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Form Opm-1170/17 - List Of College Courses And Certification Of Scholastic Achievement

Supplemental Qualifications Statement

Form Approved

OMB No. 3206-003

LIST OF COLLEGE COURSES AND CERTIFICATION OF SCHOLASTIC ACHIEVEMENT

Complete and submit this form with your Application for Federal Employment or as instructed

1. Name: (Last, First, MI)

2. Birth Date (Month, day, year)

3. Social Security Number

4. Position for which you are applying (Include options, if any)

5. List the undergraduate and/or graduate college degrees you have received or expect to receive (Give name of degree, name of college or

university granting degree and date received or to be received)

6. State your major undergraduate course(s) of study

6a. State your major graduate course(s) of study.

PART 1 - COLLEGE COURSES

List below by appropriate academic field (e.g., biology, mechanical engineering, economics, sociology, etc.) all courses you have taken

(including those failed) which appear to satisfy the qualification requirements of positions for which you are applying. List graduate and

undergraduate courses separately. Credits for each category should be totaled to determine if you meet the minimum course requirements.

Indicate Academic Field:

DESCRIPTIVE TITLE

Completion

Grade

Sem

Qtr

Class

DESCRIPTIVE TITLE

Completion

Grade

Sem

Qtr

Class

Date

Room

Date

Room

TOTAL

U.S. Office of Personnel Management

OPM-1170/17

Form Opm-1170/17 - List Of College Courses And Certification Of Scholastic Achievement