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AIR TRAFFIC ASSISTANT

AT-2154-07

(Flight Data Communications Specialist)

U.S. DEPARTMENT OF TRANSPORTATION

FEDERAL AVIATION ADMINISTRATION

APPLICATION FOR EMPLOYMENT WITH THE FEDERAL AVIATION ADMINISTRATION

FAA-AAT-01-ATA01-54972

SSN _________-________-________

Name

________________________________________________________

Last

First

Day Phone (_____) _____-________

Address _______________________________________________________

Street

Night Phone (_____) _____-________

______________________________

______

________-______

City

Ste

Zip

Date of Birth ______/______/_______

Place of ______________________

_______

______________________

Birth

City

Ste

Country

SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION

YOU MUST COMPLETE THIS PORTION OF THE FORM IN ORDER TO BE CONSIDERED FOR FEDERAL

AVIATION ADMINISTRATION EMPLOYMENT

NOTE: You must sign the application and answer each question below. If these four questions are not

answered "YES," your application cannot be considered. Read the following carefully before you sign this

form

•

I understand that a false statement on any part of this application may be grounds for not hiring me or for

firing me after I begin work. I also understand that I may be punished by fine or imprisoned for falsification

of my employment application (18 USC 1001)._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes

0 No

•

I understand that information I give may be investigated as allowed by law or Presidential order. _ _ _ _ _ _ _ _ _ 0 Yes

0 No

•

I consent to the release of information concerning my background, ability, and fitness for employment

with the Federal Aviation Administration by employers, schools, law enforcement agencies, other

individuals and organizations to investigators, personnel staffing specialists, and other authorized

employees of the Federal Aviation Administration. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes

0 No

•

I certify that, to the best of my knowledge and belief, ALL of the information provided on this application

is true, accurate, and complete, and that this application for employment with the Federal Aviation

Administration is made in good faith. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes

0 No

_________________________________________________

___________________________

(Signature)

(Month)

(Day)

(Year)

Privacy Act and Public Burden Statements

Public Law 104-50 allows the Federal Aviation Administration (FAA) to rate applicants for employment. We need the information on this application

questionnaire to see how well your education and work skills qualify you for employment with the FAA. We also need information on matters such as

citizenship and military service to see whether you are affected by laws we must follow in deciding whom the Federal government may employ.

Executive Order 9397 authorizes the solicitation of your Social Security Number (SSN) for use as an identifier in personnel records management to assure

proper identification of applicants throughout the selection and employment process. The information we collect on this questionnaire, including your SSN,

will be used for employment purposes, and it may also be used for statistical studies or computer matching with other government files. Furnishing your

SSN or any of the other information requested in the vacancy announcement is voluntary; however, failure to provide this information will prevent the

processing of your application and will prevent your consideration for employment. The nature of the information received is confidential, and authorized

officials will handle it appropriately. This information becomes part of a Privacy Act System of Records as identified in 5CFR 552a, under OPM/GOVT-1:

General Personnel Records.

We estimate it will take you 60 minutes to complete this form, including the time required to read the instructions, provide the requested information, and

review your responses. Send comments regarding this estimate or any other aspect of the collection of information, including suggestions for reducing the

burden, to the Federal Aviation Administration, Office of Human Resource Management, 800 Independence Avenue, SW, Washington D.C. 20591.

FAA Form 54972 (02/01)