INSTRUCTIONS
NUMBER OF COPIES TO BE SUBMITTED
Submit this form in duplicate.
OFFICE TO WHICH REQUEST IS SUBMITTED
Submit this request to the office which has recruiting jurisdiction over the position involved, except when instructions applicable to the case (see
Subchapters S4 and S5, Appendix A, FPM Supplement 296-31) require submission to the OPM’s central office (for example, all requests for career
appointment based on service in the legislative or judicial branch under section 2(b) or (c) of the Ramspeck Act are submitted to the Staffing Systems
and Services Group, Office of Personnel Management, Washington, D.C. 20415).
SUPPORTING DOCUMENTS AND STATEMENTS
Attach to all requests a completed copy of Standard Form 171 (or 173), Personal Qualifications Statement: except that Standard Form 172,
Amendment to Personal Qualifications Statement, may be used with requests which involve qualification requirements only. (Standard Form 172
may be omitted when the administration of a written test is the only action involved.) Attach any additional documents and include in Item 11 (or
attach) any statements required by applicable instructions in Subchapter S4 or S5, Appendix A, FPM Supplement 296-31.
REQUEST INVOLVING SEPARATION FOR CAUSE
State whether the nominee’s Official Personnel Folder is in the agency’s possession, or has been requested by it.
OPM ACTION
The action proposed on the reverse side of this form is:
Approved
Disapproved (See note below.)
The requirements which checked below were reviewed in making this decision:
Qualifications requirements only
Suitability
Reinstatement eligibility determination
Other (Specify under “Remarks”)
Note: The agency must determine whether the individual meets all other requirements for the action proposed.
Remarks:
Authorized Signature
Date (Month, Day,
OFFICE OF PERSONNEL MANAGEMENT
Year)
* U.S. Government Printing Office: 1987--201-760/60220
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