Use this form to submit your appeal
EDUCATION AND EXPERIENCE APPEAL FORM
Do Not Write Your Name Anywhere On This Form.
Print All Required Information In Black Or Blue Ink.
_ _ _- _ _ -_ _ _ _
Social Security Number
_________________________
_ _ _ _
Exam Title
Exam Number
SECTION 1 – EMPLOYMENT
I am appealing my disqualification for not indicating that I possess the minimum employment
qualification requirements.
Qualifying Employment: Job Title: ___________________Name of Employer: _________________
Address of Employer:_________________________________________________________________
Nature of Employer's Business: ____________________ Number of Hours Worked per Week: ______
Presently Employed
Dates of Employment - From:
To:
Total Time:
____/____
____/____
____/____
Month
Year
Month
Year
Month(s) Year(s)
Qualifying Experience
Describe each of your duties separately with percentages (Required for Rating).
% Time
Total Time Spent Performing These Duties =
100%
If you need more space, attach additional Education and Experience Appeal Forms. Be sure to
include your social security number, the exam title and number on each attached sheet.