Form Bc-170b - U.s. Census Employment Inquiry Page 3
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OMB No. 0607-0139
NOTE – THE ACCURACY OF YOUR STATEMENTS WILL BE VERIFIED.
U.S. DEPARTMENT OF COMMERCE
Job Announcement No.
FORM
BC-170B
Economics and Statistics Administration
(11-27-2012)
U.S. CENSUS BUREAU
U.S. CENSUS EMPLOYMENT INQUIRY
Section A
APPLICANT PERSONAL DATA
1.
9.
Social Security Number
Date and place of birth
a.
Date of birth
Month
Day
Year
2.
Name
Last Name
b.
Place of birth
City
First Name
MI
State or country
3.
10.
Residence address
Are you a citizen or national of the United States?
Street address or RFD number (Include apartment number, if any)
Yes
No – Are you a lawful permanent resident?
Yes – Specify alien No.
City
No – Provide country of citizenship
County
11.
FOR MALES ONLY: If you are a male born after December 31,
State
ZIP Code
1959, and you want to be employed by the Federal Government, you
must be registered with the Selective Service System.
Mark (X) one box.
I certify that I am registered.
4.
Mailing address (if different from Item 3)
Street address or RFD number (Include apartment number, if any)
I certify that I am not registered. If not, explain in Item 32.
12.
Military Service
a.
Do you claim veterans’ preference? Mark (X) one box.
No preference – Skip to Item 13a.
Yes – List period(s) of service
City
Month
Year
Month
Year
TO
State
ZIP Code
Branch, Rank, Awards, Badges, or Campaign medals –
5.
Intersecting streets nearest your home
b.
Veterans’ preference categories? Mark (X) one box.
5-point preference – Attach your DD-214 or other proof
10-point preference – Follow instruction below
If you claim 10-point preference, you must complete a
6.
E-mail address
Standard Form 15, which is available at any Federal Job
Information Center. ATTACH THE COMPLETED SF-15 TO
THIS APPLICATION, INCLUDE THE PROOF REQUESTED
ON THE REVERSE SIDE OF THE SF-15. Indicate the type
7.
Mark (X) one box
of 10-point preference you qualify for by marking (X) one of
Telephone number(s)
the following:
Area code
Number
(H)
(W)
(C)
Day
10-point (disability) pref.
10-point (compensable disability) pref. – less than 30%
Evening
10-point (compensable disability) pref. – 30% or more
10-point (other) pref. (use when you are a spouse,
Other
widow, or mother of a disabled veteran)
phone
c.
Kind of discharge? Mark (X) one box.
Sex Mark (X) one box.
8.
Honorable or general under honorable conditions
Female
Male
Other – Explain in Item 32.
A. Location
B. FIPS
C. FIPS
D. Census Tract
F. Test information
E. Census Block
Office or LCO
State
County
Non-Supervisory
FOR
Supervisory
.
OFFICE
Raw
USE
List A:
List B:
List C:
H. Veteran’s proof
I. Language code(s)
G. I-9
score
ONLY
Code
Verified &
Test
attached
date
Page 1
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