Form Ds-174 - Application For Employment As A Locally Employed Staff Or Family Member - U.s. Department Of State Page 4

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20b. WORK EXPERIENCE
20b. Job Title (If U.S. Government, include the series and grade)
From (mm-yyyy)
To (mm-yyyy)
Salary per Year in U.S. Dollars or Local Currency
Hours per Week
Employer's Name and Address
Supervisor's Name and Contact Information
Name
Phone Number
E-mail Address
Were you a supervisor in this position?
May HR contact your supervisor?
Yes
No
Yes
No
If yes, how many people did you supervise?
Describe your major duties/responsibilities and accomplishments.
Reason(s) for Leaving (Do not write "N/A" or "not applicable".)
20c. WORK EXPERIENCE
20c. Job Title (If U.S. Government, include the series and grade)
From (mm-yyyy)
To (mm-yyyy)
Salary per Year in U.S. Dollars or Local Currency
Hours per Week
Employer's Name and Address
Supervisor's Name and Contact Information
Name
Phone Number
E-mail Address
Were you a supervisor in this position?
May HR contact your supervisor?
Yes
No
Yes
No
If yes, how many people did you supervise?
Describe your major duties/responsibilities and accomplishments.
Reason(s) for Leaving (Do not write "N/A" or "not applicable".)
DS-174
Page 4 of 6
05-2016

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