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Form Ds-174 - Application For Employment As A Locally Employed Staff Or Family Member - U.s. Mission Page 8

Describe your major duties/responsibilities and accomplishments.

Reason(s) for leaving (Do not write “N/A” or applicable)

REFERENCES

26. List three personal references who are not relatives or former supervisors who have knowledge of your work

performance. HR will obtain your permission before contacting any references.

Name

Address

Telephone

SIGNATURE AND CERTIFICATION

27. I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true,

correct, complete, and made in good faith. I understand that false or fraudulent information on or attached to this

application may be grounds for not hiring me, or for termination/dismissal after I begin work, and may be punishable by fine

or imprisonment according to this country’s law or U.S. law. I understand that any information I voluntarily give on or

attached to this application may be investigated.

Signature

Date (mm-dd-yyyy)

- -

DS-174

Page ! 8

12-2009

Form Ds-174 - Application For Employment As A Locally Employed Staff Or Family Member - U.s. Mission Page 8