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Form Ds-174 - Application For Employment As A Locally Employed Staff Or Family Member - U.s. Mission Page 10

PRIVACY ACT STATEMENT

(for U.S. Citizens and Legal Permanent Residents of the U.S.)

AUTHORITIES: The information is sought pursuant to, e.g., the Foreign Service Act of 1980, as amended, and 22 U.S.C.

2669(c).

PURPOSE: The information solicited on this form is necessary to establish your eligibility and qualifications for advertised

positions. The information furnished may also be used in the pre-employment fitness-for-duty process, if you are selected

for a Mission position. We are authorized to solicit your social security number (SSN) by Executive Order 9397 to confirm

the identity and employment eligibility of the individual. The SSN may also be used to seek information about you from

employers, schools, banks, and others who know you. Disclosure of this information, including your social security number,

is voluntary. Failure to provide the information requested on this application may result in delays in considering your

application. It could result in you not receiving full consideration for the position. Incomplete addresses slow processing of

your application.

ROUTINE USES: The information you provide in this form may be shared with Federal, State, local, and foreign agencies

to the extent relevant and necessary for that agency’s decision about you or to the extent relevant and necessary for that

agency’s decision about you. This information may be disclosed to a member of Congress or to a congressional staff

member in response to an inquiry of the Congressional office made at the written request of the constituent about whom

the record is maintained. This information may also be disclosed in the course of presenting evidence to a court,

magistrate, or administrative tribunal, including disclosures to opposing counsel in the course of settlement negotiations.

BURDEN: Public reporting burden for this collection of information is estimated to average 60 minutes per response,

including time required for searching existing data sources, gathering the necessary documentation, providing the

information and/or documents required, and reviewing the final collection. You do not have to supply this information

unless this collection displays a currently valid OMB control number. If you have comments on this accuracy of this burden

estimate and/or recommendations for reducing it, please send them to: A/GIS/DIR, Room 2400 SA-22, U.S. Department of

State, Washington, DC 20522-2202

EQUAL OPPORTUNITY STATEMENT

The U.S. Government is an equal opportunity employer.

DS-174

Page ! 10

12-2009

Form Ds-174 - Application For Employment As A Locally Employed Staff Or Family Member - U.s. Mission Page 10