**Instructions**

The information collected on this form is used to determine your
acceptability for Federal and Federal contract employment and your
enrollment status in the Government\'s Life Insurance program. You may
be asked to complete his form at any time during the hiring process.
Follow instructions that the agency provides. If you are selected,
before you are appointed you will be asked to update your responses on
this form and on other materials submitted during the application
process and then to recertify that your answers are true.

All your answers must be truthful and complete. **A false statement on
any part of this declaration or attached forms or sheets may be grounds
for not hiring you, or for firing you after you begin work. Also, you
may be punished by a fine or imprisonment (U.S. Code, title 18, section
1001).**

Either type your responses on this form or print clearly in dark ink. If
you need additional space, attach letter-size sheets ( 8.5\" X

11\"). Include your name, Social Security Number, and item number on
each sheet. We recommend that you keep a photocopy of your completed
form for your records.

**Privacy Act Statement**

The Office of Personnel Management is authorized to request this
information under sections 1302, 3301, 3304, 3328, and 8716 of title 5,
U. S. Code. Section 1104 of title 5 allows the Office of Personnel
Management to delegate personnel management functions to other Federal
agencies. If necessary, and usually in conjunction with another form or
forms, this form may be used in conducting an investigation to determine
your suitability or your ability to hold a security clearance, and it
may be disclosed to authorized officials making similar, subsequent
determinations.

Your Social Security Number (SSN) is needed to keep our records
accurate, because other people may have the same name and birth date.
Public Law 104-134 (April 26, 1996) asks Federal agencies to use this
number to help identify individuals in agency records. Giving us your
SSN or any other information is voluntary. However, if you do not give
us your SSN or any other information requested, we cannot process your
application. Incomplete addresses and ZIP Codes may also slow
processing.

ROUTINE USES: Any disclosure of this record or information in this
record is in accordance with routine uses found in System

Notice OPM/GOVT-1, General Personnel Records. This system allows
disclosure of information to: training facilities; organizations
deciding claims for retirement, insurance, unemployment, or health
benefits; officials in litigation or administrative proceedings where
the Government is a party; law enforcement agencies concerning a
violation of law or regulation; Federal agencies for statistical reports
and studies; officials of labor organizations recognized by law in
connection with representation of employees; Federal agencies or other
sources requesting information for Federal agencies in connection with
hiring or retaining, security clearance, security or suitability
investigations, classifying jobs, contracting, or issuing licenses,
grants, or other benefits; public and private organizations, including
news media, which grant or publicize employee recognitions and awards;
the Merit Systems Protection Board, the Office of Special Counsel, the
Equal Employment Opportunity Commission, the Federal Labor Relations
Authority, the National Archives and Records Administration, and
Congressional offices in connection with their official functions;
prospective non-Federal employers concerning tenure of employment, civil
service status, length of service, and the date and nature of action for
separation as shown on the SF 50 (or authorized exception) of a
specifically identified individual; requesting organizations or
individuals concerning the home address and other relevant information
on those who might have contracted an illness or been exposed to a
health hazard; authorized Federal and non-Federal agencies for use in
computer matching; spouses or dependent children asking whether the
employee has changed from a self-and-family to a self-only health
benefits enrollment; individuals working on a contract, service, grant,
cooperative agreement, or job for the Federal government; non-agency
members of an agency\'s performance or other panel; and agency-appointed
representatives of employees concerning information issued to the
employees about fitness-for-duty or agency-filed disability retirement
procedures.

**Public Burden Statement**

Public burden reporting for this collection of information is estimated
to vary from 5 to 30 minutes with an average of 15 minutes per response,
including time for reviewing instructions, searching existing data
sources, gathering the data needed, and completing and reviewing the
collection of information. Send comments regarding the burden estimate
or any other aspect of the collection of information, including
suggestions for reducing this burden, to the U.S. Office of Personnel
Management, Reports and

Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number,
3206-0182, is valid. OPM may not collect this information, and you are
not required to respond, unless this number is displayed.

<table style="width:100%;">
<colgroup>
<col style="width: 21%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 18%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><strong>GENERAL INFORMATION</strong></td>
<td colspan="10"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="6"><strong>1. FULL NAME</strong> (First, middle,
last)<br />
<br />
     </td>
<td colspan="7"><strong>2. SOCIAL SECURITY NUMBER<br />
<br />
     </strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6"><strong>3. PLACE OF BIRTH</strong> (Include city and
state or country)<br />
<br />
     </td>
<td colspan="7"><strong>4. DATE OF BIRTH</strong> (MM/DD/YYYY)<br />
<br />
     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="6" rowspan="2"><p><strong>5. OTHER NAMES EVER USED</strong>
(For example, maiden name, nickname, etc)<br />
     </p>
<p>     </p></td>
<td colspan="7"><strong>6. PHONE NUMBERS</strong> (Include area
codes)<br />
Day      </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="7">Night      </td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"><p><strong>Selective Service Registration</strong></p>
<p>If you are a male born after December 31, 1959, and are at least 18
years of age, civil service employment law (5 U.S.C. 3328) requires that
you must register with the Selective Service System, unless you meet
certain exemptions.</p>
<p>7a. Are you a male born after December 31, 1959? YES NO <em>If "NO"
skip 7b and 7c. If "YES" go to 7b.</em></p>
<p>7b. Have you registered with the Selective Service System? YES NO
<em>If "NO" go to 7c.</em></p>
<p>7c. If "NO," describe your reason(s) in item #16.</p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="13"><p><strong>Military Service</strong></p>
<p>8. Have you ever served in the United States military? YES Provide
information below NO</p>
<p><em>If you answered "YES," list the branch, dates, and type of
discharge for all active duty.</em></p>
<p><em>If your only active duty was training in the Reserves or National
Guard, answer "NO."</em></p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Branch</td>
<td colspan="2">From<br />
MM/DD/YYYY</td>
<td colspan="4">TO<br />
MM/DD/YYYY</td>
<td colspan="5">Type of Discharge</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
<td colspan="2">     </td>
<td colspan="4">     </td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"><p><strong>Background Information</strong></p>
<p><strong>For all questions, provide all additional requested
information under item 16 or on attached sheets.</strong> The
circumstances of each event. you list will be considered, However, in
most cases you can still be considered for Federal jobs.</p>
<p>For questions 9,10, and 11, your answers should include convictions
resulting from a plea of nolo contendere (no contest), but omit (1)
traffic fines of $300 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, and (5) any conviction for which the record
was expunged under Federal or state law<strong>.</strong></p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><p>9. During the last 10 years, have you been
convicted, been imprisoned, been on probation, or been on parole?</p>
<p>(Includes felonies, firearms or explosives violations, misdemeanors,
and all other offenses.) <em>If "YES," se item 16</em></p>
<p><em>to provide the date, explanation of the violation, place of
occurrence, and the name and address of the police</em></p>
<p><em>department or court involved.</em></p></td>
<td><p><strong>YES NO</strong></p>
<p> </p></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="11">10. Have you been convicted by a military court-martial
in the past 10 years? <em>(If no military service, answer "NO.")</em>
<em>If<br />
"YES," use item 16 to provide the date, explanation of the violation,
place of occurrence, and the name and<br />
address of the military authority or court involved.</em></td>
<td><p><strong>YES NO</strong></p>
<p> </p></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="11"><p>11. Are you now under charges for any violation of
law? <em>If "YES," use item 16 to provide the date, explanation of
the</em></p>
<p><em>violation, place of occurrence, and the name and address of the
police department or court involved.</em></p></td>
<td><p><strong>YES NO</strong></p>
<p> </p></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="11"><p>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</p>
<p>be fired, did you leave any job by mutual agreement because of
specific problems, or were you debarred from<br />
Federal employment by the Office of Personnel Management or any other
Federal agency? <em>If "YES," use item 16 to<br />
provide the date, an explanation of the problem, reason for leaving, and
the employer's name and address.</em></p></td>
<td colspan="2"><p><strong>YES NO</strong></p>
<p> </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"><p>13. Are you delinquent on any Federal debt?
(Includes delinquencies arising from Federal taxes, loans, overpayment
of<br />
benefits, and other debts to the U.S. Government, plus defaults of
Federally guaranteed or insured loans such<br />
as student and home mortgage loans.) <em>If "YES," use item 16 to
provide the type, length, and amount of the</em></p>
<p><em>delinquency or default, and steps that you are taking to correct
the error or repay the debt.</em></p></td>
<td colspan="2"><p><strong>YES NO</strong></p>
<p> </p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"><strong>Additional Questions</strong></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10"><p>14. Do any of your relatives work for the agency or
government organization to which you are submitting this form?</p>
<p>(Include: father, mother, husband, wife, son, daughter, brother,
sister, uncle, aunt, first cousin, nephew, niece,</p>
<p>father-in-law, mother-in-law, son-in-law, daughter-in-law,
brother-in-law, sister-in-law, stepfather, stepmother,</p>
<p>stepson, stepdaughter, stepbrother, stepsister, half brother, and
half sister.) <em>If "YES," use item 16 to provide the</em></p>
<p><em>relative's name, relationship, and the department, agency, or
branch of the Armed Forces for which your relative</em></p>
<p><em>works.</em></p></td>
<td colspan="3"><p><strong>YES NO</strong></p>
<p> </p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="10"><p>15. Do you receive, or have you ever applied for,
retirement pay, pension, or other retired pay based on military,</p>
<p>Federal, civilian, or District of Columbia Government
service?</p></td>
<td colspan="3"><p><strong>YES NO</strong></p>
<p> </p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>Continuation Space / Agency Optional
Questions</strong></td>
<td></td>
</tr>
<tr class="even">
<td colspan="14">16. Provide details requested in items 7 through 15 and
18c in the space below or on attached sheets. Be sure to identify
attached sheets<br />
with your name, Social Security Number, and item number, and to include
ZIP Codes in all addresses. If any questions are printed<br />
below, please answer as instructed <em>(these questions are specific to
your position and your agency is authorized to ask them)</em>.</td>
</tr>
<tr class="odd">
<td colspan="13"><p><strong>Certifications / Additional
Questions</strong></p>
<p><strong>APPLICANT: If you are applying for a position and have not
yet been selected,</strong> carefully review your answers on this form
and<br />
any attached sheets. When this form and all attached materials are
accurate, read item 17, and complete 17a.</p>
<p><strong>APPOINTEE: If you are being appointed</strong>, carefully
review your answers on this form and any attached sheets, including any
other application materials that your agency has attached to this form.
If any information requires correction to be accurate as of the date you
are signing, make changes on this form or the attachments and/or provide
updated information on additional sheets, initialing and dating all
changes and additions. When this form and all attached materials are
accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and
18c as appropriate.</p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"><p>17. <strong>I certify</strong> that, to the best of
my knowledge and belief, all of the information on and attached to this
Declaration for Federal<br />
Employment, including any attached application materials, is true,
correct, complete, and made in good faith<strong>. I understand
that</strong></p>
<p><strong>a false or fraudulent answer to any question or item on any
part of this declaration or its attachments may be grounds</strong></p>
<p><strong>for not hiring me, or for firing me after I begin work, and
may be punishable by fine or imprisonment. I understand</strong>
that</p>
<p>any information I give may be investigated for purposes of
determining eligibility for Federal employment as allowed by law
or<br />
Presidential order. <strong>I consent</strong> to the release of
information about my ability and fitness for Federal employment by
employers,<br />
schools, law enforcement agencies, and other individuals and
organizations to investigators, personnel specialists, and other</p>
<p>authorized employees or representatives of the Federal
Government.</p>
<p><strong>I understand</strong> that for financial or lending
institutions, medical institutions, hospitals, health care
professionals, and some other</p>
<p>sources of information, a separate specific release may be needed,
and I may be contacted for such a release at a later date.</p></td>
<td></td>
</tr>
<tr class="odd">
<td>17a. Applicant's Signature:</td>
<td colspan="4"><p>_________________________________</p>
<p><em>(Sign in ink)</em></p></td>
<td colspan="2">Date _____________</td>
<td colspan="5" rowspan="2"><p><strong>Appointing Officer:</strong></p>
<p>Enter Date of Appointment or Conversion</p>
<p>MM / DD / YYYY</p></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td>17b. Appointee's Signature:</td>
<td colspan="4"><p>_________________________________</p>
<p><em>(Sign in ink)</em></p></td>
<td colspan="2">Date _____________</td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="13">18. <strong>Appointee (Only respond if you have been
employed by the Federal Government before):</strong> Your elections of
life insurance<br />
during previous Federal employment may affect your eligibility for life
insurance during your new appointment. These questions are<br />
asked to help your personnel office make a correct determination.</td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"><p>MM / DD / YYYY</p>
<p>18a. When did you leave your last Federal job? DATE:</p></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="9">18b. When you worked for the Federal Government the last
time, did you waive Basic Life Insurance<br />
or any type of optional life insurance?</td>
<td colspan="4"><p><strong>YES NO Do Not Know</strong></p>
<p> </p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="9">18c. If you answered "YES" to item 18b, did you later
cancel the waiver(s)? If your answer to item 18c<br />
is "NO," use item 16 to identify the type(s) of insurance for which
waivers were not canceled.</td>
<td colspan="4"><p><strong>YES NO Do Not Know</strong></p>
<p> </p></td>
<td></td>
</tr>
</tbody>
</table>