Tx Guard Forms (Page 4 of 4) in pdf

PRIVACY ACT AND PUBLIC BURDEN STATEMENTS

The Office of Personnel Management and other Federal agencies rate applicants

and awards; and the Merit Systems Protection Board, the Office of Special Counsel, the

for Federal jobs under the authority of sections 1104, 1302, 3301, 3304, 3320, 3361,

Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the

3393, and 3394 of title 5 of the United States Code. We need the information

National Archives, the Federal Acquisition Institute, and congressional offices in

requested in this form and in the associated vacancy announcements to evaluate

connection with their official functions.

your qualifications. Other laws require us to ask about citizenship, military service,

We may also give information from your records to: prospective nonfederal employers

etc.

concerning tenure of employment, civil service status, length of service, and date and

We request your Social Security Number (SSN) under the authority of Executive

nature of action for separation as shown on personnel action forms of specifically

Order 9397 in order to keep your records straight; other people may have the same

identified individuals; requesting organizations or individuals concerning the home

name.

As allowed by law or Presidential directive, we use your SSN to seek

address and other relevant information on those who might have contracted an illness

information about you from employers, schools, banks, and others who know you.

or been exposed to a health hazard; authorized Federal and nonfederal agencies for

Your SSN may also be used in studies and computer matching with other

use in computer matching; spouses or dependent children asking whether the employee

Government files, for example, files on unpaid student loans.

has changed from self-and-family to self-only health benefits enrollment; individuals

If you do not give us your SSN or any other information requested, we cannot

working on a contract, service, grant, cooperative agreement or job for the Federal

process your application, which is the first step in getting a job. Also, incomplete

Government; non-agency members of an agency’s performance or other panel; and

addresses and ZIP Codes will slow processing.

agency-appointed representatives of employees concerning information issued to the

We may give information from your records to: training facilities, organizations

employee about fitness-for-duty or agency-filed disability retirement procedures.

deciding claims for retirement, insurance, unemployment or health benefits; officials

We estimate the public reporting burden for this collection will vary from 20 to 240

in litigation or administrative proceedings where the Government is a party; law

minutes with an average of 40 minutes per response, including time for reviewing

enforcement agencies concerning violations of law or regulation; Federal agencies

instructions, searching existing data sources, gathering data, and completing and

for statistical reports and studies; officials of labor organizations recognized by law

reviewing the information. You may send comments regarding the burden estimate or

in connection with representing employees; Federal agencies or other sources

any other aspect of the collection of information, including suggestions for reducing this

requesting information for Federal agencies in connection with hiring or retaining,

burden, to U.S. Office of Personnel Management, Reports and Forms Management

security clearances, security or suitability investigations, classifying jobs,

Officer, Washington, DC 20415-0001.

contracting, or issuing licenses, grants, or other benefits; public and private

Send your application to the agency announcing the vacancy.

organizations including news media that grant or publicize employee recognition

May we contact your current supervisor?

[

]

[

]

YES

If we need to contact your current supervisor before making an offer, we will contact you first.

EDUCATION

Mark highest level completed.

Some HS [

] HS/GED [

] Associate [

] Bachelor [

] Master [

] Doctoral [

]

Last high school (HS) or GED school. Give the school’s name, city, State, ZIP Code (if known), and year diploma or GED received.

Colleges and universities attended. Do not attach a copy of your transcript unless requested.

Degree -

Year

Name

Major(s)

Total Credits Earned

(if any)

Received

Semester

Quarter

City

State

ZIP Code

OTHER QUALIFICATIONS

Job-related training courses (give title and year). Job-related skills (other languages, computer software/hardware, tools, machinery, typing speed,

etc. Job-related certificates and licenses (current only). Job-related honors, awards, and special accomplishments (publications, memberships in

professional/honor societies, leadership activities, public speaking, and performance awards.) Give dates, but do not send documents unless requested.

GENERAL

[

]

[

Are you a U.S. citizen?

YES

Give the country of your citizenship.

[

]

[

]

Do you claim veterans’ preference?

YES

Mark your claim of 5 or 10 points below.

[

]

[

]

5 points

Attach your DD 214 or other proof.

10 points

Attach an Application for 10-Point Veterans’ Preference (SF 15) and proof required.

Were you ever a Federal civilian employee?

Series

Grade

From

(MM/YY)

[

]

[

]

YES

For highest civilian grade give:

Are you eligible for reinstatement based on career or career-conditional Federal status?

[

]

[

YES

If requested, attach SF 50 proof.

APPLICANT CERTIFICATION

I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete

and made in good faith. I understand that false or fraudulent information on or attached to this application may be grounds for not hiring

me or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be

investigated.

SIGNATURE

DATE SIGNED

Tx Guard Forms Page 4

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