Ps Form 2591 - Application For Employment Form Page 4

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Name (First, MI, Last)

Social Security No.

Date

E. Other Information

Yes

1. Are you one of the following: a United States citizen, a permanent resident alien, a citizen of American

Samoa or any other territory owing allegiance to the United States?

2. RESERVED FOR OFFICIAL USE

3. RESERVED FOR OFFICIAL USE

If you answer "Yes" to question 4 and/or

4. Have you ever been fired from any job for any reason?

5, give details in Section F below. Give

the name, address (including ZIP Code)

5. Have you ever quit a job after being notified that you

of employer, approximate date, and

would be fired?

reasons in each case.

6. Do you receive or have you applied for retirement pay, pension, or other compensation based upon military,

postal, or federal civilian service? (If you answer "Yes," give details in Section F.)

7a. Have you ever been convicted of a crime or are you now under charges for any offense against the Law?

You may omit: (1) any charges that were dismissed or resulted in acquittal; (2) any conviction that has been

set aside, vacated, annulled, expunged, or sealed; (3) any offense that was finally adjudicated in a juvenile

court or juvenile delinquency proceeding; and (4) any charges that resulted only in a conviction of a non-

criminal offense. All felony and misdemeanor convictions and all convictions in state and federal

courts are criminal convictions and must be disclosed. Disclosure of such convictions is required

even if you did not spend any time in jail and/or were not required to pay a fine.

7b. While in the military service were you ever convicted by special or general court martial?

If you answer "Yes" to question 7a and/or 7b, give details in Section F. Show for each offense: (1)

Date of conviction; (2) Charge convicted of; (3) Court and location; (4) Action taken. Note: A

conviction does not automatically mean that you cannot be appointed. What you were convicted of,

and how long ago, are important. Give all of the facts so that a decision can be made.

8. Are you a former Postal Service or Federal Employee not now employed by the US Government?

If you answer "Yes," give in Section F, name of employing agency(ies), position title(s), and date(s)

employed.

9. Does the US Postal Service employ any relative of yours by blood or marriage?

Postal officials may not appoint any of their relatives or recommend them for appointment in the Postal

Service. Any relative who is appointed in violation of this restriction can not be paid. Thus it is necessary to

have information about your relatives who are working for the USPS. These include: mother, father,

daughter, son, sister, brother, aunt, uncle, first cousin, niece, nephew, wife, husband, mother-in-law, father-

in-law, daughter-in-law, son-in-law, sister-in-law, brother-in-law, stepfather, stepmother, stepdaughter,

stepson, stepsister, stepbrother, half sister, and half brother.

If you answer "Yes" to question 9, give in section F for such relatives:

(1) Full name; (2) Present address and ZIP Code; (3) Relationship; (4) Position title; (5) Name and location

of postal installation where employed.

10. Are you now dependent on or a user of ANY addictive or hallucinogenic drug, including amphetamines,

barbiturates, heroin, morphine, cocaine, mescaline, LSD, STP, hashish, marijuana, or methadone, other

than for medical treatment under the supervision of a doctor?

F. Use This Space for Detailed Answers (Use blank sheets if you need more space. Include your name, SSN, and date on each sheet.)

G. Certification

Enter number of additional sheets you have attached as part of this application:

Signature of Applicant

Date Signed

I certify that all of the statements made in this

application are true, complete, and correct to the best

of my knowledge and belief and are in good faith.

Disclosure by you of your Social Security Number (SSN) is mandatory to obtain the services, benefits, or processes that you are seeking. Solicitation of

the SSN by the USPS is authorized under provisions of Executive Order 9397, dated November 22, 1943. The information gathered through the use of

the number will be used only as necessary in authorized personnel administration processes.

A false or dishonest answer to any question in this application may be grounds for not employing you or for dismissing you after you begin work, and

may be punishable by fine or imprisonment. (US Code, Title 18, Sec. 1001). All information you give will be considered in reviewing your application

and is subject to investigation.

2591

PS Form

, March 1999 (Page 4 of 4)