SF-171 Fillable.pdf

DO NOT WRITE IN THIS AREA

Are you willing to travel away from home for:

What kind of job are you applying for? Give title and announcement no. (if any)1

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

GENERAL INFORMATION

2 Social Security Number 3 Sex

4 5Birth date (Month, Day, Year) Birthplace (City and State or Country)

6 Name (Last, First, Middle)

Mailing address (include apartment number, if any)

State ZIP Code

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

Number

9 Work Phone

Number Extension

10 Were you ever employed as a civilian by the Federal Government? If "NO", go to

Dates at highest grade: FROM

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

Temporary Career-Conditional Career Excepted

TO

AVAILABILITY

1 When can you start work? 1 What is the lowest pay you will accept? (You will

Pay $ Per OR Grade

1 In what geographic area(s) are you willing to work?

1 Are you willing to work:

YES NO

F.

5 Are you willing to take a temporary job lasting:

MILITARY SERVICE AND VETERAN PREFERENCE

YES NO

MILITARY SERVICE AND VETERAN PREFERENCE (Cont.)

1 YES NO

2 List the dates (Month, Day, Year) , and branch for all active duty military service instructions, place an "X" in the box next to your veteran preference claim.

NO PREFERENCE

5-POINT PREFERENCE - You must show proof when you are hired.

Non-compensably disabled or Purple Heart recipient.

Compensably disabled, less than 30 percent.

Spouse, widow(er), or mother of a deceased or disabled veteran.

Compensably disabled, 30 percent or more.

NSN 7540-00-935-7150 171-110

Discharge Date Type of Discharge (Month, Day, Year)

From To Branch of Service

FOR USE OF EXAMINING OFFICE ONLY

FOR USE OF APPOINTING OFFICE ONLY

5-Point Signature and Title

Augmented

Date entered register

Option Grade

Initials and Date

Other

1 2

Form Approved OMB No. 3206-0012

Area Code Area Code

Item 11. If "YES ", mark each type of job you held with an "X".

Male Female

(Month and Year) indicate.)

not be considered for jobs which pay less than you

E.

A.

B.

C.

D.

40 hours per week (full-time)?

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

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

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

An intermittent job (on call/seasonal)?

Weekends, shifts, or rotating shifts?

A.

B.

C.

5 to 12 months (sometimes longer)?

Less than 1 month?

1 to 4 months?

A.

B.

C. 11 or more nights each month?

1 to 5 nights each month?

6 to 10 nights each month?

answer "NO", If "NO", go to item 22.

Have you served in the United States Military Service? If your only active duty was training in the Reserves or National Guard, lieutenant commander?

Did you or will you retire at or above the rank of major or

THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER

PREVIOUS EDITION USABLE UNTIL 12-31-90

Standard Form 171 (Rev. 6-88)

U.S. Office of Personnel Management FPM Chapter 295

THE COMPLETED SF 15 AND REQUESTED PROOF TO THIS APPLICATION.

10-POINT PREFERENCE - If you claim 10-point preference, place an "X" in 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

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

When you have determined your eligibility for veteran preference from the campaign badges or expeditionary medals you received or were entitled to receive.

If all your active duty was after October 14, 1976, list the full names and dates of all

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 received a clemency discharge, answer "NO".)

If "NO ", provide below the date and type of discharge you received.

10-point - 30% or More Compensable Disability

10-point - Less Than 30% Compensable Disability Other

10-Point -under honorable conditions, and other proof as required.

Preference has been verified through proof that the separation was

10 Points

10 Pts. (Less than 30% Comp. Dis.)

10 Pts. (30% or More Comp. Dis.)

5 Points (Tentative)

Preference Claimed

No

Being Investi-gated

Rating Veteran

Preference Earned Rating

Form reviewed:

Form approved:

Agency Date

City

Home Phone

Disallowed

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

READ WORK EXPERIENCE IN THE INSTRUCTIONS BEFORE YOU BEGIN.

Name and address of employer's organization (include ZIP Code, if known)

Exact title of your job

A

YES NO

For Agency Use (skill codes, etc.)

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

Dates employed (give month, day and year) Average number of Number of employees hours per week you supervise

From: To:

Your reason for leaving

Your immediate supervisor Area CodeTelephone No.

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

B

For Agency Use (skill codes, etc.)

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

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.

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

Salary or earnings Starting

Ending per per

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

Name and address of employer's organization (include ZIP Code, if known)

Exact title of your job

Dates employed (give month, day and year) Average number of Number of employees hours per week you supervised

From: To:

Your reason for leaving

Your immediate supervisor Area CodeTelephone No.

Description of work: Describe your specific duties, responsibilities and accomplishments in this job, including the job title(s) of any employees you supervised. If you

Salary or earnings Starting

Ending per per

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

EDUCATION

ATTACH ANY ADDITIONAL FORMS AND SHEETS HERE

Did you graduate from high school? If you have a GED high school 2 Write the name and location (city and state) of the last high school you attended or

2 Have you ever attendedor received GED equivalency:

YES

NO

YES

NO

If "YES ", continue with 28.

Name

1)

2)

3)

Semester QuarterFrom ToCity State ZIP Code

Semester Quarter

1) 2) 3)

1) 2) 3)

Semester Quarter

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.

NAME AND LOCATION (city, state and ZIP Code) OF SCHOOL

School Name From To

SUBJECT(S)

YES NO

1) City State ZIP Code

School Name

2) City State ZIP Code

SPECIAL SKILLS, ACCOMPLISHMENTS AND AWARDS

TYPE? TAKE DICTATION?

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

LICENSE OR CERTIFICATE

1) 2)

3 YES

NO

LANGUAGE(S) CAN SPEAK AND UNDERSTAND CAN TRANSLATE ARTICLES

Fluently FluentlyWith Difficulty With DifficultyEasilyPassably Into English From English

REFERENCES

1) 2)

FULL NAME OF REFERENCE STATE ZIP CODE

1)

2)

3)

5 6

3 4 equivalency or will graduate within the next nine months, answer "YES ".

If "YES", give month and year graduated

If "NO", give the highest grade you completed:

where you obtained your GED high school equivalency.

college or graduate school? If "NO ", go to 31 .

MONTH AND YEAR

ATTENDED

NUMBER OF CREDIT

HOURS COMPLETED

TYPE OF

DEGREE

(e.g. B.A., M.A.)

MONTH

AND

YEAR OF

DEGREE

uate within nine months, give the month and year you expect to receive your degree:

NAME AND LOCATION (city, state and ZIP Code) OF COLLEGE OR UNIVERSITY. If you expect to grad-

CHIEF UNDERGRADUATE SUBJECTS

Show major on the first line

NUMBER OF CREDIT

HOURS COMPLETED

CHIEF GRADUATE SUBJECTS

Show major on the first line

NUMBER OF CREDIT

HOURS COMPLETED

MONTH AND YEAR

ATTENDED ROOM

CLASS-

HOURS

COMPLETED

TRAINING

Give the title and year of any honors, awards or fellowships you have received. List your special qualifications, skills or accomplishments that may help you get a job.

Some examples are: skills with computers or other machines; most important publications (do not submit copies); public speaking and writing experience; membership in professional or scientific societies; patents or inventions; etc.

How many words per minute can you:

Agencies may test your skills before hiring you.

DATE OF LATEST LICENSE

OR CERTIFICATE

STATE OR OTHER

LICENSING AGENCY

Do you speak or read a language other than English (include sign language)? Applicants for jobs that require a language other than English may be given an interview conducted solely in that language.

At least one should know you well on a personal basis.

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.

(Number, street and city)

PRESENT BUSINESS OR HOME ADDRESSTELEPHONE NUMBER(S)

(Include Area Code)

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

If "NO", go to 36.

CAN PREPARE AND

GIVE LECTURES

CAN READ ARTICLES

FOR OWN USE

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

3 YES NO

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

Are you now under charges for any violation of law?

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

YES NO

4 If "YES" in:

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

Explanation Mailing Address

Name of Employer, Police, Court, or Federal Agency

City State ZIP Code

Name of Employer, Police, Court, or Federal Agency

City State ZIP Code

Name Relationship Department, Agency or Branch of Armed Forces

SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION

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

4 SIGNATURE (Sign each application in dark ink) 4 DATE SIGNED (Month, day, year)

*U.S. Government Printing Office: 1992 312-071/50114

YES NO

8 9

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 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 be grounds for not hiring you, for firing you after you begin work or for criminal prosecution (18 USC 1001).

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.)

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

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

Explain for each job the problem(s) and your reason(s) for leaving. Give the employer's name and address.

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

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.

38 -

44 - 39 through 43 -

Item No.

Date (Mo./Yr.)

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 United States 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.

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.