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SUPPLEMENTAL-A EMPLOYMENT APPLICATION FORM FOR CHILD-YOUTH SERVICES POSITIONS

For use of this form, see AR 215-3; the proponent agency is DCS, G1.

DATA REQUIRED BY THE PRIVACY ACT OF 1974

Public Law 101-64.

AUTHORITY:

PRINCIPAL PURPOSE:

To determine your eligibility for service in a child care services position.

ROUTINE USES:

We must have your social security number (SSN) to keep your records straight because other people may have the

same name and birth date. The SSN has been used to keep records since 1943, when Executive Order 9397 asked

agencies to do so. We may also use your SSN to make requests for information about you from employers,

schools, banks, and other who know you, but only where allowed by law. The information we collect by using your

SSN will be used for employment purposes, and also for studies and statistics that will not identify you. We may

give information from your records to appropriated federal agencies such as the Department of Labor and the Equal

Employment Opportunity Commission, to resolve and/or adjudicate matters falling within their jurisdiction. Records

may also be disclosed to labor organizations in response to requests for names of employees and identifying

information. Information we have about you may also be given to federal, state, and local agencies for checking on

law violations or other lawful purposes.

DISCLOSURE:

Your responses to the collection of this information are voluntary, but we cannot determine your eligibility, which is

the first step toward getting the job, if you do not answer these questions.

1. NAME

2a. SSN

3. JOB ANNOUNCEMENT/TITLE

4. ADDRESS

2b. DOB (YYYYMMDD)

5. WORK PHONE

6. HOME PHONE

7. FAX TELEPHONE NUMBER

8. E-MAIL ADDRESS

9. HAVE YOU EVER BEEN ARRESTED FOR OR CHARGED WITH A SEX CRIME, A CRIME INVOLVING A CHILD, A SUBSTANCE ABUSE

FELONY OR A VIOLENT CRIME? HAVE YOU EVER BEEN ASKED TO RESIGN BECAUSE OF OR BEEN DECERTIFIED FOR A SEXUAL OFFENSE?

If so, provide an description of the case disposition.

YES

Note: A false statement rendered by an employee may result in adverse action up to and including

removal. Under 18 U.S. Code 1001, the federal punishment for perjury is fine or imprisonment for

up to 5 years, or both.

I declare under penalty of perjury that the information contained in this application form and any attachments or

documents submitted in connection with my application for this position are true and correct to the best of my

knowledge, information, and belief.

10. SIGNATURE

11. DATE (YYYYMMDD)

DA FORM 3433-2, JAN 2002, IS OBSOLETE.

DA FORM 3433-2, AUG 2002

USAPA V1.00ES

Da Form 3433-2 - Supplemental-A Employment Application Form For Child-Youth Services Positions

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