Federal Employment Form Packet

First legal name Middle name statusSelect…Full middle nameNo middle nameInitial only Middle name or initial Last legal name Suffix Mailing address Street, city, state, and postal code for the NDA notice section. Social Security number Format: 123-45-6789 Date of birth Place of birth City, state, and country

Are you a U.S. citizen?

Yes No

If no, country of citizenship

Have you ever used other names?

Yes No

Other names ever used Day phone

Is your night phone the same as your day phone?

Yes No

Night phone

Were you born male after December 31, 1959?

Yes No

Are you registered with Selective Service?

Yes No

Selective Service explanation, if applicable

Have you served in the U.S. military?

Yes No

Branch Type of discharge From To Branch Type of discharge From To Branch Type of discharge From To

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole? (Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.)

Yes No

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer “NO.”)

Yes No

11. Are you currently under charges for any violation of law?

Yes No

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency?

Yes No

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

Yes No

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

Yes No

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

Yes No

16. Continuation/details for items 7c, 9–14, and 18c

18. Have you ever been employed by the Federal government?

Yes No

18a. Date left last Federal job 18b. Waived Basic/optional life insurance?Not applicableYESNODO NOT KNOW 18c. If yes to 18b, later cancel waiver?Not applicableYESNODO NOT KNOW

1. Have you ever engaged in sexual abuse in a prison, jail, holding facility, community confinement facility, juvenile facility, or other institution as defined in 42 USC 1997?

Yes No

2. Have you ever been convicted of engaging or attempting to engage in sexual activity facilitated by force, overt or implied threats of force, or coercion?

Yes No

3. Have you ever been convicted of engaging or attempting to engage in sexual activity where the victim did not consent or was unable to consent or refuse?

Yes No

4. Have you ever had a civil or administrative adjudication against you for engaging in activity described in questions 1 through 3 above?

Yes No

Electronic communications consentSelect…AGREEDO NOT AGREE Phone number Primary email Alternate email SSA authorization reasonSelect…MortgageLoanCredit cardJobLicensing requirementBank accountRetirement accountOther If other, explain

Will the person whose Social Security number appears on the SSA-89 sign it?

Yes No

Use the optional 365-day SSA consent period? You must initial that choice by hand after printing.

Yes No

SSA-89 relationship If signer is not the SSN holder.

1. Does the applicant have prior Federal Contract/Employee Service?

Yes No

Last affiliation end date Last government agency

2. Does this position involve the direct handling of Detainees in a capacity that intentionally places them into a one-on-one contact situation with any Detainee?

Yes No

3. IAW the parameters of 6 CFR Part 115, Standards to Prevent, Detect, and Respond to Sexual Abuse and Assault (PREA) in Confinement Facilities, does this position have contact with any detainee?

Yes No

4. Is this a law enforcement position with the applicant working in either an armed position requiring a weapon now, or will a weapon potentially be required in the future?

Yes No

5. Will the applicant require TECS Access?

Yes No

6. Will the applicant require Access to Classified National Security Information?

Yes No

7. Will the applicant support an Unaccompanied Non-citizen Children Location?

Yes No

City/state of assignment