Standard Form 171-A - Continuation Sheet For Sf 171 Page 2

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Standard Form 171-A Continuation Sheet for SF 171 (Back)
Form Approved:
OMB No. 3206-0012
Attach all SF 171-A's to your application at the top of page 3.
1. Name (Last, First, Middle Initial)
2. Social Security Number
3. Job Title or Announcement Number You Are Applying For
4. Date Completed
ADDITIONAL WORK EXPERIENCE BLOCKS
Name and address of employer's organization (include ZIP Code, if known)
Dates employed (give month, day and year)
Average number of
Number of employees
hours per week
you supervise
From:
To:
Salary or earnings
Your reason for wanting to leave
Starting $
per
Ending $
per
Your immediate supervisor
Exact title of your job
If Federal employment (civilian or military) list series, grade
N a me
Te l eph on e N o .
or rank, and, if promoted in this job, the date of your last
promotion
Description of work: Describe your specific duties, responsibilities and accomplishments in this job, including the job title(s) of any employees you supervise. If you describe
more than one type of work (for example, carpentry and painting, or personnel and budget), write the approximate percentage of time you spent doing each.
For Agency Use (skill codes, etc.)
Standard F orm 171-A (BA CK) (Rev. 6-88)
U.S . Office of Pe rsonnel M an agement
FPM Chapter 295
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