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Form Ds-174 - Application For Employment As A Locally Employed Staff Or Family Member - U.s. Mission Page 2

13. Do you have permanent U.S. Resident status?

Yes

If yes, provide

Number

14a. U.S. Social Security Number (for U.S. Citizens / Permanent U.S. Residents)

- -

and /or

14b. Country identification Number

15. Are you eligible to work in this country?

Yes

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). If you are not sure if you need to submit proof of

eligibility, contact the Mission’s HR office.

16. 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

If yes, please explain

17. If you are applying for a position that includes driving a U.S. Government vehicle, do you have a valid driver’s license?

Yes

If yes, Class/Type of License

If yes, have you operated a vehicle without incident for the past three years?

Yes

18. What days are you available to work as part of a regularly scheduled work week? (Check all that apply)

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

19. Do any of your relatives or members of your household work for the United States Government?

If yes, provide the details below. If you need more space, use an additional sheet of paper. (See Instructions for

Completing the DS-174 for the definition of relatives and members of household.)

Name

Relationship

Agency, Position,

and Location

DS-174

Page ! 2

12-2009

Form Ds-174 - Application For Employment As A Locally Employed Staff Or Family Member - U.s. Mission Page 2