Form Bc-170b - U.s. Census Employment Inquiry Page 5
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5Section F – BACKGROUND INFORMATION
Mark (X) one
Answer questions 27 through 31 below. Read each statement carefully before responding.
When answering questions 27 through 29 you may omit: 1) traffic fines of $300 or less; 2) any violation
of law committed before your 16th birthday, 3) any violation of law committed before your 18th birthday if finally
decided in juvenile court or under a Youth Offender law, 4) any conviction set aside under the Federal Youth
Corrections Act or similar state law, and 5) any conviction for which the record was expunged under federal or state
law. NOTE: You must include convictions resulting from a plea of nolo contendere (no contest).
Important note about questions 27, 28, 29 and 30. We will consider the date, facts, and circumstances of each
event you list. In most cases you can still be considered for federal jobs. However, if you fail to tell the truth or fail to list
all relevant events, this failure may be grounds for not hiring you, for firing you after you begin work, or for criminal
prosecution [18 U.S.C. 1001]. If "YES," use Item 32 to provide the date, explanation of the violation, place of occurrence,
and the name and address of the police department or court involved.
27.
During the last 7 years, have you been convicted, been imprisoned, been on probation or been on
parole? (Include felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 32
to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department
or court involved.
Yes
No
28.
Have you been convicted by a military court-martial in the past 7 years? If no military service, answer "NO." If
"YES," use Item 32 to provide the date, explanation of the violation, place of occurrence, and the name and address of
the military authority or court involved.
Yes
No
29.
Are you currently under charges for any violation of law? If "YES," use Item 32 to provide the date, explanation of
the violation, place of occurrence, and the name and address of the police department or court involved.
Yes
No
30.
During the past 5 years, have you been fired from any job for any reason, did you quit after being told
that you would be fired, or did you leave any job by mutual agreement because of specific problems, or
were you debarred from federal employment by the Office of Personnel Management or any other federal
agency? If "YES," use Item 32 to write for each job a) the name and address of the employer; b) the
approximate date you left the job, and c) an explanation of the problem and the reason for leaving.
Yes
No
31.
Are you delinquent on any federal debt? (Include delinquencies arising from federal taxes, loans, overpayment of
benefits, and other debts to the U.S. Government plus defaults on federally guaranteed or insured loans such as student
and home mortgage loans.) If "YES," use Item 32 to provide the type, length, and amount of the delinquency or default,
and steps that you are taking to correct the error or repay the debt.
Yes
No
32.
EXPLANATIONS OR ANSWERS TO QUESTIONS 1 THROUGH 31 – Attach additional listing if needed.
Section G – PRIVACY ACT STATEMENT
Solicitation of this information is authorized by section 23 of title 13, U.S. Code, which authorizes temporary appointments in the Census
Bureau. The information will be used primarily to determine your qualifications for employment and may be used also to identify you to other
sources asked to comment on your qualifications, e.g., educational institutions, former employers, and law enforcement agencies, or to a
court during legal proceedings.
We must have your Social Security Number (SSN) to keep our records straight because other people may have the same name and birth date.
The SSN has been used to keep records since 1943, when Executive Order 9397 asked agencies to do so. The furnishing of all the information
is voluntary, but failure to provide any part or all of the data requested will result in your receiving no further consideration for employment.
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: Paperwork Project 0607-0139, U.S. Census Bureau, 4600 Silver Hill Road, Washington, DC 20233-1500. You may
E-mail comments to Paperwork@census.gov; use "Paperwork Project 0607-0139" as the subject.
The eight digit OMB control number on the first page of this form confirms our authority to collect this information.
Section H – SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION
YOU MUST SIGN THIS APPLICATION IN DARK INK. Read the following carefully before you sign. A false statement on any
part of your application may be grounds for not hiring you, or for firing you after you begin work. Also, you may be
punished by fine or imprisonment (U.S. Code, Title 18, Section 1001).
I understand that any information I give may be investigated as allowed by law or Presidential order. I consent to the
release of information about my ability and fitness for federal employment by employers, schools, law enforcement
agencies and other individuals and organizations, to investigators, personnel staffing specialists, and other authorized
employees of the Federal Government. I certify that, to the best of my knowledge and belief, all of my statements are true,
correct, complete, and made in good faith.
Signature
Date signed
Print name
FORM BC-170B (11-27-2012)
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