Form Approved:

Declaration for Federal Employment* oval eet

("This form may also be used to assess fitness for federal contract employment)

BENE ALUN CAT) TY

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate “initial only". If you do not have a middie name,
indicate "No Middle Name". If you are a “Jr.," "Sr.,” etc. enter this under Suffix. First, Middle, Last, Suffix)

o
2. SOCIAL SECURITY NUMBER 3a. PLACE OF BIRTH (inciude city and state or country)
¢ +
3b. ARE YOU A U.S. CITIZEN? 4. DATE OF BIRTH (MM/DD/YYYY)
[T YES [7 NO (fNO”, provide country of citizenship) ¢
6. OTHER NAMES EVER USED (For example, maiden name, nickname, etc) 6. PHONE NUMBERS (Include area codes)
o Day +
o Night #

SceciveSeviceRes Stato ——————
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.

7a Are you a male bom after December 31, 19597 [7 Yes [7 NO (if-No", proceed to'8)

7b. Have you registered with the Selective Service System? [7 YES (f°YES", proceed to 8.) [~ NO (If°NO", proceed to 7c.)
7c. If"NO," describe your reason(s) in item 16.

Military Service seems
8. Have you ever served in the United States military? [YES (if"YES", provide information below) [~ NO

if you answered "YES," list the branch, dates, and type of discharge for ail active duty.
if your only active duty was training in the Reserves or National Guard, answer "NO."

Branch From (MMIDDIYYYY) To (MMIDDIYYYY) Type of Discharge

Background Pe Rater 210 ee

For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event
you list will be considered. However, in most cases you can still be considered for Federal jobs.

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 .

9 During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole? i YES a NO
(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) /f "YES," use item 16
to provide the date, explanation of the violation, place of occurrence, and the name and address of the police
department or court involved.

40. Have you been convicted by a military court-martial in the past 7 years? (if no military service, answer "NO.") if 0 YES fi NO
"YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and
address of the military authority or court involved.

41. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of [~ YES [~ NO
the violation, place of occurrence, and the name and address of the police department or court involved.

42. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you [ yes | a NO
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 Personne! Management or any other Federal agency? /f "YES," use item
16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment { YES Ea NO
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.) /f "YES," use item 16 to provide the type, jength, and amount of the

delinquency or default, and steps that you sre taking to correct the error or repay the debt.
U.S. Office of Personne! Management Vier onbinan tad
SUSC 1302, 320%, 3204, e278 4.8716 Provicus ecitions cbsciete and uwsebie



Declaration for Federal Employment* oweis alee

(‘This form may also be used to assess fitness for federal contract employment)

AOR thoreal Qe tS | er

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?
(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, T" Yes [TM No
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.) /f "YES," use item 16 to provide the
relative's name,relationship, and the department, agency, or branch of the Armed Forces for which your relative
works.

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, [ Yes [T No
Federal civilian, or District of Columbia Government service?

Continuation Space / Agency Optional QUS1S

46 Provide detalis requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with
your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please
answer as instructed (these questions are specific to your position and your agency is authorized to ask them),

Certifications / Additional QueStionS esses

APPLICANT: If you are applying for a position and have not yet been selected, carefully review your answers on this form and any
attached sheets. When this form and all attached materials are accurate, read item 17, and complete 17a

APPOINTEE: If you are being appointed, 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 18¢ as appropriate.

47. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Deciaration for Federal Employment,
including any attached application materials, is true, correct, complete, and made in good faith . | understand that a false or fraudulent
answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing
me after | begin work, and may be punishable by fine or imprisonment. | understand that any information | give may be investigated
for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. | 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 specialists, and other authorized employees or representatives of the Federal Government I
understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of
information, a separate specific release may be needed, and | may be contacted for such a release at a later date.

‘Appointing Officer:
17a. Applicant's Signature: Date Entor Date of Appointment or Conversion
(Sign in ink) MM /DD/YYYY
17b, Appointee's Signature: Date
(Sign in ink)

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during
previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help
your personnel office make a correct determination.

MM /00/YYYY
48a. When did you leave your last Federal job? ee ee

418b. When you worked for the Federal Government the last time, did you waive Basic Life [- yes [~ no [~ DONOTKNOW
Insurance or any type of optional life insurance?

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item YES N NOT KI
18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not io Oo 2 D a ini
canceled,

U.S. Office of Personnel Management ‘Opsonsl Form 305
SUSE. 1922. 390%, 3504, S328 88716 Provious exitions cbecele and usable