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.
To determine your eligibility for service in a child care services position.
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.
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.
3. JOB ANNOUNCEMENT/TITLE
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.
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.
11. DATE (YYYYMMDD)
DA FORM 3433-2, JAN 2002, IS OBSOLETE.
DA FORM 3433-2, AUG 2002