Sf 171 Form - Application For Federal Employment
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4Bureau of Indian Affairs Water Resources Technician Training Program Spring / Summer for American Indians and Alaska Natives
Application for Federal Employment - SF 171
Form Approved
OMB No. 3206-0012
Read the instructions before you complete this application. Type or print clearly in dark ink.
GENERAL INFORMATION
DO NOT WRITE IN THIS AREA
What kind of job are you applying for? Give title and announcement no. (if any)
1
FOR USE OF EXAMINING OFFICE ONLY
Bureau of Indian Affairs Water Resources Technician Training Program
Date entered register
Form reviewed:
Form approved:
2
Social Security Number
3
Sex
Male
Female
Earned
Veteran
Augmented
Option
Grade
Rating
Preference
Rating
Birth date (Month, Day, Year)
Birthplace (City and State or Country)
4
5
No
Preference
Claimed
6
Name (Last, First, Middle)
5 Points
(Tentative)
10 Pts. (30%
Mailing address (include apartment number, if any)
or More
Comp. Dis.)
City
State
ZIP Code
10 Pts. (Less
than 30%
Comp. Dis.)
Other
10 Points
Other names ever used (e.g., maiden name, nickname, etc.)
7
Initials and Date
Being
Investi-
Disallowed
gated
Home Phone
Work Phone
8
9
FOR USE OF APPOINTING OFFICE ONLY
Area Code
Number
Area Code
Number
Extension
Preference has been verified through proof that the separation was
under honorable conditions, and other proof as required.
10-point - 30% or More
10-point - Less Than 30%
10-Point -
Were you ever employed as a civilian by the Federal or Tribal Government? If "NO"
10
5-Point
Compensable Disability
Compensable Disability
Other
go to Item 11. If "YES ", mark each type of job you held with an "X".
Signature and Title
Temporary
Career-Conditional
Career
Excepted
What is your highest grade, classification series and job title?
Agency
Date
Dates at highest grade: FROM
TO
AVAILABILITY
MILITARY SERVICE AND VETERAN PREFERENCE (Cont.)
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1
When can you start work?
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2
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What is the lowest pay you will accept? (You will
YES NO
Were you discharged from the military service under honorable
not be considered for jobs which pay less than you
(Month and Year)
conditions? (If your discharge was changed to "honorable" or "general"
indicate.)
by a Discharge Review Board, answer "YES". If you received a clemency
discharge, answer "NO".)
Pay $
Per
OR Grade
If "NO ", provide below the date and type of discharge you received.
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3
In what geographic area(s) are you willing to work?
Discharge Date
Type of Discharge
(Month, Day, Year)
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4
Are you willing to work:
YES NO
List the dates (Month, Day, Year) , and branch for all active duty military service
2
0
From
To
Branch of Service
A.
40 hours per week (full-time)?
B.
25-32 hours per week (part-time)?
C.
17-24 hours per week (part-time)?
2
1
If all your active duty was after October 14, 1976, list the full names and dates of all
campaign badges or expeditionary medals you received or were entitled to receive.
D.
16 or fewer hours per week (part-time)?
E.
An intermittent job (on call/seasonal)?
F.
Weekends, shifts, or rotating shifts?
Are you willing to take a temporary job lasting:
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5
Read the instructions that came with this form before completing this item.
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2
When you have determined your eligibility for veteran preference from the
A.
5 to 12 months (sometimes longer)?
instructions, place an "X" in the box next to your veteran preference claim.
B.
1 to 4 months?
NO PREFERENCE
C.
Less than 1 month?
5-POINT PREFERENCE - You must show proof when you are hired.
Are you willing to travel away from home for:
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A.
1 to 5 nights each month?
10-POINT PREFERENCE - If you claim 10-point preference, place an "X" in the
box below next to the basis for your claim.
To receive 10-point preference you
B.
6 to 10 nights each month?
must also complete a Standard Form 15, Application for 10-Point Veteran
C. 11 or more nights each month?
Preference, which is available from any Federal Job Information Center. ATTACH
THE COMPLETED SF 15 AND REQUESTED PROOF TO THIS APPLICATION.
MILITARY SERVICE AND VETERAN PREFERENCE
Non-compensably disabled or Purple Heart recipient.
Have you served in the United States Military Service? If your only
YES NO
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active duty was training in the Reserves or National Guard,
Compensably disabled, less than 30 percent.
answer "NO", If "NO", go to item 22.
Spouse, widow(er), or mother of a deceased or disabled veteran.
Did you or will you retire at or above the rank of major or
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lieutenant commander?
Compensably disabled, 30 percent or more.
THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER
NSN 7540-00-935-7150
171-110
Standard Form 171 (Rev. 6-88)
U.S. Office of Personnel Management
PREVIOUS EDITION USABLE UNTIL 12-31-90
FPM Chapter 295
Page 1
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