Form Aid 1420-17 - Contractor Employee Biographical Data Sheet printable pdf download

OMB Control No. 0412-0520; Expiration Date: 10/31/2010

CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET

2. Contractor’s Name

1. Name (Last, First, Middle)

3. Employee’s Address (include ZIP code)

4. Contract Number

5. Position Under Contract

6. Proposed Salary

7. Duration of Assignment

8. Telephone Number (include area code)

9. Place of Birth

10. Citizenship (If non-U.S. citizen, give visa status)

11. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment

12. EDUCATION (include all college or university degrees)

13. LANGUAGE PROFICIENCY (see Instruction on Page 2)

Proficiency

NAME AND LOCATION OF INSTITUTION

MAJOR

DEGREE

DATE

LANGUAGE

Speaking

Reading

2/S

2/R

2/S

2/R

2/S

2/R

14. EMPLOYMENT HISTORY

Give last three (3) years. List salaries separate for each year. Continue on separate sheet of paper if required to list all employment related to

duties of proposed assignment.

Salary definition – basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions, consultant fees,

extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.

Dates of Employment (M/D/Y)

Annual Salary

EMPLOYER’S NAME AND ADDRESS

POSITION TITLE

POINT OF CONTACT &TELEPHONE #

From

Dollars

15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)

Dates of Employment (M/D/Y)

EMPLOYER’S NAME AND ADDRESS

Days at

Daily Rate

SERVICES PERFORMED

POINT OF CONTACT &TELEPHONE #

Rate

In Dollars

From

16. CERTIFICATION:

To the best of my knowledge, the above facts as stated are true and correct.

Signature of Employee

Date

17. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)

Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information

contained in this form. Contractor understands that USAID may rely on the accuracy of such information in negotiating and reimbursing personne l under

this contract. The making of certifications that are false, fictitious, or fraudulent, or that are based on inadequately verified information, may result in

appropriate remedial action by USAID, taking into consideration all of the pertinent facts and circumstances, ranging from re fund claims to criminal

prosecution.

Signature of Contractor’s Representative

Date

AID 1420-17 (04/2007)

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