Va Form 0120 - Va Police Officer Pre-Employment Screening Checklist Page 2

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OMB Approved No. 2900-0524

Respondent Burden: 10 Minutes

FACILITY LOCATION

FBI ORI.

PART I - APPLICANT (From page 1)

A. LAST NAME, FIRST NAME, MIDDLE INITIAL

B. SOCIAL SECURITY NO.

C. DATE OF BIRTH

D. SEX

PART IV - BASIS FOR QUALIFICATION AND CERTIFICATION

(Human Resources Management Must Complete This Section)

ACCEPTABLE JOB EXPERIENCE MEETING GS-083 MINIMUM QUALIFICATION REQUIREMENTS

(Statement of qualifications must be entered into

Part

V):

ACCEPTABLE SUBSTITUTE EDUCATION EVIDENCED BY TRANSCRIPT COPY

(All substitute education used as qualifications must be entered into

Part

V):

______ YEARS ACTIVE MILITARY SERVICE IN THE QUALIFYING SPECIALTY OF

(When Military service is used to meet the GS-083 minimum

Qualification Requirements the applicant must have one of these Qualifying Specialties listed on their

DD214):

ARMY:

95B

95C

31A

31B

31D

MARINE CORPS:

5805

5811

5812

5813

5814

5821

5803

AIR FORCE:

08111-114

81110

81170

81172

81130

81150

81112

81132

81152

81199

3P1-4

3P011

3P031

3P051

3P071

3P091

75011

75031

75051

75071

75091

NAVY:

COAST GUARD:

9545

0000MA

(No code)

Military service in the above checked specialty verified by review of DD Form 214, Certificate of Release of Discharge from Active Duty or other official

(If other specify in Part V)

document.

PART V - CLARIFYING STATEMENT (For Parts II, III, and IV)

CERTIFICATION: Human Resources Management Service certifies that the applicant is suitable and meets current qualification standards for the GS-083 Police Officer

series. Telephone interviews have been satisfactorily completed and documented in Part III of this form.

SIGNATURE AND TITLE

DATE

OF VERIFIER

Click here to print form for Shipment

0120

VA FORM

SEP 2013