) Type of Discharge

Are you willing to work: YES NO List the dates (MM/DD/YY), and branch for all active duty military service.

A. 40 hours per week (full-time)?............................... From To Branch of Service

B. 25-32 hours per week (part-time)?

C. 17-24 hours per week (part-time)?

D. 16 or fewer hours per week (part-time)?

E. An intermittent job (on-call/seasonal)?

If all your active military duty was after 10/14/76, list the full names/dates of all campaign badges/expeditionary medals you received/were entitled to receive.

F. Weekends, shifts, or rotating shifts?

Are you willing to take a temporary job lasting:

A. 5 to 12 months (sometimes longer)?

B. 1 to 4 months?

C. Less than 1 month?

Read the instructions that came with this form before completing this item.

When you have determined your eligibility for veteran preference from the instructions, place an "X" in the box next to your veteran preference claim.

Are you willing to travel away from home for: NO PREFERENCE

A. 1 to 5 nights each month?..................................... 5-POINT PREFERENCE -- You must show proof when you are hired.

B. 6 to 10 nights each month?................................... 10-POINT PREFERENCE -- If you claim 10-point preference, place an "X" in

C. 11 or more nights each month?

MILITARY SERVICE AND VETERAN PREFERENCE

YES NO

the box below next to the basis for your claim. To receive 10-point preference, you must also complete a Standard Form 15, Application for 10-Point Veteran Preference, which is available from any Federal Job Information Center. Attach The Completed SF 15 And Requested Proof To This Application.

Non-compensably disabled or Purple Heart recipient.

17 Have you served in the United States Military Service? If your only active duty was training in the Reserves or National Guard, answer "NO". If "NO" go to item 22.

Compensably disabled, less than 30 percent.

Spouse, widow(er), or mother of a deceased or disabled veteran. 18 Did you or will you retire at or above the rank of major or lieutenant commander?

Compensably disabled, 30 percent or more.

THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER

PREVIOUS EDITION USABLE UNTIL 12-31-90

NSN 7540-00-935-7150 171-110 Standard Form 171 (Rev. 6-88) U.S. Office of Personnel Management, FPM Chapter 295

WORK EXPERIENCE If you have no work experience, write "NONE" in A below and go to 25 on page 3.

YES NO 23 May we ask your present employer about your character, qualifications, and work record? A "NO" will not affect our review of your qualifications.

If you answer "NO" and we need to contact your present employer before we can offer you a job, we will contact you first.

24 READ WORK EXPERIENCE IN THE INSTRUCTIONS BEFORE YOU BEGIN.

? Describe your current or most recent job in Block A and work backwards, describing each job you held during the past 10 years. If you were unemployed for longer than 3 months within the past 10 years, list the dates and your address(es) in an experience block.

? You may sum up in one block work that you did more than 10 years ago. But if that work is related to the type of job you are applying for, describe each related job in a separate block.

? INCLUDE VOLUNTEER WORK (non-paid work)--If the work (or a part of the work) is like the job you are applying for , complete all parts of the experience block, just as you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other organizations.

? INCLUDE MILITARY SERVICE--You should complete all parts of the experience block just as you would for a non-military job, including all supervisory experience.

Describe each major change of duties or responsibilities in a separate experience block.

? IF YOU NEED MORE SPACE TO DESCRIBE A JOB--Use sheets of paper the same size as this page (be sure to include all information we ask for in A and B below). On each sheet show your name, Social Security Number, and the announcement number or job title.

? IF YOU NEED MORE EXPERIENCE BLOCKS, use the SF 171-A or a sheet of paper.

? IF YOU NEED TO UPDATE (ADD MORE RECENT JOBS), use the SF 172 or a sheet of paper as described above.

A Name/address of employer's organization (include ZIP Code, if known) Dates employed (give MM/DD/YY) Average number of

hr. per week

No. of employees you supervise

From: To:

Salary or earnings Your reason for wanting to leave

Starting$ per

Ending $ per

Exact title of your job Your immediate supervisor Name Area Code Telephone No.

If Federal employment (civilian or military) list series, grade or rank, and, if promoted in this job, the date of your last promotion

Description of work: Describe your specific duties, responsibilities and accomplishments in this job, including the job title(s) of any employees you supervise. If you describe more than one type of work (for example, carpentry, painting, or personnel and budget), write the approximate percentage of time you spent doing each.

For Agency Use (skill codes, etc.)

Page

B Name/address of employer's organization (include ZIP Code, if known) Dates employed (give MM/DD/YY) Average number of hours per week

Number of employees you supervise

From: To:

Salary or earnings Your reason for want ing to leave

Starting$ per

Ending $ per

Your immediate supervisor Exact title of your job Name Area Code Telephone No.

If Federal employment (civilian or military) list series, grade or rank, and, if promoted in this job, the date of your last promotion

Description of work: Describe your specific duties, responsibilities and accomplishments in this job, including the job title(s) of any employees you supervise. If you describe more than one type of work (for example, carpentry and painting, or personnel and budget), write the approximate percentage of time you spent doing each.

For Agency Use (skill codes, etc.)

Page IF YOU NEED MORE EXPERIENCE BLOCKS, USE SF 171-A (SEE BACK OF INSTRUCTION PAGE).

ATTACH ANY ADDITIONAL FORMS AND SHEETS HERE

EDUCATION

Did you graduate from high school? If you have a GED high school equivalency or will graduate within the next nine months, answer "YES".

26 Write the name and location (city and state) of the last high school you attended or where you obtained your GED high school equivalency.

If "YES", give month and year graduated YES or received GED equivalency:.................. 27 Have you ever attended YES If "YES", continue with 28.

NO If "NO", give the highest grade you completed:. college or graduate school? NO If "NO", go to 31.

NAME/LOCATION (City, state, ZIP Code) OF COLLEGE OR UNIVERSITY. If you expect to graduate within 9 months, give the month/year you expect to receive your degree:

MONTH AND

YEAR ATTENDED

NO. OF CR. HRS

COMPLETED

TYPE OF

DEGREE

MONTH AND

YEAR OF

Name City ST. ZIP Code From To Sem. Quarter (e.g. BA, MA) DEGREE 1) 2)

3)

CHIEF UNDERGRADUATE SUBJECTS

Show major on the first line

NO. CR. HRS.

COMPLETED

30 CHIEF GRADUATE SUBJECTS

Show major on the first line

NO. CR. HRS.

COMPLETED

Sem. Quarter Sem. Quarter

1) 1)

2) 2)

3) 3) If you have completed any other courses or training related to the kind of jobs you are applying for (trade, vocational, Armed Forces, business) give information below. 31

NAME AND LOCATION (City, State and ZIP Code)

OF SCHOOL

MO./YR.

ATTENDED

CLASS-

ROOM

SUBJECT(S) TRAINING

COMPLETE?

From To HOURS YES NO School Name 1) City State ZIP Code

School Name 2) City State ZIP Code

SPECIAL SKILLS, ACCOMPLISHMENTS AND AWARDS

32 Give the title /year of honors, awards or fellowships you have received. List special qualifications, skills or accomplishments that may help you get a job. Some examples are: skills with computers; most important publications (do not submit copies); public speaking/writing experience; membership in societies; patents or inventions; etc.

33 How many words per minute can you:

34 List job-related licenses or certificates that you have, such as: registered nurse; lawyer; radio operator; driver's; pilot's; etc.

Type? Take Dictation?

LICENSE OR CERTIFICATE DATE OF LATEST LICENSE

OR CERTIFICATE

STATE OR OTHER

LICENSING AGENCY

Agencies may test your 1) skills before hiring you. 2) 35 Do you speak or read a language other than English (include sign language)? Applicants for jobs that require a language other

YES

If "YES", list each language and place an "X" in each column that applies to you.

than English may be given an interview conducted solely in that language.

NO If "NO", go to 36.

LANGUAGE(S)

CAN PREPARE AND

GIVE LECTURES

CAN SPEAK AND

UNDERSTAND

CAN TRANSLATE

ARTICLES

CAN READ ARTICLES

FOR OWN USE

Fluently With Difficulty Fluently Passably Into English From English Easily With Difficulty

1) 2)

REFERENCES

36 List three people who are not related to you and are not supervisors you listed under 24 who know your qualifications and fitness for the kind of job for which you are applying. At least one should know you well on a personal basis.

FULL NAME OF REFERENCE

TELEPHONE

NUMBER(S)

(Include Area Code)

PRESENT BUSINESS OR

HOME ADDRESS

(Number, street and city)

STATE

ZIP

CODE

1)

2)

3)

BACKGROUND INFORMATION-- You must answer each question in this section before we can process your application.

37 Are you a citizen of the United States? (In most cases you must be a U.S. Citizen to be hired. You will be required to submit proof of YES NO identity and citizenship at the time you are hired.) If "NO", give the country or countries you are a citizen of:

NOTE: It is important that you give complete and truthful answers to questions 38 through 44 . If you answer "YES" to any of them, provide your explanation(s) in Item 45. Include convictions resulting from a plea of nolo contendere (no contest). Omit: 1) traffic fines of $100.00 or less; 2) any violation of law committed before your 16th birthday; 3) any violation of law committed before your 18th birthday, if finally decided in juvenile court or under a Youth Offender law; 4) any conviction set aside under the Federal Youth Corrections Act or similar State law; 5) any conviction whose record was expunged under Federal or State law. We will consider the date, facts, and circumstances of each event you list. In most cases you can still be considered for Federal jobs. However, if you fail to tell the truth or fail to list all relevant events or circumstances, this may grounds for not hiring you, for firing you after you begin work, or for criminal prosecution (18 USC 1001).

38 YES NO

During the last 10 years, were you fired from any job for any reason, did you quit after being told that you would be fired, or did you leave by mutual agreement because of specific problems?

Have you ever been convicted of, or forfeited collateral for any felony violation? (Generally, a felony is defined as any violation of law punishable by imprisonment of longer than one year, except for violations called misdemeanors under State law which are punishable by imprisonment of two years or less.)

40 Have you ever been convicted of, or forfeited collateral for any firearms or explosives violation?

41 Are you now under charges for any violation of law?

During the last 10 years have you forfeited collateral, been convicted, been imprisoned, been on probation, or been on parole? Do not include violations reported in 39, 40, or 41, above

43 Have you ever been convicted by a military court-martial? If no military service, answer "NO"

Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the US Government plus defaults on Federally guaranteed or insured loans such as student or home mortgage loans.)

45 If "YES" in: 38 - Explain for each job the problem(s) and your reason(s) for leaving. Give the employer's name and address.

39 through 43 - Explain each violation. Give place of occurrence and name/address of police or court involved.

44 - Explain the type, length and amount of the delinquency or default, and steps you are taking to correct errors or repay the debt.

Give any identification number associated with the debt and the address of the Federal agency involved.

NOTE: If you need more space, use a sheet of paper, and include the item number.

Item No.

Date (Mo./Yr.)

Explanation

Mailing Address

Name of Employer, Police, Court, or Federal Agency

State ZIP Code

City

City State ZIP Code

City State ZIP Code

46 YES NO

Do you receive, or have you ever applied for retirement pay, pension, or other pay based on military, Federal civilian, or District of Columbia Government service?

Do any of your relatives work for the US Government or the United States Armed Forces? Include: father; mother; husband; wife; son;

daughter; brother; sister; uncle; aunt; first cousin; nephew; niece; father-in-law; mother-in-law; son-in-law; daughter-in-law;

brother-in-law; sister-in-law; stepfather; stepmother; stepson; stepdaughter; stepbrother; stepsister; half brother; and half sister If "YES", provide details below. If you need more space, use a sheet of paper.

Name Relationship Dept., Agency or Branch of Armed Forces

SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION

YOU MUST SIGN THIS APPLICATION. Read the following carefully before you sign.

? A false statement on any part of your application may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by fine or imprisonment (U.S. Code, title 18, section 1001).

? If you are a male born after December 31, 1959, you must be registered with the Selective Service System or have a valid exemption in order to be eligible for Federal employment. You will be required to certify as to your status at the time of appointment.

? I understand that any information I give may be investigated as allowed by law or Presidential order.

? I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies and other individuals and organizations, to investigators, personnel staffing specialists, and other authorized employees of the Federal Government.

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

48 SIGNATURE (Sign each application in dark ink) 49 DATE SIGNED (Month, day, year)