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SECTION 4: WORK EXPERIENCE (Continued)

Job Title

From (mm-yyyy)

To (mm-yyyy)

Yearly salary (Local

Currency)

Full Time

Part time

Employer Name, Address and Phone Number

Supervisory Responsibilities?

Supervisor Name

Yes

Main Duties and Responsibilities

Reason for leaving

SECTION 5: CITIZENSHIP

Are you a U.S. citizen listed on the travel orders or approved OF-126 (or other agency equivalent) of a direct hire FS, CS or uniformed

service member assigned (not TDY) to this U.S. Mission and under Chief of Mission authority, or to an office of the American

Institute in Taiwan?

If no, proceed to Section 6.

Yes

If yes, select all that apply:

I am a member of the Foreign Service Family Reserve Corps 9FSFRC). (SF-50 required)

I am a preference eligible U.S. Veteran. I have not invoked my preference at this Post. (DD214 required)

I am a preference eligible U.S. Veteran. I have invoked my preference at this Post. I have worked in (enter Agency/job)_________

I am Foreign Service on Leave Without Pay (LWOP).

I am Civil Service on LWOP with Bureau-specific reemployment rights.

SECTION 6: DECLARATION

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 termination/dismissal after I begin work, and may be punishable by fine or imprisonment

according to this country’s law or U.S. law. I understand that any information I voluntarily provide on or attached to this

application may be investigated.

PRIVACY AND PAPERWORK REDUCTION ACT STATEMENTS

(For U.S. Citizens and Legal Permanent Residents on the U.S.)

AUTHORITIES The information is sought pursuant to the Foreign Service Act of 1980, as amended, and 22 U.S.C. 2669 (c). Your social security number (SSN) maybe

used to confirm the identity and employment eligibility of the individual, pursuant to Executive Order 9397, as amended.

PURPOSE The information solicited on this form will be used to establish your eligibility and qualifications for job vacancies at U.S. Missions.

ROUTINE USES the information may be shared with other federal agencies to the extent relevant and necessary for that agency to make employment decisions and

to a Congressional Office in response to your written request. More information on Routine uses can be found in System of records Notices state-31, Human

Resource Records, and OPM/GOVT-5, Recruiting, Examining, and Placement Records.

DISCLOSURE Disclosure of this information, including your social security number, is voluntary. Failure to provide the requested information may result in your

application not receiving full consideration or being delayed for consideration.

BURDEN Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time required for searching existing

data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You dot have to

supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or

recommendations for reducing it, please send them to: HR/OE, SA-22, 1800 G Street, NW, Washington, DC 20006.

EQUAL OPPORTUNITY EMPLOYEER

The U.S. Mission provides equal opportunity and fair and equitable treatment in employment to all people without regard to race, color, religion, sex, national origin,

age, disability, political affiliation, marital status, protected genetic information, or sexual orientation.

The EEO complaint procedure is not available to individuals who believe they have been denied equal opportunity based upon marital status or political affiliation.

Individuals with such complaints should avail themselves of the appropriate grievance procedures, remedies for prohibited personnel practices, and/or courts for

relief.

DS-174

Page 3 of 3

Form Ds-174 - Application For Employment As A Locally Employed Staff Or Family Member Page 3

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