U.S. Department of State
APPLICATION FOR EMPLOYMENT AS A
OMB APPROVAL NO. 1405-0189
LOCALLY EMPLOYED STAFF OR FAMILY MEMBER
ESTIMATED BURDEN: 1 Hour
(This application is for positions recruited by the U. S. Mission under the
Office of Overseas Employment's Interagency Local Employment Recruitment Policy)
1. Position Title
3. Vacancy Announcement Number
4. Date Available for Work
6. Other Names Used
7. Date of Birth
8. Place of Birth
9. Current Address
10. Phone Numbers
11. E-mail Address
12. Are you a U. S. Citizen?
13. Do you have permanent U.S. Resident status?
No If yes, provide number
14a. U.S. Social Security Number (for U.S. Citizens/Permanent U.S. Residents)
14b. Country Identification Number
15. Are you legally eligible to work in this country?
If yes, Mission HR may require verification of eligibility. Please attach copies of all documentation that confirms your legal
eligibility to work in this country (e.g., work permit, residency permit). If you are not sure if you need to submit proof of
eligibility, contact the Mission's HR office.
16. If hired, are there accommodations the Mission needs to provide so that you can perform all the essential functions
and duties of the position?
If yes, please explain
17. If you are applying for a position that includes driving a U.S. Government vehicle, do you have a valid drivers license?
If yes, Class/Type of License
If yes, have you operated a vehicle without incident for the past three years?
Page 1 of 7