+-----------------------------------------------------------------------+
| **NRC FORM 356** U.S. NUCLEAR REGULATORY COMMISSION                   |
|                                                                       |
| (09-2007)                                                             |
|                                                                       |
| NRCMD 10.135                                                          |
|                                                                       |
| **APPLICATION FOR THE U.S. NUCLEAR REGULATORY COMMISSION**            |
|                                                                       |
| **SENIOR EXECUTIVE SERVICE**                                          |
|                                                                       |
| **CANDIDATE DEVELOPMENT PROGRAM**                                     |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| THIS APPLICATION PACKAGE CONSISTS OF FOUR PARTS:                      |
|                                                                       |
| PART I: PERSONAL DATA AND SUMMARY OF WORK EXPERIENCE                  |
|                                                                       |
| PART II: DESCRIPTION OF EXECUTIVE COMPETENCIES                        |
|                                                                       |
| PART III: SUPERVISORY ENDORSEMENT                                     |
|                                                                       |
| PART IV: MOBILITY STATEMENT AND CERTIFICATION                         |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| Each applicant should complete Parts I, II and IV and forward the     |
| entire package, **along with a copy of your most recent performance   |
| appraisal**, to your immediate supervisor. **Only use the space       |
| provided on the form. Do not attach additional sheets or materials    |
| such as resumes, position descriptions, certificates of training, or  |
| publications.** The supervisor will complete Part III addressing the  |
| applicant's strengths and weaknesses in each of the executive         |
| competency areas, and forward the entire package (the applicant's     |
| materials and the supervisor's own input) to the next level of        |
| management. Each successive management official will provide his/her  |
| endorsement on a separate Part III, up to and including the Office    |
| Director/Regional Administrator level for NRC applicants, and up to   |
| the second level supervisor for non-NRC applicants.                   |
|                                                                       |
| For NRC applicants, the Office Director/Regional Administrator will   |
| forward all application materials, including supervisory              |
| endorsements, to the Office of Human Resources. The mailing address   |
| for external applications is:                                         |
|                                                                       |
| SES CDP Coordinator                                                   |
|                                                                       |
| Office of Human Resources                                             |
|                                                                       |
| Mail Stop O-3 E17A                                                    |
|                                                                       |
| U.S. Nuclear Regulatory Commission                                    |
|                                                                       |
| 11555 Rockville Pike                                                  |
|                                                                       |
| Rockville, MD 20852-2738                                              |
|                                                                       |
| Questions concerning the application package or supervisory           |
| statements should be directed to:                                     |
|                                                                       |
| Human Resources Policy and Programs                                   |
|                                                                       |
| Office of Human Resources                                             |
|                                                                       |
| 301-415-2026                                                          |
+-----------------------------------------------------------------------+

NRC FORM 356 (09-2007) PAGE 1

+-----------------------------------------------------------------------+
| **PART I: PERSONAL DATA AND SUMMARY OF WORK EXPERIENCE**              |
|                                                                       |
| *PLEASE TYPE OR PRINT*                                                |
+-----------------------------------------------------------------------+

  ----------------------------------- -----------------------------------
  NAME                                TITLE

  ----------------------------------- -----------------------------------

  ----------------- ----------------- ----------------- -----------------
  WORK TELEPHONE    HOME TELEPHONE    SERIES/GRADE      ORGANIZATION

  ----------------- ----------------- ----------------- -----------------

  ----------------------------------- -----------------------------------
  WORK ADDRESS (*IF NRC GIVE MAIL     HOME ADDRESS
  STOP ONLY)*                         

  ----------------------------------- -----------------------------------

  -----------------------------------------------------------------------
  **EDUCATION**

  -----------------------------------------------------------------------

  ---- ------------- ------------- ----------------------------- -----------
       DEGREE EARNED MAJOR FIELD   UNIVERSITY/COLLEGE            YEAR
                                                                 RECEIVED

  1                                                              

  2                                                              

  3                                                              

  4                                                              
  ---- ------------- ------------- ----------------------------- -----------

  -----------------------------------------------------------------------------------
  **SIGNIFICANT                                                           
  AWARDS, HONORS,                                                         
  AND COMMUNITY                                                           
  SERVICE**                                                               
  --------------- ------------------------------------------------------- -----------
                  DESCRIPTION                                             DATE
                                                                          RECEIVED

  1                                                                       

  2                                                                       

  3                                                                       

  4                                                                       
  -----------------------------------------------------------------------------------

  ----------------------------------------------------------------------------------
  **RELEVANT                                                             
  TRAINING                                                               
  COURSES                                                                
  COMPLETED**                                                            
  ------------- -------------------------- ----------------------------- -----------
                COURSE TITLE               INSTITUTION                   DATE

  1                                                                      

  2                                                                      

  3                                                                      

  4                                                                      

  5                                                                      

  6                                                                      

  7                                                                      

  8                                                                      

  9                                                                      

  10                                                                     
  ----------------------------------------------------------------------------------

NRC FORM 356 (09-2007) PAGE 2

+-----------------------------------------------------------------------+
| **SUMMARY OF WORK EXPERIENCE, WITH EMPHASIS ON ACCOMPLISHMENTS**      |
|                                                                       |
| *PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT EACH OF YOUR          |
| PROFESSIONAL POSITIONS.*                                              |
|                                                                       |
| *INCLUDE EXPERIENCE THAT DEMONSTRATES YOUR ABILITY TO DIRECT AND      |
| EVALUATE ACTIVITIES IN MORE THAN ONE*                                 |
|                                                                       |
| *FUNCTIONAL AREA OR FIELD OF SPECIALIZATION.*                         |
+-----------------------------------------------------------------------+

+------------------------------------------------------+---------------+
| 1\. JOB TITLE                                        | SERIES/GRADE  |
|                                                      | (IF           |
|                                                      | APPROPRIATE)  |
+------------------------------------------------------+---------------+
| ORGANIZATION                                         | DATES         |
|                                                      |               |
|                                                      | TO PRESSENT   |
|                                                      |               |
|                                                      | FDFDFD        |
+------------------------------------------------------+---------------+

  -----------------------------------------------------------------------
  SUMMARY

  -----------------------------------------------------------------------

+------------------------------------------------------+---------------+
| 2\. JOB TITLE                                        | SERIES/GRADE  |
|                                                      | (IF           |
|                                                      | APPROPRIATE)  |
+------------------------------------------------------+---------------+
| ORGANIZATION                                         | DATES         |
|                                                      |               |
|                                                      | TO            |
+------------------------------------------------------+---------------+

  -----------------------------------------------------------------------
  SUMMARY

  -----------------------------------------------------------------------

NRC FORM 356 (09-2007) PAGE 3

+-----------------------------------------------------------------------+
| **SUMMARY OF WORK EXPERIENCE, WITH EMPHASIS ON ACCOMPLISHMENTS        |
| (Continued)**                                                         |
|                                                                       |
| *PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT EACH OF YOUR          |
| PROFESSIONAL POSITIONS.*                                              |
|                                                                       |
| *INCLUDE EXPERIENCE THAT DEMONSTRATES YOUR ABILITY TO DIRECT AND      |
| EVALUATE ACTIVITIES IN MORE THAN ONE*                                 |
|                                                                       |
| *FUNCTIONAL AREA OR FIELD OF SPECIALIZATION.*                         |
+-----------------------------------------------------------------------+

+------------------------------------------------------+---------------+
| 3\. JOB TITLE                                        | SERIES/GRADE  |
|                                                      | (IF           |
|                                                      | APPROPRIATE)  |
+------------------------------------------------------+---------------+
| ORGANIZATION                                         | DATES         |
|                                                      |               |
|                                                      | TO            |
|                                                      |               |
|                                                      | FDFDFD        |
+------------------------------------------------------+---------------+

  -----------------------------------------------------------------------
  SUMMARY

  -----------------------------------------------------------------------

+------------------------------------------------------+---------------+
| 4\. JOB TITLE                                        | SERIES/GRADE  |
|                                                      | (IF           |
|                                                      | APPROPRIATE)  |
+------------------------------------------------------+---------------+
| ORGANIZATION                                         | DATES         |
|                                                      |               |
|                                                      | TO            |
+------------------------------------------------------+---------------+

  -----------------------------------------------------------------------
  SUMMARY

  -----------------------------------------------------------------------

NRC FORM 356 (09-2007) PAGE 4

+-----------------------------------------------------------------------+
| **SUMMARY OF WORK EXPERIENCE, WITH EMPHASIS ON ACCOMPLISHMENTS**      |
|                                                                       |
| *PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT EACH OF YOUR          |
| PROFESSIONAL POSITIONS.*                                              |
|                                                                       |
| *INCLUDE EXPERIENCE THAT DEMONSTRATES YOUR ABILITY TO DIRECT AND      |
| EVALUATE ACTIVITIES IN MORE THAN ONE*                                 |
|                                                                       |
| *FUNCTIONAL AREA OR FIELD OF SPECIALIZATION.*                         |
+-----------------------------------------------------------------------+

+------------------------------------------------------+---------------+
| 5\. JOB TITLE                                        | SERIES/GRADE  |
|                                                      | (IF           |
|                                                      | APPROPRIATE)  |
+------------------------------------------------------+---------------+
| ORGANIZATION                                         | DATES         |
|                                                      |               |
|                                                      | TO            |
|                                                      |               |
|                                                      | FDFDFD        |
+------------------------------------------------------+---------------+

  -----------------------------------------------------------------------
  SUMMARY

  -----------------------------------------------------------------------

+------------------------------------------------------+---------------+
| 6\. JOB TITLE                                        | SERIES/GRADE  |
|                                                      | (IF           |
|                                                      | APPROPRIATE)  |
+------------------------------------------------------+---------------+
| ORGANIZATION                                         | DATES         |
|                                                      |               |
|                                                      | TO            |
+------------------------------------------------------+---------------+

  -----------------------------------------------------------------------
  SUMMARY

  -----------------------------------------------------------------------

NRC FORM 356 (09-2007) PAGE 5

+-----------------------------------------------------------------------+
| **PART II: DESCRIPTION OF EXECUTIVE COMPETENCIES**                    |
+-----------------------------------------------------------------------+
| "Executive qualifications" is the term used in 5 U.S.C. to describe   |
| the managerial qualifications that are required for initial           |
| appointment to the Senior Executive Service (SES). The Office of      |
| Personnel Management (OPM) has defined these qualifications in terms  |
| of five Executive Core Qualifications (ECQs) that describe the        |
| leadership skills needed to succeed in the SES. In addition, there    |
| are six fundamental competencies that serve as the foundation for     |
| each of the ECQs: Interpersonal skills, Oral Communication,           |
| Integrity/Honesty, Written Communication, Continual Learning, and     |
| Public Service Motivation.                                            |
|                                                                       |
| Selection to the Nuclear Regulatory Commission SES Candidate          |
| Development Program is based to a large extent on the degree to which |
| applicants can demonstrate competence or potential in the Executive   |
| Core Qualifications. Consequently, it is important for applicants to  |
| devote adequate time and attention to this portion of the             |
| application.                                                          |
|                                                                       |
| OPM's Executive Core Qualifications are listed below. The ECQs and    |
| their associated competencies are described on the individual         |
| Description of Executive Competencies pages which follow.             |
|                                                                       |
| EXECUTIVE CORE QUALIFICATION 1: Leading Change                        |
|                                                                       |
| EXECUTIVE CORE QUALIFICATION 2: Leading People                        |
|                                                                       |
| EXECUTIVE CORE QUALIFICATION 3: Results Driven                        |
|                                                                       |
| EXECUTIVE CORE QUALIFICATION 4: Business Acumen                       |
|                                                                       |
| EXECUTIVE CORE QUALIFICATION 5: Building Coalitions                   |
+-----------------------------------------------------------------------+
| **INSTRUCTIONS FOR PREPARING DESCRIPTIONS**                           |
|                                                                       |
| **OF YOUR EXECUTIVE COMPETENCIES**                                    |
+-----------------------------------------------------------------------+
| On the following pages, please describe your executive competencies   |
| and/or potential as they relate to each of the Executive Core         |
| Qualifications. For each ECQ you should prepare a brief summary of    |
| your experience (three-five sentences) as it relates to the ECQ.      |
| Additionally you should provide at least two specific examples        |
| demonstrating your competency and/or potential in each ECQ. Include   |
| any relevant professional and volunteer experience, education,        |
| training, and awards that demonstrate your skills in a particular     |
| ECQ. **Please limit your response to the space provided for each      |
| ECQ.** In describing your accomplishments, use the following          |
| Challenge-Context-Action-Result approach in a narrative format:       |
| **Challenge** - Describe a specific problem or goal. **Context** -    |
| Talk about the individuals and groups you worked with, and/or the     |
| environment in which you worked, to tackle a particular challenge     |
| (e.g., clients, co-workers, members of Congress, shrinking budget,    |
| low morale). **Action** - Discuss the specific actions you took to    |
| address a challenge. **Result** - Give specific examples of the       |
| results of your actions.                                              |
|                                                                       |
| The Office of Personnel Management's (OPM) *Guide to Senior Executive |
| Service Qualifications* provides valuable information to assist       |
| applicants in describing their executive qualifications and examples  |
| that serve to illustrate specific competency examples containing the  |
| above elements. The *Guide to Senior Executive Service                |
| Qualifications* is available on the OPM Web site at                   |
| http://www.OPM.gov/ses/qualify.asp or by contacting the NRC Office of |
| Human Resources at 301-415-2026.                                      |
+-----------------------------------------------------------------------+

NRC FORM 356 (09-2007) PAGE 6

+-----------------------------------------------------------------------+
| NAME (PLEASE TYPE OR PRINT)                                           |
+-----------------------------------------------------------------------+
| **DESCRIPTION OF EXECUTIVE COMPETENCIES**                             |
+-----------------------------------------------------------------------+
| **EXECUTIVE CORE QUALIFICATION 1: [LEADING CHANGE]{.underline}**      |
+-----------------------------------------------------------------------+
| **Description:** The ability to bring about strategic change, both    |
| within and outside the organization, to meet organizational goals.    |
| Inherent to this ECQ is the ability to establish an organizational    |
| vision and to implement it in a continuously changing environment.    |
|                                                                       |
| Competencies: Creativity and Innovation, External Awareness,          |
| Flexibility, Resilience, Strategic Thinking, Vision                   |
+-----------------------------------------------------------------------+
| SPECIFIC EXAMPLES *(USE ONLY THE SPACE PROVIDED - DO NOT ATTACH       |
| ADDITIONAL SHEETS)*                                                   |
+-----------------------------------------------------------------------+

NRC FORM 356 (09-2007) PAGE 7

  -----------------------------------------------------------------------
  NAME (PLEASE TYPE OR PRINT)

  **DESCRIPTION OF EXECUTIVE COMPETENCIES**

  **EXECUTIVE CORE QUALIFICATION 2: [LEADING PEOPLE]{.underline}**

  **Description:** The ability to lead people toward meeting the
  organization's vision, mission, and goals. Inherent to this ECQ is the
  ability to provide an inclusive workplace that fosters the development
  of others, facilitates cooperation and teamwork, and supports
  constructive resolution of conflicts. Competencies: Conflict
  Management, Leveraging Diversity, Developing Others, Team Building

  SPECIFIC EXAMPLES *(USE ONLY THE SPACE PROVIDED - DO NOT ATTACH
  ADDITIONAL SHEETS)*
  -----------------------------------------------------------------------

NRC FORM 356 (09-2007) PAGE 8

  -----------------------------------------------------------------------
  NAME (PLEASE TYPE OR PRINT)

  **DESCRIPTION OF EXECUTIVE COMPETENCIES**

  **EXECUTIVE CORE QUALIFICATION 3: [RESULTS DRIVEN]{.underline}**

  **Description:** The ability to meet organizational goals and customer
  expectations. Inherent to this ECQ is the ability to make decisions
  that produce high-quality results by applying technical knowledge,
  analyzing problems, and calculating risks. Competencies:
  Accountability, Customer Service, Decisiveness, Entrepreneurship,
  Problem Solving, Technical Credibility

  SPECIFIC EXAMPLES *(USE ONLY THE SPACE PROVIDED - DO NOT ATTACH
  ADDITIONAL SHEETS)*
  -----------------------------------------------------------------------

NRC FORM 356 (09-2007) PAGE 9

  -----------------------------------------------------------------------
  NAME (PLEASE TYPE OR PRINT)

  **DESCRIPTION OF EXECUTIVE COMPETENCIES**

  **EXECUTIVE CORE QUALIFICATION 4: [BUSINESS ACUMEN]{.underline}**

  **Description:** The ability to manage human, financial, and
  information resources strategically. Competencies: Financial
  Management, Human Capital Management, Technology Management

  SPECIFIC EXAMPLES *(USE ONLY THE SPACE PROVIDED - DO NOT ATTACH
  ADDITIONAL SHEETS)*
  -----------------------------------------------------------------------

NRC FORM 356 (09-2007) PAGE 10

  -----------------------------------------------------------------------
  NAME (PLEASE TYPE OR PRINT)

  **DESCRIPTION OF EXECUTIVE COMPETENCIES**

  **EXECUTIVE CORE QUALIFICATION 5: [BUILDING COALITIONS]{.underline}**

  **Description:** The ability to build coalitions internally and with
  other Federal agencies, State and local governments, nonprofit and
  private sector organizations, foreign governments, or international
  organizations to achieve common goals. Competencies: Partnering,
  Political Savvy, Influencing/Negotiating

  -----------------------------------------------------------------------

NRC FORM 356 (09-2007) PAGE 11

<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 29%" />
<col style="width: 41%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><p><strong>PART III: SENIOR EXECUTIVE SERVICE CANDIDATE
DEVELOPMENT PROGRAM</strong></p>
<p><strong>SUPERVISORY ENDORSEMENT</strong></p></td>
</tr>
<tr class="even">
<td colspan="11">NAME OF APPLICANT (<em>TO BE COMPLETED BY
APPLICANT)</em></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>INSTRUCTIONS FOR SUPERVISORS:</strong> Please
provide your input on the above-named applicant’s executive competencies
and/or potential as they related to the SES Executive Core
Qualifications and the NRC’s SES Candidate Development Program. The
information you furnish will be an important element in determining the
degree to which the applicant has the executive experience or potential
necessary to be successful in the Program. Attach the completed form to
the application materials and forward to the next level in your office’s
chain of command. Each supervisor in the chain completes a separate
supervisory endorsement form.</td>
</tr>
<tr class="even">
<td colspan="4"><p>BASIS FOR</p>
<p>APPRAISAL</p></td>
<td colspan="2"><strong>SECTION I – SUPERVISORY ASSESSMENT OF
DEMONSTRATED EXPERIENCE AND/OR POTENTIAL</strong></td>
<td colspan="5"><p>LEVEL OF PEFORMANCE</p>
<p>(See Scale Below)</p></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>EXTERNAL ACTIVITIES</p>
</blockquote></td>
<td><blockquote>
<p>ON-THE-JOB</p>
</blockquote></td>
<td><blockquote>
<p>FORMAL TRAINING</p>
</blockquote></td>
<td><blockquote>
<p>POTENTIAL</p>
</blockquote></td>
<td colspan="2"><p>Performance Level Scale:</p>
<p>Assign <u>Level 3</u> to indicate performance would <u>exceed</u>
what is expected of a competent SES manager.</p>
<p>Assign <u>Level 2</u> to indicate performance would be what is
expected of a <u>fully competent</u> SES manager.</p>
<p>Assign <u>Level 1</u> to indicate performance would be <u>below</u>
what is expected of a competent SES manager.</p>
<p>Assign <u>Level 0</u> to indicate you have had no opportunity to
observe your employee’s performance in that area.</p>
<p><strong>EXECUTIVE CORE QUALIFICTIONS</strong></p></td>
<td colspan="2">3</td>
<td>2</td>
<td>1</td>
<td>0</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"><strong>LEADING CHANGE:</strong> The ability to bring
about strategic change, both within and outside the organization, to
meet organizational goals. Inherent to this ECQ is the ability to
establish an organizational vision and to implement it in a continuously
changing environment. Competencies: Creativity and Innovation, External
Awareness, Flexibility, Resilience, Strategic Thinking, Vision</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"><strong>LEADING PEOPLE:</strong> The ability to lead
people toward meeting the organization’s vision, mission, and goals.
Inherent to this ECQ is the ability to provide an inclusive workplace
that fosters the development of others, facilitates cooperation and
teamwork, and supports constructive resolution of conflicts.
Competencies: Conflict Management, Leveraging Diversity, Developing
Others, Team Building</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"><strong>RESULTS DRIVEN:</strong> The ability to meet
organizational goals and customer expectations. Inherent to this ECQ is
the ability to make decisions that produce high-quality results by
applying technical knowledge, analyzing problems, and calculating risks.
Competencies: Accountability, Customer Service, Decisiveness,
Entrepreneurship, Problem Solving, Technical Credibility</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"><strong>BUSINESS ACUMEN:</strong> The ability to manage
human, financial, and information resources strategically. Competencies:
Financial Management, Human Capital Management, Technology
Management</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"><strong>BUILDING COALITIONS:</strong> The ability to
build coalitions internally and with other Federal agencies, State and
local governments, nonprofit and private sector organizations, foreign
governments, or international organizations to achieve common goals.
Competencies: Partnering, Political Savvy, Influencing/Negotiating</td>
<td colspan="2"></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11">BREIFLY DESCRIBE THE APPLICANT’S OVERALL POTENTIAL FOR
SUCCESSFUL PERFORMANCE IN THE SES CANDIDATE DEVELOPMENT PROGRAM AND
FUTURE SES POSITIONS</td>
</tr>
<tr class="even">
<td colspan="11"><strong>SECTION II – SUPERVISORY
ENDORSEMENT</strong></td>
</tr>
<tr class="odd">
<td colspan="11"><p>[ ] I highly recommend this employee for selection
into the SES Candidate Development Program.</p>
<p>[ ] I recommend this employee for selection into the SES Candidate
Development Program.</p>
<p>[ ] I do not recommend this employee for selection into the SES
Candidate Development Program at this time.</p></td>
</tr>
<tr class="even">
<td colspan="11"><p>RELATIONSHIP TO APPLICANT (<em>PLEASE CHECK
ONE)</em></p>
<p>[ ] IMMEDIATE SUPERVISOR [ ] OFFICE DIRECTOR/REGIONAL
ADMINISTRATOR</p>
<p>[ ] 2<sup>ND</sup> LEVEL SUPERVISOR [ ] OTHER (<em>SPECIFY)</em></p>
<p>[ ] 3<sup>RD</sup> LEVEL SUPERVISOR</p></td>
</tr>
<tr class="odd">
<td colspan="5">TYPED OR PRINTED NAME AND TITLE</td>
<td colspan="2">SIGNATURE</td>
<td colspan="4">DATE</td>
</tr>
</tbody>
</table>

NRC FORM 356 (09-2007) PAGE 12

+-------------------------------------------------------+---------------+
| **PART IV: MOBILITY STATEMENT AND CERTIFICATION**     |               |
+-------------------------------------------------------+---------------+
| **APPLICANT'S MOBILITY STATEMENT**                    |               |
|                                                       |               |
| Mobility is an important aspect of the Senior         |               |
| Executive Service and the Candidate Development       |               |
| Program. In the space provided below, please describe |               |
| your flexibility and willingness to participate in a  |               |
| rotational assignment and relocate to a different     |               |
| geographic location in order to meet the needs of the |               |
| agency.                                               |               |
|                                                       |               |
| I am \[ \] I am not \[ \] able to participate in a    |               |
| rotational assignment to a different geographic       |               |
| location as part of the CDP                           |               |
|                                                       |               |
| \[ \] I am mobile and willing to permanently relocate |               |
| to a different geographic location upon completion of |               |
| the CDP as SES                                        |               |
|                                                       |               |
| opportunities occur.                                  |               |
|                                                       |               |
| \[ \] While I am not currently mobile, I will be      |               |
| available to permanently relocate to a different      |               |
| geographic location in:                               |               |
|                                                       |               |
| \[ \] 1-2 years \[ \] 3-5 years \[ \] Other (*Enter   |               |
| Number)* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_         |               |
|                                                       |               |
| ADDITIONAL COMMENTS                                   |               |
+-------------------------------------------------------+---------------+
| **FINAL CHECKLIST FOR APPLICANTS**                    |               |
|                                                       |               |
| \[ \] Part I of the application is complete and       |               |
| current.                                              |               |
|                                                       |               |
| \[ \] Part II of the application is complete and full |               |
| describes your executive qualifications.              |               |
|                                                       |               |
| \[ \] You have completed the above Mobility Statement |               |
|                                                       |               |
| \[ \] You have attached a copy of your most recent    |               |
| performance appraisal                                 |               |
|                                                       |               |
| \[ \] You sent your package, including multiple       |               |
| copies of Part III, Supervisory Endorsement, to your  |               |
| immediate supervisor for his/her endorsement and      |               |
| forwarding through successive managerial levels, up   |               |
| to the Office Director/Regional Administrator.        |               |
|                                                       |               |
| \[ \] Your signature appears on the line below this   |               |
| checklist.                                            |               |
+-------------------------------------------------------+---------------+
| **CERTIFICATION**                                     |               |
|                                                       |               |
| I certify that, to the best of my knowledge and       |               |
| belief, all of the statements contained in this       |               |
| application are true, correct, complete, and made in  |               |
| good faith. I agree to fully participate in and       |               |
| complete all of the requirements of the program, if   |               |
| selected. I understand that his may require           |               |
| rescheduling of activities previously planned during  |               |
| the program. I understand the requirements of the     |               |
| program cannot be waived.                             |               |
+-------------------------------------------------------+---------------+
| SIGNATURE -- APPLICANT                                | DATE          |
+-------------------------------------------------------+---------------+
| **PRIVACY ACT STATEMENT**                             |               |
|                                                       |               |
| Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by  |               |
| Section 3 of the Privacy Act of 1974 (Public Law      |               |
| 93-579), the following statement is furnished to      |               |
| individuals who supply information to the U.S.        |               |
| Nuclear Regulatory Commission (NRC) on NRC Form 356.  |               |
| This information is maintained in a system of records |               |
| designated as NRC-19 and described at 65 *Federal     |               |
| Register* 56428 (September 18, 2000), or the most     |               |
| recent *Federal Register* publication of the NRC's    |               |
| "Republication of Systems of Records Notices" that is |               |
| available at the NRC Public Document Room, 11555      |               |
| Rockville Pike, Rockville, Maryland, or located in    |               |
| the Agencywide Documents Access and Management System |               |
| (ADAMS).                                              |               |
|                                                       |               |
| 1\. **AUTHORITY:** 5 U.S.C. 3396, 4103 (2000);        |               |
| Executive Order 9397, November 22, 1943; Executive    |               |
| Order 11348, April 20, 1967, as amended.              |               |
|                                                       |               |
| 2\. **PRINCIPAL PURPOSE(S):** To apply for the NRC    |               |
| Senior Executive Service (SES) Candidate Development  |               |
| Program.                                              |               |
|                                                       |               |
| 3\. **ROUTINE USE(S):** Information may be extracted  |               |
| from the records and made available to the Office of  |               |
| Personnel Management; other Federal,                  |               |
|                                                       |               |
| State, and local Government agencies; and educational |               |
| institutions for use in training programs related to  |               |
| NRC employees. Information may also                   |               |
|                                                       |               |
| be disclosed to a Congressional office to respond to  |               |
| their inquiry made at your request, or to NRC-paid    |               |
| experts, consultants, and others under                |               |
|                                                       |               |
| contract with the NRC, on a need-to-know basis.       |               |
|                                                       |               |
| 4\. **WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY    |               |
| AND EFFECT ON INDIVIDUAL NOT PROVIDING INFORMATION**: |               |
| Disclosure is                                         |               |
|                                                       |               |
| voluntary; however, failure to provide the requested  |               |
| information may prevent your being considered for the |               |
| Candidate Development Program.                        |               |
|                                                       |               |
| 5\. **SYSTEM MANAGER AND ADDRESS:** Chief,            |               |
| Professional Development and Knowledge Management,    |               |
| Office of Human Resources, U.S. Nuclear               |               |
|                                                       |               |
| Regulatory Commission, Washington, DC 20555-0001      |               |
+-------------------------------------------------------+---------------+

NRC FORM 356 (09-2007) PAGE 13