U.S. Department of State
OMB APPROVAL NO. 1405-0189
EXPIRES: 03/31/2016
APPLICATION FOR EMPLOYMENT AS A
ESTIMATED BURDEN: 1 Hour
LOCALLY EMPLOYED STAFF OR FAMILY MEMBER
(This application is for positions recruited by the U.S. Mission under the
Office of Overseas Employment’s Interagency Local Employment Recruitment Policy)
POSITION
1. Position Title
2. Grade
3. Vacancy Announcement Number
4. Date Available for Work (mm-dd-yyyy)
PERSONAL INFORMATION
5. Last Name(s)/Surnames
First Name
Middle Name
6. Other Names Used
7. Current Address
8. Phone Numbers
Day
Evening
Mobile
9. E-mail Address
10. Are you a U.S. Citizen?
Yes
No
11. Do you have permanent U.S. Resident status (green card)?
Yes
No
If yes, provide number.
12a. U.S. Social Security Number (for U.S. Citizens/Permanent U.S. Residents)
and/or
12b. Country Identification Number
13. Are you legally eligible to work in this country?
Yes
No
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).
14. If hired, are there accommodations the Mission needs to provide so that you can perform all the essential functions and duties of the
position?
Yes
No
If yes, please explain.
15. If you are applying for a position that includes driving a U.S. Government vehicle, do you have a current and valid driver’s license?
Yes
No
Not Applicable
If yes, Class/Type of License
If yes, have you operated a vehicle without incident for the past three years?
Yes
No
DS-174
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