Application For Federal Employment-Sf 171 Page 4

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BACKGROUND INFORMATION-- You must answer each question in this section before we can process your application.
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YES
NO
Are you a citizen of the United States? (In most cases you must be a U.S. citizen to be hired. You will be required to submit proof of
identity and citizenship at the time you are hired.) If "NO", give the country or countries you are a citizen of :
NOTE: It is important that you give complete and truthful answers to questions 38 through 44. If you answer "YES" to any of them, provide your explanation(s) in Item
45. Include convictions resulting from a plea of nolo contendere (no contest) . Omit: 1) traffic fines of $100.00 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; 5) any conviction whose record was expunged under Federal or State law. 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 or
circumstances, this may be grounds for not hiring you, for firing you after you begin work, or for criminal prosecution (18 USC 1001).
YES
NO
During the last 10 years, were you fired from any job for any reason, did you quit after being told that you would be fired, or did you
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leave by mutual agreement because of specific problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Have you ever been convicted of, or forfeited collateral for any felony violation? (Generally, a felony is defined as any violation of law
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punishable by imprisonment of longer than one year, except for violations called misdemeanors under State law which are punishable by
imprisonment of two years or less.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Have you ever been convicted of, or forfeited collateral for any firearms or explosives violation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Are you now under charges for any violation of law? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41
During the last 10 years have you forfeited collateral, been convicted, been imprisoned, been on probation, or been on parole? Do not
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include violations reported in 39, 40, or 41, above. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43
Have you ever been convicted by a military court-martial? If no military service, answer "NO". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits, and other
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debts to the U.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgage loans.) . . . . . . . . . . . . . . . . . . . . . .
45
If "YES" in: 38 - Explain for each job the problem(s) and your reason(s) for leaving. Give the employer's name and address.
39 through 43 - Explain each violation. Give place of occurrence and name/address of police or court involved.
44 - Explain the type, length and amount of the delinquency or default, and steps you are taking to correct errors or repay the debt. Give any
identification number associated with the debt and the address of the Federal agency involved.
NOTE: If you need more space, use a sheet of paper, and include the item number.
Item
Date
Explanation
Mailing Address
No.
(Mo./Yr.)
Name of Employer, Police, Court, or Federal Agency
City
State ZIP Code
Name of Employer, Police, Court, or Federal Agency
City
State ZIP Code
YES
NO
Do you receive, or have you ever applied for retirement pay, pension, or other pay based on military, Federal civilian, or District of
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Columbia Government service? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do any of your relatives work for the United States Government or the United States Armed Forces? Include: father; mother; husband;
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wife; son; daughter; brother; sister; uncle; aunt; first cousin; nephew; niece; father-in-law; son-in-law; daughter-in-law;
brother-in-law; sister-in-law; stepfather; stepmother; stepson; stepdaughter; stepbrother; stepsister; half brother; and half sister . . . . . . . . . . . . . . . . . . . . . . . . . .
If "YES", provide details below. If you need more space, use a sheet of paper.
Name
Relationship
Department, Agency or Branch of Armed Forces
SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION
YOU MUST SIGN THIS APPLICATION.
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).
If you are a male born after December 31, 1959 you must be registered with the Selective Service System or have a valid exemption in order to be
eligible for Federal employment. You will be required to certify as to your status at the time of appointment.
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.
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SIGNATURE (Sign each application in dark ink)
DATE SIGNED (Month, day, year)
//
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U.S. Government Printing Office: 1992 312-071/50009
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