+----------------------------------------------------------+-----------+
| # U.S. DEPARTMENT OF LABOR                               | FORM      |
|                                                          | APPROVED  |
|                                                          |           |
|                                                          | OMB No.   |
|                                                          | 1225-0072 |
|                                                          |           |
|                                                          | (Exp.     |
|                                                          | 4         |
|                                                          | -30-2002) |
+----------------------------------------------------------+-----------+
| **APPLICANT BACKGROUND QUESTIONNAIRE**                   |           |
+----------------------------------------------------------+-----------+

+-----------------------------------+----------------------------------+
| The U.S. Department of Labor is   | Information provided on this     |
| requesting your completion of     | form will be used for program    |
| this form to assist the agency in | evaluation. Personal identifying |
| evaluating and improving its      | information will not be included |
| efforts to publicize job openings | in the tabulation of data in the |
| and to encourage applications for | DOL database.                    |
| employment from a diverse group   |                                  |
| of qualified candidates,          | The public reporting burden for  |
| including minorities and persons  | this collection of information   |
| with disabilities. The Department | is estimated to average 5        |
| will use the data you supply to   | minutes per response, including  |
| determine how many applicants are | the time for reviewing           |
| from different groups and how     | instructions, searching existing |
| many of these applicants are      | data sources, gathering and      |
| qualified for the job.            | maintaining the data needed, and |
|                                   | completing and reviewing the     |
| EFFECTS OF NONDISCLOSURE:         | collection of information. Send  |
| Providing the information         | comments regarding this burden   |
| requested on this form is         | estimate or any other aspect of  |
| voluntary. This information will  | this collection of information,  |
| have no effect on hiring          | including suggestions for        |
| decisions.                        | reducing this burden to the U.S. |
|                                   | Department of Labor, Human       |
| Persons are not required to       | Resource Services Center, FPB,   |
| respond to this collection of     | Washington, D.C. 20210; and the  |
| information unless it displays a  | Office of Management and Budget, |
| currently valid OMB control       | Paperwork Reduction Project,     |
| number.                           | Washington, D.C. 20503.          |
|                                   |                                  |
|                                   | Solicitation of this information |
|                                   | is in accordance with 5 CFR      |
|                                   | Section 720, "Federal Equal      |
|                                   | Opportunity Recruitment Program" |
|                                   | (FEORP).                         |
+-----------------------------------+----------------------------------+
| PLEASE COMPLETE THE FOLLOWING:    |                                  |
+-----------------------------------+----------------------------------+
| Name:                             | Do you have a Disability? Yes No |
|                                   |                                  |
|                                   | If You checked "Yes" above, is   |
|                                   | your disability one of the       |
|                                   | targeted disabilities listed     |
|                                   | below? Yes No                    |
|                                   |                                  |
|                                   | Blind                            |
|                                   |                                  |
|                                   | Deaf                             |
|                                   |                                  |
|                                   | Missing Extremity(s)             |
|                                   |                                  |
|                                   | Partial Paralysis                |
|                                   |                                  |
|                                   | Complete Paralysis               |
|                                   |                                  |
|                                   | Convulsive Disorder              |
|                                   |                                  |
|                                   | Mental Retardation               |
|                                   |                                  |
|                                   | Mental Illness                   |
|                                   |                                  |
|                                   | Genetic or physical condition    |
|                                   | affecting limbs or spine         |
+-----------------------------------+----------------------------------+
| Sex:                              |                                  |
|                                   |                                  |
| Male Female                       |                                  |
+-----------------------------------+----------------------------------+
| Title, Grade, and Announcement    |                                  |
| Number of Position for with       |                                  |
| applying:                         |                                  |
+-----------------------------------+----------------------------------+

+---+---+----------------+---+----------+-----------------+-----------------+
| # |   |                |   |          |                 |                 |
| # |   |                |   |          |                 |                 |
|   |   |                |   |          |                 |                 |
| * |   |                |   |          |                 |                 |
| * |   |                |   |          |                 |                 |
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|   |   |                |   |          |                 |                 |
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| * |   |                |   |          |                 |                 |
| * |   |                |   |          |                 |                 |
+---+---+----------------+---+----------+-----------------+-----------------+
|   |   | ### Are y      |   |          | (Definition: A  |                 |
|   |   | ou Hispanic, L |   |          | person of       |                 |
|   |   | atino, or of S |   |          | Cuban, Mexican, |                 |
|   |   | panish Origin? |   |          | Puerto Rican,   |                 |
|   |   |                |   |          | South or        |                 |
|   |   |                |   |          | Central         |                 |
|   |   |                |   |          | American, or    |                 |
|   |   |                |   |          | other Spanish   |                 |
|   |   |                |   |          | culture or      |                 |
|   |   |                |   |          | origin,         |                 |
|   |   |                |   |          | regardless of   |                 |
|   |   |                |   |          | race.)          |                 |
+---+---+----------------+---+----------+-----------------+-----------------+
|   |   | **Yes** **No** |   |          |                 |                 |
+---+---+----------------+---+----------+-----------------+-----------------+
| # |   |                |   |          |                 |                 |
| # |   |                |   |          |                 |                 |
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+---+---+----------------+---+----------+-----------------+-----------------+
|   | P |                |   |          |                 |                 |
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|   | t |                |   |          |                 |                 |
|   | e |                |   |          |                 |                 |
|   | w |                |   |          |                 |                 |
|   | h |                |   |          |                 |                 |
|   | a |                |   |          |                 |                 |
|   | t |                |   |          |                 |                 |
|   | y |                |   |          |                 |                 |
|   | o |                |   |          |                 |                 |
|   | u |                |   |          |                 |                 |
|   | c |                |   |          |                 |                 |
|   | o |                |   |          |                 |                 |
|   | n |                |   |          |                 |                 |
|   | s |                |   |          |                 |                 |
|   | i |                |   |          |                 |                 |
|   | d |                |   |          |                 |                 |
|   | e |                |   |          |                 |                 |
|   | r |                |   |          |                 |                 |
|   | y |                |   |          |                 |                 |
|   | o |                |   |          |                 |                 |
|   | u |                |   |          |                 |                 |
|   | r |                |   |          |                 |                 |
|   | s |                |   |          |                 |                 |
|   | e |                |   |          |                 |                 |
|   | l |                |   |          |                 |                 |
|   | f |                |   |          |                 |                 |
|   | t |                |   |          |                 |                 |
|   | o |                |   |          |                 |                 |
|   | b |                |   |          |                 |                 |
|   | e |                |   |          |                 |                 |
|   | : |                |   |          |                 |                 |
+---+---+----------------+---+----------+-----------------+-----------------+
|   | A |                |   | A person |                 |                 |
|   | m |                |   | having   |                 |                 |
|   | e |                |   | origins  |                 |                 |
|   | r |                |   | in any   |                 |                 |
|   | i |                |   | of the   |                 |                 |
|   | c |                |   | original |                 |                 |
|   | a |                |   | peoples  |                 |                 |
|   | n |                |   | of North |                 |                 |
|   | I |                |   | and      |                 |                 |
|   | n |                |   | South    |                 |                 |
|   | d |                |   | America  |                 |                 |
|   | i |                |   | (i       |                 |                 |
|   | a |                |   | ncluding |                 |                 |
|   | n |                |   | Central  |                 |                 |
|   | o |                |   | A        |                 |                 |
|   | r |                |   | merica), |                 |                 |
|   | A |                |   | and who  |                 |                 |
|   | l |                |   | m        |                 |                 |
|   | a |                |   | aintains |                 |                 |
|   | s |                |   | tribal   |                 |                 |
|   | k |                |   | aff      |                 |                 |
|   | a |                |   | iliation |                 |                 |
|   | N |                |   | or       |                 |                 |
|   | a |                |   | c        |                 |                 |
|   | t |                |   | ommunity |                 |                 |
|   | i |                |   | att      |                 |                 |
|   | v |                |   | achment. |                 |                 |
|   | e |                |   |          |                 |                 |
+---+---+----------------+---+----------+-----------------+-----------------+
|   | A |                |   | A person |                 |                 |
|   | s |                |   | having   |                 |                 |
|   | i |                |   | origins  |                 |                 |
|   | a |                |   | in any   |                 |                 |
|   | n |                |   | of the   |                 |                 |
|   |   |                |   | original |                 |                 |
|   |   |                |   | peoples  |                 |                 |
|   |   |                |   | of the   |                 |                 |
|   |   |                |   | Far      |                 |                 |
|   |   |                |   | East,    |                 |                 |
|   |   |                |   | S        |                 |                 |
|   |   |                |   | outheast |                 |                 |
|   |   |                |   | Asia, or |                 |                 |
|   |   |                |   | the      |                 |                 |
|   |   |                |   | Indian   |                 |                 |
|   |   |                |   | subc     |                 |                 |
|   |   |                |   | ontinent |                 |                 |
|   |   |                |   | in       |                 |                 |
|   |   |                |   | cluding, |                 |                 |
|   |   |                |   | for      |                 |                 |
|   |   |                |   | example, |                 |                 |
|   |   |                |   | C        |                 |                 |
|   |   |                |   | ambodia, |                 |                 |
|   |   |                |   | China,   |                 |                 |
|   |   |                |   | India,   |                 |                 |
|   |   |                |   | Japan,   |                 |                 |
|   |   |                |   | Korea,   |                 |                 |
|   |   |                |   | M        |                 |                 |
|   |   |                |   | alaysia, |                 |                 |
|   |   |                |   | P        |                 |                 |
|   |   |                |   | akistan, |                 |                 |
|   |   |                |   | the      |                 |                 |
|   |   |                |   | Ph       |                 |                 |
|   |   |                |   | ilippine |                 |                 |
|   |   |                |   | Islands, |                 |                 |
|   |   |                |   | T        |                 |                 |
|   |   |                |   | hailand, |                 |                 |
|   |   |                |   | and      |                 |                 |
|   |   |                |   | Vietnam. |                 |                 |
+---+---+----------------+---+----------+-----------------+-----------------+
|   | B |                |   | A person |                 |                 |
|   | l |                |   | having   |                 |                 |
|   | a |                |   | origins  |                 |                 |
|   | c |                |   | in any   |                 |                 |
|   | k |                |   | of the   |                 |                 |
|   | o |                |   | black    |                 |                 |
|   | r |                |   | racial   |                 |                 |
|   | A |                |   | groups   |                 |                 |
|   | f |                |   | of       |                 |                 |
|   | r |                |   | Africa.  |                 |                 |
|   | i |                |   |          |                 |                 |
|   | c |                |   |          |                 |                 |
|   | a |                |   |          |                 |                 |
|   | n |                |   |          |                 |                 |
|   | A |                |   |          |                 |                 |
|   | m |                |   |          |                 |                 |
|   | e |                |   |          |                 |                 |
|   | r |                |   |          |                 |                 |
|   | i |                |   |          |                 |                 |
|   | c |                |   |          |                 |                 |
|   | a |                |   |          |                 |                 |
|   | n |                |   |          |                 |                 |
+---+---+----------------+---+----------+-----------------+-----------------+
|   | N |                |   | A person |                 |                 |
|   | a |                |   | having   |                 |                 |
|   | t |                |   | origins  |                 |                 |
|   | i |                |   | in any   |                 |                 |
|   | v |                |   | of the   |                 |                 |
|   | e |                |   | original |                 |                 |
|   | H |                |   | peoples  |                 |                 |
|   | a |                |   | of       |                 |                 |
|   | w |                |   | Hawaii,  |                 |                 |
|   | a |                |   | Guam,    |                 |                 |
|   | i |                |   | Samoa,   |                 |                 |
|   | i |                |   | or other |                 |                 |
|   | a |                |   | Pacific  |                 |                 |
|   | n |                |   | Islands. |                 |                 |
|   | o |                |   |          |                 |                 |
|   | r |                |   |          |                 |                 |
|   |   |                |   |          |                 |                 |
|   | O |                |   |          |                 |                 |
|   | t |                |   |          |                 |                 |
|   | h |                |   |          |                 |                 |
|   | e |                |   |          |                 |                 |
|   | r |                |   |          |                 |                 |
|   | P |                |   |          |                 |                 |
|   | a |                |   |          |                 |                 |
|   | c |                |   |          |                 |                 |
|   | i |                |   |          |                 |                 |
|   | f |                |   |          |                 |                 |
|   | i |                |   |          |                 |                 |
|   | c |                |   |          |                 |                 |
|   | I |                |   |          |                 |                 |
|   | s |                |   |          |                 |                 |
|   | l |                |   |          |                 |                 |
|   | a |                |   |          |                 |                 |
|   | n |                |   |          |                 |                 |
|   | d |                |   |          |                 |                 |
|   | e |                |   |          |                 |                 |
|   | r |                |   |          |                 |                 |
+---+---+----------------+---+----------+-----------------+-----------------+
|   | W |                |   | A person |                 |                 |
|   | h |                |   | having   |                 |                 |
|   | i |                |   | origins  |                 |                 |
|   | t |                |   | in any   |                 |                 |
|   | e |                |   | of the   |                 |                 |
|   |   |                |   | original |                 |                 |
|   |   |                |   | peoples  |                 |                 |
|   |   |                |   | of       |                 |                 |
|   |   |                |   | Europe,  |                 |                 |
|   |   |                |   | the      |                 |                 |
|   |   |                |   | Middles  |                 |                 |
|   |   |                |   | East, or |                 |                 |
|   |   |                |   | North    |                 |                 |
|   |   |                |   | Africa.  |                 |                 |
+---+---+----------------+---+----------+-----------------+-----------------+

  ------------------------- ------------------------- ------------ -------------------------------
  **[SOURCE OF INFORMATION                                         
  ABOUT THIS                                                       
  VACANCY:]{.underline}**                                          
  (Check all that apply)                                           

  \_\_\_\_\_                1\. Magazine              \_\_\_\_\_   7\. Federal, State, or Local
                                                                   Job Info. Center

  \_\_\_\_\_                2\. Newspaper             \_\_\_\_\_   8\. Friend or Relative Working
                                                                   for the Agency

  \_\_\_\_\_                3\. Radio/Television      \_\_\_\_\_   9\. Internet
                            Broadcast                              

  \_\_\_\_\_                4\. Agency Personnel      \_\_\_\_\_   10\. Federal/DOL Jobsline
                            Office                                 

  \_\_\_\_\_                5\. State Employment      \_\_\_\_\_   11\. Other
                            Office                                 

  \_\_\_\_\_                6\. Government                         
                            Recruitment at School                  
  ------------------------- ------------------------- ------------ -------------------------------