Form 170B – Fill Out and Use This PDF

A UNIQUE OPPORTUNITY: EARN MONEY WHILE YOU SERVE YOUR COMMUNITY

Ｉｎ฀ｔｈｅ฀ｎｅａｒ฀ｆｕｔｕｒｅ，฀ｔｈｅ฀Ｕ．Ｓ．฀Ｃｅｎｓｕｓ฀Ｂｕｒｅａｕ฀ｗｉｌｌ฀ｃｏｎｄｕｃｔ฀ａ

ｓｐｅｃｉａｌ฀ｃｅｎｓｕｓ฀ｉｎ฀ｔｈｉｓ฀ａｒｅａ．฀Ｙｏｕｒ฀ｃｏｍｍｕｎｉｔｙ฀ｈａｓ฀ｒｅｑｕｅｓｔｅｄ฀ｉｔ ａｎｄ฀ｗｉｌｌ฀ｉｎｃｕｒ฀ｔｈｅ฀ｃｏｓｔ．฀Ｌｏｃａｌ฀ｒｅｓｉｄｅｎｔｓ฀ｗｉｌｌ฀ｂｅ฀ｎｅｅｄｅｄ฀ｔｏ฀ｗｏｒｋ ａｓ฀ｃｅｎｓｕｓ฀ｔａｋｅｒｓ．฀Ｃｅｎｓｕｓ฀ｔａｋｅｒｓ฀ｖｉｓｉｔ฀ｈｏｕｓｅｈｏｌｄｓ฀ａｎｄ฀ｃｏｌｌｅｃｔ ａ฀ｆｅｗ฀ｆａｃｔｓ฀ａｂｏｕｔ฀ｅａｃｈ฀ｍｅｍｂｅｒ฀ｓｕｃｈ฀ａｓ฀ｎａｍｅ，฀ａｇｅ，

ｒｅｌａｔｉｏｎｓｈｉｐ฀ｔｏ฀ｔｈｅ฀ｈｏｕｓｅｈｏｌｄｅｒ，฀ｅｔｃ．

WHY A SPECIAL CENSUS?

Ｌｏｃａｌ฀ｇｏｖｅｒｎｍｅｎｔｓ฀ｃｏｎｓｉｄｅｒ฀ｕｐ－ｔｏ－ｄａｔｅ฀ｐｏｐｕｌａｔｉｏｎ

ｉｎｆｏｒｍａｔｉｏｎ฀ｂｅｎｅｆｉｃｉａｌ฀ｔｏ฀ｒｅｓｉｄｅｎｔｓ฀ｔｏ฀ｄｅｔｅｒｍｉｎｅ฀ｔｈｅ฀ａｌｌｏｃａｔｉｏｎ ｏｆ฀ｓｔａｔｅ฀ｆｕｎｄｓ฀ｔｏ฀ｃｏｍｍｕｎｉｔｉｅｓ，฀ｉｍｐｒｏｖｅｄ฀ａｂｉｌｉｔｙ฀ｔｏ฀ｐｌａｎ฀ｆｏｒ

ｓｃｈｏｏｌｓ，฀ｂｅｔｔｅｒ฀ｔｒａｎｓｐｏｒｔａｔｉｏｎ，฀ａｎｄ฀ｆｏｒ฀ｍａｎｙ฀ｏｔｈｅｒ฀ｐｕｒｐｏｓｅｓ． Ｙｏｕｒ฀ｃｏｍｍｕｎｉｔｙ฀ｍａｙ฀ｂｅｎｅｆｉｔ฀ｆｒｏｍ฀ｔｈｉｓ฀ｕｐｄａｔｅｄ฀ｏｆｆｉｃｉａｌ

ｐｏｐｕｌａｔｉｏｎ฀ｃｏｕｎｔ．

TRAINING

Ｂｅｆｏｒｅ฀ｙｏｕ฀ｇｏ฀ｔｏ฀ｗｏｒｋ，฀ｙｏｕ฀ｗｉｌｌ฀ａｔｔｅｎｄ฀ａ฀ｔｒａｉｎｉｎｇ฀ｓｅｓｓｉｏｎ ｗｈｅｒｅ฀ｙｏｕ฀ｗｉｌｌ฀ｌｅａｒｎ฀ｔｈｅ฀ｕｓｅ฀ｏｆ฀ｃｅｎｓｕｓ฀ｆｏｒｍｓ฀ａｎｄ฀ｃｅｎｓｕｓ ｔｅｃｈｎｉｑｕｅｓ฀ｓｕｃｈ฀ａｓ฀ｉｎｔｅｒｖｉｅｗｉｎｇ฀ａｎｄ฀ｍａｐ฀ｒｅａｄｉｎｇ．฀Ｉｎ฀ｍｏｓｔ ｃａｓｅｓ，฀ｙｏｕｒ฀ｓｕｐｅｒｖｉｓｏｒ฀ｗｉｌｌ฀ｔｒａｉｎ฀ｙｏｕ，฀ａｓｓｉｇｎ฀ａｎｄ฀ｒｅｖｉｅｗ฀ ｙｏｕｒ฀ｗｏｒｋ，฀ａｎｄ฀ａｎｓｗｅｒ฀ｑｕｅｓｔｉｏｎｓ．

PAY

Ｙｏｕ฀ｗｉｌｌ฀ｂｅ฀ｐａｉｄ฀ｆｏｒ฀ａｃｔｕａｌ฀ｈｏｕｒｓ฀ｏｆ฀ｗｏｒｋ฀ｉｎｃｌｕｄｉｎｇ฀ｔｉｍｅ฀ｓｐｅｎｔ ｉｎ฀ｔｒａｉｎｉｎｇ．฀Ｙｏｕ฀ｗｉｌｌ฀ｇｅｔ฀ｓｐｅｃｉｆｉｃ฀ｉｎｆｏｒｍａｔｉｏｎ฀ａｂｏｕｔ฀ｐａｙ฀ｆｒｏｍ ｔｈｅ฀ｃｅｎｓｕｓ฀ｓｕｐｅｒｖｉｓｏｒ．

DUTIES

Ｗｈｅｎ฀ｙｏｕ฀ｈａｖｅ฀ｓｕｃｃｅｓｓｆｕｌｌｙ฀ｃｏｍｐｌｅｔｅｄ฀ｙｏｕｒ฀ｔｒａｉｎｉｎｇ，฀ｙｏｕ ｗｉｌｌ฀ｂｅ฀ｇｉｖｅｎ฀ｓｅｖｅｒａｌ฀ｎｅｉｇｈｂｏｒｈｏｏｄ฀ｂｌｏｃｋｓ฀ｃａｌｌｅｄ

＂Ａｓｓｉｇｎｍｅｎｔ฀Ａｒｅａｓ＂．฀Ｎｏｒｍａｌｌｙ，฀ｙｏｕｒ฀ｆｉｒｓｔ฀ａｓｓｉｇｎｍｅｎｔ฀ｗｉｌｌ฀ｂｅ ｔｈｅ฀ａｒｅａ฀ｉｎ฀ｗｈｉｃｈ฀ｙｏｕ฀ｌｉｖｅ．฀Ｙｏｕ฀ｗｉｌｌ฀ｂｅ฀ｐｒｏｖｉｄｅｄ฀ａ฀ｍａｐ฀ｏｆ ｅａｃｈ฀Ａｓｓｉｇｎｍｅｎｔ฀Ａｒｅａ฀ａｎｄ฀ｔｈｅ฀ｎｅｃｅｓｓａｒｙ฀ｃｅｎｓｕｓ฀ｆｏｒｍｓ฀ ａｎｄ฀ｍａｔｅｒｉａｌｓ฀ｔｏ฀ｄｏ฀ｔｈｅ฀ｊｏｂ．฀Ｍｏｓｔ฀ｏｆ฀ｔｈｅ฀ｊｏｂｓ฀ａｒｅ฀ｉｎ฀ｔｈｅ฀ｆｉｅｌｄ， ａｎｄ฀ｒｅｑｕｉｒｅ฀ｙｏｕ฀ｔｏ฀ｌｏｃａｔｅ฀ａｎｄ฀ｉｎｔｅｒｖｉｅｗ฀ｈｏｕｓｅｈｏｌｄｓ฀ａｎｄ

ｒｅｃｏｒｄ฀ｉｎｆｏｒｍａｔｉｏｎ฀ａｂｏｕｔ฀ｔｈｅ฀ｒｅｓｉｄｅｎｔｓ．฀Ｗｈｅｎ฀ｙｏｕ฀ａｃｃｅｐｔ ｙｏｕｒ฀ａｐｐｏｉｎｔｍｅｎｔ，฀ｙｏｕ฀ａｓｓｕｍｅ฀ａｎ฀ｏｂｌｉｇａｔｉｏｎ฀ｔｏ฀ｓｔａｙ฀ｗｉｔｈ฀ ｔｈｅ฀ｊｏｂ฀ｕｎｔｉｌ฀ｙｏｕｒ฀ａｓｓｉｇｎｍｅｎｔ฀ｉｓ฀ｃｏｍｐｌｅｔｅｄ．

The information you collect is confidential and must not be disclosed to anyone who has not sworn to protect Census Bureau information.

HOW CAN YOU QUALIFY FOR CENSUS WORK?

1.Ｎｏｎｃｉｔｉｚｅｎｓ฀ｗｉｌｌ฀ｏｎｌｙ฀ｂｅ฀ｃｏｎｓｉｄｅｒｅｄ฀ｆｏｒ฀ｃｅｎｓｕｓ฀ｊｏｂｓ฀ｉｆ ｑｕａｌｉｆｉｅｄ฀ｃｉｔｉｚｅｎｓ฀ａｒｅ฀ｎｏｔ฀ａｖａｉｌａｂｌｅ，฀ｐａｒｔｉｃｕｌａｒｌｙ฀ｉｎ฀ａｒｅａｓ ｗｈｅｒｅ฀ｂｉｌｉｎｇｕａｌ฀ａｂｉｌｉｔｙ฀ｉｓ฀ａ฀ｎｅｃｅｓｓａｒｙ฀ｑｕａｌｉｆｉｃａｔｉｏｎ．฀Ｙｏｕ ｍｕｓｔ฀ｐｒｅｓｅｎｔ฀ｄｏｃｕｍｅｎｔａｔｉｏｎ฀ｏｆ฀ｅｍｐｌｏｙｍｅｎｔ฀ｅｌｉｇｉｂｉｌｉｔｙ． Ｔｈｅ฀ｔｙｐｅｓ฀ｏｆ฀ａｃｃｅｐｔａｂｌｅ฀ｄｏｃｕｍｅｎｔａｔｉｏｎ฀ａｒｅ฀ｌｉｓｔｅｄ฀ｏｎ฀ ｔｈｅ฀ｒｅｖｅｒｓｅ฀ｓｉｄｅ฀ｏｆ฀ｔｈｉｓ฀ｐａｇｅ．

2.Ｙｏｕ฀ｍａｙ฀ｂｅ฀ｈｉｒｅｄ฀ｉｆ฀ｙｏｕ฀ａｒｅ฀１８฀ｙｅａｒｓ฀ｏｒ฀ｏｌｄｅｒ．฀Ｉｆ฀ｙｏｕ฀ ａｒｅ฀ｕｎｄｅｒ฀１８฀ａｎｄ฀ａ฀ｆｕｎｃｔｉｏｎ฀ｏｆ฀ｔｈｅ฀ｊｏｂ฀ｉｓ฀ｔｏ฀ｄｒｉｖｅ，฀ｔｈｅｎ ｙｏｕ฀ｃａｎｎｏｔ฀ｂｅ฀ｈｉｒｅｄ．฀（Ｔｈｏｓｅ฀ａｇｅｓ฀１６฀ａｎｄ฀１７฀ｍａｙ฀ｂｅ ｈｉｒｅｄ฀ｆｏｒ฀ｐｏｓｉｔｉｏｎｓ฀ｎｏｔ฀ｉｎｖｏｌｖｉｎｇ฀ｄｒｉｖｉｎｇ฀ｓｏ฀ｌｏｎｇ฀ａｓ฀ｔｈｅｙ ｍｅｅｔ฀ｓｔａｔｅ฀ａｎｄ฀ｌｏｃａｌ฀ｅｍｐｌｏｙｍｅｎｔ฀ｒｅｑｕｉｒｅｍｅｎｔｓ．）

3.Ｙｏｕ฀ｍｕｓｔ฀ｈａｖｅ฀ａ฀ｖａｌｉｄ฀Ｓｏｃｉａｌ฀Ｓｅｃｕｒｉｔｙ฀Ｎｕｍｂｅｒ．

4.Ａｐｐｌｉｃａｎｔｓ฀ｍｕｓｔ฀ｔａｋｅ฀ａ฀ｗｒｉｔｔｅｎ฀ｔｅｓｔ฀ｏｆ฀ｂａｓｉｃ฀ｓｋｉｌｌｓ．฀Ｔｈｅ ｔｅｓｔ฀ｍａｙ฀ｂｅ฀ｔａｋｅｎ฀ｉｎ฀Ｓｐａｎｉｓｈ，฀ｕｐｏｎ฀ｒｅｑｕｅｓｔ，฀ａｌｏｎｇ฀ｗｉｔｈ ａｎ฀Ｅｎｇｌｉｓｈ฀Ｐｒｏｆｉｃｉｅｎｃｙ฀Ｔｅｓｔ．

5.Ｍｏｓｔ฀ｃｅｎｓｕｓ฀ｊｏｂｓ฀ｒｅｑｕｉｒｅ฀ｔｈｅ฀ｅｍｐｌｏｙｅｅ฀ｔｏ฀ｃｏｎｄｕｃｔ

ｆａｃｅ－ｔｏ－ｆａｃｅ฀ｉｎｔｅｒｖｉｅｗｓ฀ｗｉｔｈ฀ｒｅｓｐｏｎｄｅｎｔｓ．฀Ｔｈｉｓ฀ｉｎｖｏｌｖｅｓ ｖｉｓｉｔｉｎｇ฀ｒｅｓｐｏｎｄｅｎｔｓ฀ｉｎ฀ａ฀ｖａｒｉｅｔｙ฀ｏｆ฀ｒｅｓｉｄｅｎｃｅ฀ｔｙｐｅｓ，

ａｓｋｉｎｇ฀ｑｕｅｓｔｉｏｎｓ฀ａｎｄ฀ｒｅｃｏｒｄｉｎｇ฀ｒｅｓｐｏｎｓｅｓ．

6.Ｍａｌｅ฀ａｐｐｌｉｃａｎｔｓ฀ｂｏｒｎ฀ａｆｔｅｒ฀Ｄｅｃｅｍｂｅｒ฀３１，฀１９５９，฀ｍｕｓｔ ｂｅ฀ｒｅｇｉｓｔｅｒｅｄ฀ｗｉｔｈ฀ｔｈｅ฀Ｓｅｌｅｃｔｉｖｅ฀Ｓｅｒｖｉｃｅ฀Ｓｙｓｔｅｍ．

7.Ｔｈｅ฀Ｃｅｎｓｕｓ฀Ｂｕｒｅａｕ฀ｐｅｒｆｏｒｍｓ฀ｃｒｉｍｉｎａｌ฀ｂａｃｋｇｒｏｕｎｄ ｃｈｅｃｋｓ฀ａｎｄ฀ｒｅｖｉｅｗｓ฀ｃｒｉｍｉｎａｌ฀ｒｅｃｏｒｄｓ฀（ｉｎｃｌｕｄｉｎｇ

ｆｉｎｇｅｒｐｒｉｎｔｉｎｇ）฀ａｓ฀ｐａｒｔ฀ｏｆ฀ａｓｓｅｓｓｉｎｇ฀ａｐｐｌｉｃａｎｔｓ＇฀ｐａｓｔ ｃｏｎｄｕｃｔ฀ａｎｄ฀ｓｕｉｔａｂｉｌｉｔｙ฀ｆｏｒ฀ｅｍｐｌｏｙｍｅｎｔ．

8.Ｙｏｕ฀ｗｉｌｌ฀ｎｏｔ฀ｅｎｇａｇｅ฀ｉｎ฀ａｎｙ฀ｐａｒｔｉｓａｎ฀ｐｏｌｉｔｉｃａｌ฀ａｃｔｉｖｉｔｙ ｗｈｉｌｅ฀ｏｎ฀ｄｕｔｙ．

9.Ａｌｌ฀ｎｏｎ－ｃｅｎｓｕｓ฀ｅｍｐｌｏｙｍｅｎｔ฀（ｉｎｃｌｕｄｉｎｇ฀ｌａｗ฀ａｎｄ

ｒｅｇｕｌａｔｏｒｙ฀ｅｎｆｏｒｃｅｍｅｎｔ฀ｊｏｂｓ）฀ｗｉｌｌ฀ｂｅ฀ｒｅｖｉｅｗｅｄ฀ｏｎ฀ａ ｃａｓｅ－ｂｙ－ｃａｓｅ฀ｂａｓｉｓ฀ｆｏｒ฀ｃｏｍｐａｔｉｂｉｌｉｔｙ฀ｗｉｔｈ฀Ｃｅｎｓｕｓ Ｂｕｒｅａｕ฀ｅｍｐｌｏｙｍｅｎｔ．

10.Ａｐｐｌｉｃａｎｔｓ฀ｍｕｓｔ฀ｂｅ฀ａｖａｉｌａｂｌｅ฀ｔｏ฀ｗｏｒｋ฀ｄａｙｓ，฀ｅｖｅｎｉｎｇｓ，

ａｎｄ฀ｗｅｅｋｅｎｄｓ．฀Ｓｉｎｃｅ฀ｎｏｔ฀ａｌｌ฀ｐｅｏｐｌｅ฀ｗｉｌｌ฀ｂｅ฀ｈｏｍｅ฀ｄｕｒｉｎｇ฀ ｔｈｅ฀ｄａｙ，฀ｙｏｕ฀ｗｉｌｌ฀ｈａｖｅ฀ｔｏ฀ｖｉｓｉｔ฀ｓｏｍｅ฀ｈｏｍｅｓ฀ｄｕｒｉｎｇ฀ｔｈｅ

ｅｖｅｎｉｎｇ฀ａｎｄ฀ｏｎ฀ｔｈｅ฀ｗｅｅｋｅｎｄｓ．฀Ｔｈｉｓ฀ｗｉｌｌ฀ｕｓｕａｌｌｙ฀ｂｅ฀ｎｏ ｌａｔｅｒ฀ｔｈａｎ฀９：００฀ｐ．ｍ．฀Ｙｏｕ฀ｇｅｎｅｒａｌｌｙ฀ｗｉｌｌ฀ｈａｖｅ฀ｆｌｅｘｉｂｉｌｉｔｙ฀ｔｏ ｃｈｏｏｓｅ฀ｗｈｉｃｈ฀ｈｏｕｒｓ฀ｔｏ฀ｗｏｒｋ฀ｄｕｒｉｎｇ฀ｔｈｅｓｅ฀ｐｒｏｄｕｃｔｉｖｅ ｔｉｍｅ฀ｐｅｒｉｏｄｓ．

Ｆｏｒ฀ｍｏｒｅ฀ｉｎｆｏｒｍａｔｉｏｎ，฀ｃｏｎｔａｃｔ：

（１１－２７－２０１２）

Instructions to prepare for the testing session

are on reverse side.

How do I complete the BC-170B, Census Employment Inquiry?

1.Print clearly using a black or blue pen. We cannot accept your form if it is not legible. Print neatly in uppercase. For example

2.Follow the instructions provided with every item. If you do not answer all questions fully and correctly, you may delay the processing of your application.

3.Enter one letter or number within each white block or complete the information on the line provided.

Here are a few explanatory notes for some of the items:

Page 3

Section A – Applicant Personal Data

3.Enter your street address followed by your city, county, and state. Enter the state postal abbreviation for the state in which you live, for example, MS for Mississippi.

7.Enter your telephone number(s) and Mark (X) box(es) H – home, W – work, or C – cell

9.Enter your Date of Birth. For example, enter July 6, 1952 as follows:

Month			Day				Year

Page 4

Section C – Application Data

15.Enter an (X) in the yes or no response box for: Are you willing to work in the field? If you enter "yes" in the response box, you will be considered for positions in the field. These positions include working primarily outside the office environment.

16.Enter an (X) in the yes or no response box for: Are you willing to work in the office? If you enter "yes" in the response box, you will be considered for positions in the office. These positions include working primarily within the office environment.

By entering a yes for both office and field positions, you will be considered for positions in both those areas.

What is the test like?

Each applicant interested in Census Bureau employment must take a written test. One such test is called the Field Employee Selection Aid. It consists of 28 questions designed to measure the knowledge, skills, and abilities, required to perform a variety of census jobs. You will have 30 minutes to complete the multiple choice test. Provided here are some sample questions to help better prepare you for the test. You may also request a practice test to help prepare for the test.

The test is physically accessible to people with disabilities. Requests for reasonable accommodations for persons with disabilities (such as sign language interpretation) should be directed to the contact office and phone number on the front of this form.

Sample Questions

Review the numbers in Column A to those in Column B. Then answer the question below.

Column A		Column B
75823	85537	87537	73358
82537	87537	85537	82357
73358		75823

Which number in Column A has no match?

(A) 82537	(C) 97537
(B) 85537	(D) None of the above
	ANSWER A
Multiply the numbers below:
1.5 x 6.3
(A) .945	(C) 94.5
(B) 9.45	(D) 945
	ANSWER B

Can I receive veterans’ preference?

If you served on active duty in the United States military and were separated under honorable conditions, you may be eligible for veterans’ preference. To receive 5-point veterans’ preference, applicants must bring a copy of a completed DD-214, Certificate of Release or Discharge from Active Duty, to the testing site. To receive 10-point veterans’ preference, applicants must also bring a completed SF-15, Application for Veterans’ Preference, with the appropriate documentation as shown on the reverse of the SF-15.

LIST A – Documents that Establish Both Identity and Employment

Eligibility

OR

1.U.S. Passport or Passport Card

2.Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

3.Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4.Employment Authorization Document that contains a photograph (Form I-766)

5.In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien’s nonimmigrant status, as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

6.Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

	LIST B – Documents that Establish		LIST C – Documents that Establish
		Identity	Employment Eligibility
	1.	Driver’s license or ID card issued by a state	AND 1. Social Security Account Number card
		or outlying possession of the United States	other than one that specifies on the
		provided it contains a photograph or	face that the issuance of the card
		information such as name, date of birth,	does not authorize employment in the
		gender, height, eye color, and address	United States
	2.	ID card issued by federal, state, or local	2. Certificate of Birth Abroad issued by
		government agencies or entities, provided it	the Department of State
		contains a photograph or information such	(Form FS-545)
		as name, date of birth, gender, height, eye	3. Certification of Report of Birth issued
		color, and address
			by the Department of State
	3.	School ID card with a photograph	(Form DS-1350)
	4.	Voter’s registration card	4. Original or certified copy of birth
	5.	U.S. Military card or draft record	certificate issued by a state, county,
			municipal authority, or territory of the
	6.	Military dependent’s ID card
			United States bearing an official seal
	7.	U.S. Coast Guard Merchant Mariner Card	5. Native American tribal document
	8.	Native American tribal document	6. U.S. Citizen ID Card (Form I-197)
	9.	Driver’s license issued by a Canadian	7. Identification Card for Use of Resident
		government authority
			Citizen in the United States
	For persons under age 18 who are		(Form I-179)
			8. Employment authorization document
	unable to present a document listed
	above:		issued by the Department of
	10. School record or report card		Homeland Security

11.Clinic, doctor, or hospital record

12.Day care or nursery school record

ＦＯＲＭ BC-170B	Ｕ．Ｓ．฀ＤＥＰＡＲＴＭＥＮＴ฀ＯＦ฀ＣＯＭＭＥＲＣＥ
（１１－２７－２０１２）	Ｅｃｏｎｏｍｉｃｓ฀ａｎｄ฀Ｓｔａｔｉｓｔｉｃｓ฀Ａｄｍｉｎｉｓｔｒａｔｉｏｎ
U.S. CENSUS EMPLOYMENT INQUIRY	Ｕ．Ｓ．฀ＣＥＮＳＵＳ฀ＢＵＲＥＡＵ

Ｊｏｂ฀Ａｎｎｏｕｎｃｅｍｅｎｔ฀Ｎｏ．

1.Social Security Number

2.Name

Ｌａｓｔ฀Ｎａｍｅ

Ｆｉｒｓｔ฀Ｎａｍｅ

ＭＩ

3.Residence address

Ｓｔｒｅｅｔ฀ａｄｄｒｅｓｓ฀ｏｒ฀ＲＦＤ฀ｎｕｍｂｅｒ฀(Include apartment number, if any)

Ｃｉｔｙ

Ｃｏｕｎｔｙ

Ｓｔａｔｅ ＺＩＰ฀Ｃｏｄｅ

4.Mailing address (if different from Item 3)

Ｓｔｒｅｅｔ฀ａｄｄｒｅｓｓ฀ｏｒ฀ＲＦＤ฀ｎｕｍｂｅｒ฀(Include apartment number, if any)

Ｃｉｔｙ

Ｓｔａｔｅ ＺＩＰ฀Ｃｏｄｅ

5.Intersecting streets nearest your home

6.E-mail address

7. Telephone number(s)

Mark (X) one box

Ｄａｙ

Ａｒｅａ฀ｃｏｄｅ

Ｎｕｍｂｅｒ

（Ｈ）

（Ｗ）

（Ｃ）

Ｅｖｅｎｉｎｇ

Ｏｔｈｅｒ ｐｈｏｎｅ

8.Sex Mark (X) one box.

Ｆｅｍａｌｅ Ｍａｌｅ

9.Date and place of birth a. Date of birth

Ｍｏｎｔｈ Ｄａｙ Ｙｅａｒ

b.Place of birth

Ｃｉｔｙ

Ｓｔａｔｅ฀ｏｒ฀ｃｏｕｎｔｒｙ

10.Are you a citizen or national of the United States?

Ｙｅｓ

Ｎｏ฀ｮ Are you a lawful permanent resident?

Ｙｅｓ ｮ Specify alien No.

Ｎｏ ｮ Provide country of citizenship

11.FOR MALES ONLY: Ｉｆ฀ｙｏｕ฀ａｒｅ฀ａ฀ｍａｌｅ฀ｂｏｒｎ฀ａｆｔｅｒ฀Ｄｅｃｅｍｂｅｒ฀３１，

１９５９，฀ａｎｄ฀ｙｏｕ฀ｗａｎｔ฀ｔｏ฀ｂｅ฀ｅｍｐｌｏｙｅｄ฀ｂｙ฀ｔｈｅ฀Ｆｅｄｅｒａｌ฀Ｇｏｖｅｒｎｍｅｎｔ，฀ｙｏｕ ｍｕｓｔ฀ｂｅ฀ｒｅｇｉｓｔｅｒｅｄ฀ｗｉｔｈ฀ｔｈｅ฀Ｓｅｌｅｃｔｉｖｅ฀Ｓｅｒｖｉｃｅ฀Ｓｙｓｔｅｍ．฀

Mark (X) one box.

Ｉ฀ｃｅｒｔｉｆｙ฀ｔｈａｔ฀Ｉ฀am ｒｅｇｉｓｔｅｒｅｄ．

Ｉ฀ｃｅｒｔｉｆｙ฀ｔｈａｔ฀Ｉ฀am not ｒｅｇｉｓｔｅｒｅｄ．฀If not, explain in Item 32.

12.Military Service

a. Do you claim veterans’ preference? Mark (X) one box.

Ｎｏ฀ｐｒｅｆｅｒｅｎｃｅ฀ｮ฀Skip to Item 13a.

Ｙｅｓ฀ｮ฀List period(s) of service
Ｍｏｎｔｈ	Ｙｅａｒ	Ｍｏｎｔｈ	Ｙｅａｒ

TO

Ｂｒａｎｃｈ，฀Ｒａｎｋ，฀Ａｗａｒｄｓ，฀Ｂａｄｇｅｓ，฀ｏｒ฀Ｃａｍｐａｉｇｎ฀ｍｅｄａｌｓ฀ｮ

b.Veterans’ preference categories? Mark (X) one box.

５－ｐｏｉｎｔ฀ｐｒｅｆｅｒｅｎｃｅ฀ｮ฀Attach your DD-214 or other proof

１０－ｐｏｉｎｔ฀ｐｒｅｆｅｒｅｎｃｅ฀ｮ฀Follow instruction below

Ｉｆ฀ｙｏｕ฀ｃｌａｉｍ฀１０－ｐｏｉｎｔ฀ｐｒｅｆｅｒｅｎｃｅ，฀ｙｏｕ฀ｍｕｓｔ฀ｃｏｍｐｌｅｔｅ฀ａ Ｓｔａｎｄａｒｄ฀Ｆｏｒｍ฀１５，฀ｗｈｉｃｈ฀ｉｓ฀ａｖａｉｌａｂｌｅ฀ａｔ฀ａｎｙ฀Ｆｅｄｅｒａｌ฀Ｊｏｂ

Ｉｎｆｏｒｍａｔｉｏｎ฀Ｃｅｎｔｅｒ．฀ＡＴＴＡＣＨ฀ＴＨＥ฀ＣＯＭＰＬＥＴＥＤ฀ＳＦ－１５฀ＴＯ ＴＨＩＳ฀ＡＰＰＬＩＣＡＴＩＯＮ，฀ＩＮＣＬＵＤＥ฀ＴＨＥ฀ＰＲＯＯＦ฀ＲＥＱＵＥＳＴＥＤ ＯＮ฀ＴＨＥ฀ＲＥＶＥＲＳＥ฀ＳＩＤＥ฀ＯＦ฀ＴＨＥ฀ＳＦ－１５．฀ Indicate the type of 10-point preference you qualify for by marking (X) one of the following:

１０－ｐｏｉｎｔ฀（ｄｉｓａｂｉｌｉｔｙ）฀ｐｒｅｆ．

１０－ｐｏｉｎｔ฀（ｃｏｍｐｅｎｓａｂｌｅ฀ｄｉｓａｂｉｌｉｔｙ）฀ｐｒｅｆ．฀ｮ฀ｌｅｓｓ฀ｔｈａｎ฀３０％

１０－ｐｏｉｎｔ฀（ｃｏｍｐｅｎｓａｂｌｅ฀ｄｉｓａｂｉｌｉｔｙ）฀ｐｒｅｆ．฀ｮ฀３０％฀ｏｒ฀ｍｏｒｅ

１０－ｐｏｉｎｔ฀（ｏｔｈｅｒ）฀ｐｒｅｆ．฀（ｕｓｅ฀ｗｈｅｎ฀ｙｏｕ฀ａｒｅ฀ａ฀ｓｐｏｕｓｅ， ｗｉｄｏｗ，฀ｏｒ฀ｍｏｔｈｅｒ฀ｏｆ฀ａ฀ｄｉｓａｂｌｅｄ฀ｖｅｔｅｒａｎ）

c.Kind of discharge? Mark (X) one box.

Ｈｏｎｏｒａｂｌｅ฀ｏｒ฀ｇｅｎｅｒａｌ฀ｕｎｄｅｒ฀ｈｏｎｏｒａｂｌｅ฀ｃｏｎｄｉｔｉｏｎｓ

Ｏｔｈｅｒ฀ｮ฀Explain in Item 32.

Section A – APPLICANT PERSONAL DATA – Con.

13a. Education – Mark (X) highest education level.

Ｓｏｍｅ฀ｈｉｇｈ฀ｓｃｈｏｏｌ฀ｮ฀Ｄｉｄ฀ｎｏｔ฀ｇｒａｄｕａｔｅ Ｈｉｇｈ฀ｓｃｈｏｏｌ฀ｄｉｐｌｏｍａ／ＧＥＤ

Ｔｅｃｈｎｉｃａｌ฀ｄｅｇｒｅｅ／Ｔｒａｄｅ฀ｓｃｈｏｏｌ฀ｄｅｇｒｅｅ฀ｏｒ฀ｃｅｒｔｉｆｉｃａｔｅ Ａｓｓｏｃｉａｔｅ＇ｓ฀ｄｅｇｒｅｅ

Ｂａｃｈｅｌｏｒ＇ｓ฀ｄｅｇｒｅｅ Ｍａｓｔｅｒ＇ｓ฀ｄｅｇｒｅｅ Ｄｏｃｔｏｒａｌ฀ｄｅｇｒｅｅ

b.Complete when a Technical/Trade school program,

an Associate’s, Bachelor’s, Master’s or		Ｄｅｇｒｅｅ	Ｙｅａｒ
Doctoral degree is selected in 13a.		（ｉｆ฀ａｎｙ）	ｒｅｃｅｉｖｅｄ
Ｎａｍｅ฀ｏｆ
ｉｎｓｔｉｔｕｔｉｏｎ
Ｃｉｔｙ
Ｓｔａｔｅ฀ｏｒ
ｃｏｕｎｔｒｙ

Section B – RECRUITING SOURCES

14.How did you hear about census job opportunities?

Mark (X) one box only.

Ｐｏｓｔｅｒ

Ｃｏｍｍｕｎｉｔｙ฀ｏｒ฀ｏｒｇａｎｉｚａｔｉｏｎ฀ｎｅｗｓｌｅｔｔｅｒ／ｎｅｗｓｐａｐｅｒ／ｌｅａｄｅｒ

Ｆｅｄｅｒａｌ，฀ｓｔａｔｅ，฀ｔｒｉｂａｌ฀ｅｍｐｌｏｙｍｅｎｔ฀ｏｆｆｉｃｅ／ Ｊｏｂ฀ｓｅｒｖｉｃｅ฀ａｎｄ฀ｉｎｆｏｒｍａｔｉｏｎ฀ｃｅｎｔｅｒ

Ｃｅｎｓｕｓ฀Ｒｅｃｒｕｉｔｅｒ

Ｆｒｉｅｎｄ฀ｏｒ฀ｒｅｌａｔｉｖｅ฀ｗｏｒｋｉｎｇ฀ｆｏｒ฀Ｃｅｎｓｕｓ

Ｔｏｌｌ－ｆｒｅｅ฀Ｃｅｎｓｕｓ฀ｎｕｍｂｅｒ฀ｏｒ฀ｊｏｂ฀ｌｉｎｅ

Ｃｅｎｓｕｓ฀ｊｏｂ฀ｍａｉｌｉｎｇ฀ｏｒ฀ｐｏｓｔｃａｒｄ

Ｆｒｉｅｎｄ฀ｏｒ฀ｒｅｌａｔｉｖｅ฀ｎｏｔ฀ｗｏｒｋｉｎｇ฀ｆｏｒ฀Ｃｅｎｓｕｓ

Ｊｏｂ฀Ｆａｉｒ

Ｎｅｗｓｐａｐｅｒ฀ｮ฀ａｄｖｅｒｔｉｓｅｍｅｎｔ

Ｎｅｗｓｐａｐｅｒ฀ｮ฀ａｒｔｉｃｌｅ

Ｒａｄｉｏ

Ｉｎｔｅｒｎｅｔ／Ｅ－Ｍａｉｌ

Ｓｃｈｏｏｌ฀ｏｒ฀ｃｏｌｌｅｇｅ

Ｃｅｎｓｕｓ฀Ｊｏｂ฀Ｗｅｂｓｉｔｅ

ＴＶ

Ｂｒｏｃｈｕｒｅ／Ｈａｎｄ－ｏｕｔ

Ｏｔｈｅｒ฀ｮ฀Specify

Section C – APPLICATION DATA

Most field positions require dealing with the public and knocking on doors to collect personal information, which may not be discussed or shared with anyone except for sworn Census Bureau employees.

15.Are you willing to work in the field, verifying household address listings and knocking on doors to collect information?

	Ｙｅｓ		Ｎｏ

Most office positions involve working with computers.

16.Are you willing to work in the office? (There are a limited number of these jobs available.)

Ｙｅｓ

Ｎｏ

17.Do you have computer or data entry experience?

Ｙｅｓ

Ｎｏ

18.Have you ever worked on previous census operations?

Ｙｅｓ

Ｎｏ

19.Are you now employed by a federal, state, local or tribal government? – If yes, indicate date of hire and current grade level in Item 32.

Ｙｅｓ ｮ Name of agency Ｎｏ

20.Are you now employed by a law enforcement agency?

Ｙｅｓ ｮ Name of agency Ｎｏ

21.Do you have supervisory experience?

	Ｙｅｓ ｮ Describe in Item 32.		Ｎｏ

22.Do you receive retirement or have you ever applied for retirement pay, pension, or other pay based on nonmilitary, federal civilian, or District of Columbia Government service?

Ｙｅｓ ｮ Explain in Item 32.

Ｎｏ

23.Do any of your relatives work for the Census Bureau?

Include – Father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, brother-in-law, sister-in-law, son-in-law, daughter-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and half sister.

Ｙｅｓ ｮ Provide location (city and state) and position.

Ｎｏ

24.Hiring may be based in part on the hours you are available to work. Indicate your availability by placing

	"X" in the appropriate
		Ｓｕｎ	Ｍｏｎ	Ｔｕｅｓ	Ｗｅｄ	Ｔｈｕｒｓ	Ｆｒｉ	Ｓａｔ
	box(es) for each day.

a. Ａｎｙ฀ｈｏｕｒｓ

b.Ｍｏｒｎｉｎｇ

（８฀ａ．ｍ．฀ｮ฀１２฀ｎｏｏｎ）

c.Ａｆｔｅｒｎｏｏｎ฀

（１２฀ｎｏｏｎ฀ｮ฀４฀ｐ．ｍ．）

d.Ｅｖｅｎｉｎｇ฀

（４฀ｐ．ｍ．฀ｮ฀９฀ｐ．ｍ．）

Ｃｅｎｓｕｓ฀ｆｉｅｌｄ฀ｗｏｒｋ฀ｗｉｌｌ฀ｕｓｕａｌｌｙ฀ｒｅｑｕｉｒｅ฀ｙｏｕ฀ｔｏ฀ｗｏｒｋ฀ｅｖｅｎｉｎｇｓ฀ａｎｄ ｗｅｅｋｅｎｄｓ．

Section D – LANGUAGE SKILLS

25.Ｓｏｍｅ฀ｃｅｎｓｕｓ฀ｊｏｂｓ฀ｒｅｑｕｉｒｅ฀ｃｅｎｓｕｓ฀ｅｍｐｌｏｙｅｅｓ฀ｔｏ฀ｃｏｎｄｕｃｔ฀ｔｈｅ฀ｃｅｎｓｕｓ

ｉｎｔｅｒｖｉｅｗ฀ｂｙ฀ｒｅａｄｉｎｇ฀ａｎｄ฀ｒｅｃｏｒｄｉｎｇ฀ｒｅｓｐｏｎｓｅｓ฀ｔｏ฀ｑｕｅｓｔｉｏｎｓ฀ｉｎ฀ａ฀ｌａｎｇｕａｇｅ ｏｔｈｅｒ฀ｔｈａｎ฀Ｅｎｇｌｉｓｈ．฀Ｔｈｅ฀ｃｅｎｓｕｓ฀ｅｍｐｌｏｙｅｅ฀ｍｕｓｔ฀ａｌｓｏ฀ｂｅ฀ａｂｌｅ฀ｔｏ฀ｃｏｎｖｉｎｃｅ ｉｎｄｉｖｉｄｕａｌｓ฀ｗｈｏ฀ｓｐｅａｋ฀ｎｏ฀Ｅｎｇｌｉｓｈ฀ｔｏ฀ｒｅｓｐｏｎｄ฀ｔｏ฀ｔｈｅ฀ｉｎｔｅｒｖｉｅｗ฀ｂｙ฀ｅｘｐｌａｉｎｉｎｇ ｔｈｅ฀ｐｕｒｐｏｓｅ฀ａｎｄ฀ｉｍｐｏｒｔａｎｃｅ฀ｏｆ฀ｔｈｅ฀ｃｅｎｓｕｓ．฀ Employees will receive

Census training, but not language training.

Ａｒｅ฀ｙｏｕ฀ｆｌｕｅｎｔ฀ｅｎｏｕｇｈ฀ｉｎ฀ａｎｙ฀ｓｐｅｃｉｆｉｃ฀ｌａｎｇｕａｇｅ฀ｔｏ฀ｈｏｌｄ฀ａ฀ｃｏｎｖｅｒｓａｔｉｏｎ，฀ｔｏ ｅａｓｉｌｙ฀ｒｅａｄ฀ａｎｄ฀ｒｅｃｏｒｄ฀ｒｅｓｐｏｎｓｅｓ，฀ａｓ฀ｗｅｌｌ฀ａｓ฀ｔｏ฀ｒｅｓｐｏｎｄ฀ｔｏ฀ｑｕｅｓｔｉｏｎｓ฀ｉｎ

ｔｈａｔ฀ｌａｎｇｕａｇｅ฀ｗｉｔｈ฀ｉｎｄｉｖｉｄｕａｌｓ฀ｗｈｏ฀ｓｐｅａｋ฀ no Ｅｎｇｌｉｓｈ？฀If so, please list the language(s) below and mark (X) to all that apply.

Ｌａｎｇｕａｇｅ（ｓ）	Ｓｐｅａｋ			Ｒｅａｄ			Ｗｒｉｔｅ

Section E – TRANSPORTATION

26a.Indicate the type(s) of transportation available for your use – Mark (X) ALL that apply.

Ａｕｔｏｍｏｂｉｌｅ

４－Ｗｈｅｅｌ฀Ｄｒｉｖｅ Ａｉｒｐｌａｎｅ

Ｂｏａｔ

ＡＴＶ฀（Ａｌｌ฀ｔｅｒｒａｉｎ฀ｖｅｈｉｃｌｅ） Ｏｔｈｅｒ฀ｮ฀Describe

Ｎｏｎｅ

b.Do you have a valid driver’s license?

Ｙｅｓ Ｎｏ

Signature

Print name

Date signed