Form Fsa 675 PDF Details

The FSA-675 form represents a crucial document for individuals aspiring to secure county employment within the U.S. Department of Agriculture's Farm Service Agency (FSA). Developed under the auspices of the Privacy Act of 1974 and the Paperwork Reduction Act of 1980, as amended, it serves as the primary application individuals must complete to be considered for roles at FSA county offices. The form, approved with an OMB No. 0560-0016, gathers comprehensive data spanning personal information, education, military service, work history, and various certifications about the applicant's background and eligibility for employment. Crucially, it asks for disclosure about any convictions, parole, probation, or delinquent federal debt, reflecting the government's commitment to thorough and transparent evaluation processes. Applicants also provide information regarding education, previous employments, farm or agri-business experience, and any potential conflicts of interest, such as holding positions in farm or commodity organizations. By supplying this information voluntarily, candidates facilitate the recruitment, screening, and selection processes, although non-compliance might render them ineligible for consideration. The USDA’s non-discrimination policy underscores its broad commitment to equality, ensuring a fair opportunity for all applicants regardless of their background. As such, the FSA-675 form is not only a procedural necessity but also a reflection of the USDA's broader ethical and procedural standards for employment.

QuestionAnswer
Form NameForm Fsa 675
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesfsa 675, form 6755, form fsa agency, fsa employment application

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REPRODUCE LOCALLY. Include date and form number on all reproductions.

Form Approved - OMB No. 0560-0016

FSA-675

U. S. DEPARTMENT OF AGRICULTURE

(07-02-99)

Farm Service Agency

APPLICATION FOR FSA COUNTY EMPLOYMENT

1. STATE

2. COUNTY

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a) and the Paperwork Reduction Act of 1980, as amended. The authority for requesting the following information is 7 CFR Part 7. The information will be used for recruitment, screening and selection of candidates for FSA County Office employment. Furnishing the requested information is voluntary; however, persons not furnishing it will not be considered for employment. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal Law enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including 18 USC 286, 287, 371, 651, 1001; 15 USC 714m; and 31 USC 3729, may be applicable to the information provided.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0016. The time required to complete this information collection is estimated to average 64 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. RETURN THIS COMPLETED FORM TO YOUR COUNTY FSA OFFICE.

3. POSITION APPLIED FOR

 

 

4. LOWEST SALARY ACCEPTABLE

5. NO. DAYS NOTICE REQUIRED

 

 

 

 

BEFORE REPORTING TO DUTY

 

 

 

$

 

 

 

 

 

 

6. NAME (First)

(Middle)

(Maiden)

(Last)

7. SOCIAL SECURITY NUMBER

 

 

 

 

 

8. ADDRESS (street, rural route, city, state, zip code)

9.U.S. CITIZEN?

YES

 

NO

 

 

 

 

 

 

 

10. TELEPHONE NUMBER (Include area code)

11. PLACE OF BIRTH (town or city, state)

YES

NO

12.Have you ever been convicted of, or forfeited collateral for any firearms or explosive violation?

13.Are you now under charges for any violation of law?

14. During the last 10 years have you forfeited collateral, been convicted, been imprisoned, been on probation, or been on parole? Do not include violations reported in 13 or 14, above.

15. Have you ever been convicted by a military court-martial? If no military service, answer “NO”.

16. Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgage loans.)

17. If “YES” in: 15 - Explain each violation. Give place of occurrence and name/address of police or court involved.

16 - 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 NO.

DATE

EXPLANATION

 

MAILING ADDRESS

 

 

 

 

 

 

 

 

 

 

Name of Employer, Police, Court, or Federal Agency

 

 

 

 

 

 

 

 

 

 

 

City

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employer, Police, Court, or Federal Agency

 

 

 

 

 

 

 

 

 

 

City

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. Do any of your relatives work for the United States Government, the United States Armed Forces, or any County FSA Office? If “yes”, include: father; mother; husband, wife; son; daughter; brother; sister; uncle; aunt; first cousin, nephew; niece; father-in-law; mother-in-law; son-in-law; daughter-in-law, brother-in-law, and sister-in-law.

YES

NO

NAME

RELATIONSHIP

DEPARTMENT, AGENCY, OR BRANCH OF ARMED

FORCES

19.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 leave by mutual agreement because of specific problems?

YES

NO

20.Do you receive, or have you applied for retirement pay, pension or other based on military, Federal civilian, or District of Columbia Government service?

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W , W hitten Building, 1400 Independence Avenue, SW , W ashington, D.C. 20250-9410 or call (202) 720-5964 (voice or TDD). USDA is an equal opportunity provider and employer.

FSA-675 (07-02-99) (Page 2)

21.

Do you hold any office or serve in any position with a general or specialized

YES

NO

If yes, give the names of the organization and the offices and

 

farm or commodity organization.

positions held. You may be required to give up these positions if

 

 

 

 

 

 

 

you are accepted for employment with FSA.

 

 

 

 

(Attach a separate sheet, if necessary.)

 

 

 

 

 

22.

During any past FSA service, have you ever been removed from office or are

 

 

If yes, give details and attach a separate sheet.

 

you at present disqualified for future FSA employment?

 

 

 

 

 

 

 

 

23.

EDUCATION

 

 

 

A.

Did you graduate from high school? If you have a GED high school

 

equivalency or will graduate within the next nine months, answer “YES”.

 

 

If “YES”, give month, and

MONTH

YEAR

YES

 

year graduated or received

 

 

 

 

 

 

GED equivalency.

 

 

 

 

If “NO”, give the highest

HIGHEST GRADE COMPLETED

NO

 

grade you completed.

 

 

 

 

 

 

 

 

 

 

B. DESCRIBE ANY SPECIAL TRAINING YOU RECEIVED WHICH MAY BE HELPFUL TO YOU IN WORKING FOR THE COUNTY FSA OFFICE.

C. List All Other Schools Attended Above High School Level and Give the Following Information:

1. NAME AND LOCATION

2. DATES ATTENDED

3. COMPLETED

4. CHECK

 

 

 

 

 

 

 

 

SCHOOL

CREDIT HOURS

 

 

FROM

TO

(Semester or

DAY

NIGHT

YEARS

 

 

Quarters)

 

 

 

 

 

 

 

 

 

 

 

 

 

5. DEGREES RECEIVED

D.Major field of study at highest level of college work:

1. CHIEF UNDERGRADUATE COLLEGE SUBJECTS STUDIED AND/OR DEGREE LEVEL

2. CREDIT HOURS EARNED

SEMESTER

QUARTER

 

 

3.CHIEF GRADUATE COLLEGE SUBJECTS STUDIED

4. CREDIT HOURS EARNED

SEMESTER

QUARTER

 

 

24. MILITARY SERVICE

A. BRANCH OF SERVICE

B. DATE OF ENTRY

C. DATE OF DISCHARGE

D. TYPE OF DISCHARGE

 

 

 

 

25.REFERENCES (Give name, address and occupation of two persons not related to you who have knowledge of your qualifications and abilities)

A.

NAME

ADDRESS

OCCUPATION

 

 

 

 

B.

NAME

ADDRESS

OCCUPATION

 

 

 

 

26. FARM/AGRI-BUSINESS EXPERIENCE (Give dates, nature, type, and extent of your experience)

FSA-675 (07-02-99) (Page 3)

27. EXPERIENCE (Start with current or last position and work back)

1

 

A. DATE OF EMPLOYMENT

 

B. SALARY

 

C. TITLE OF POSITION

 

 

 

 

 

 

 

 

 

 

FROM (Mo., Yr..)

 

TO(Mo., Yr..)

STARTING

PER

FINAL

PER

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

D. NAME AND ADDRESS OF EMPLOYER

 

 

 

 

E. NO. HOURS PER WEEK WORKED (If

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other than full time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. REASON FOR LEAVING

 

 

 

 

 

 

 

 

 

G. DESCRIPTION OF WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

A. DATE OF EMPLOYMENT

 

B. SALARY

 

C. TITLE OF POSITION

 

 

 

 

 

 

 

 

 

FROM (Mo., Yr..)

 

TO(Mo., Yr..)

STARTING

PER

FINAL

PER

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

D. NAME AND ADDRESS OF EMPLOYER

 

 

 

 

E. NO. HOURS PER WEEK WORKED (If

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other than full time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. REASON FOR LEAVING

 

 

 

 

 

 

 

G. DESCRIPTION OF WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

A. DATE OF EMPLOYMENT

 

B. SALARY

 

C. TITLE OF POSITION

 

 

 

 

 

 

 

 

 

FROM (Mo., Yr..)

 

TO(Mo., Yr..)

STARTING

PER

FINAL

PER

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

D. NAME AND ADDRESS OF EMPLOYER

 

 

 

 

E. NO. HOURS PER WEEK WORKED (If

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other than full time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. REASON FOR LEAVING

 

 

 

 

 

 

 

G. DESCRIPTION OF WORK

 

 

 

 

 

 

FSA-675 (07-02-99) (Page 4)

4

 

A. DATE OF EMPLOYMENT

 

B. SALARY

 

 

C. TITLE OF POSITION

 

 

 

 

 

 

 

 

 

 

 

FROM (Mo., Yr..)

 

TO(Mo., Yr..)

STARTING

PER

FINAL

PER

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

D. NAME AND ADDRESS OF EMPLOYER

 

 

 

 

E.

NO. HOURS PER WEEK WORKED (If

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other than full time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. REASON FOR LEAVING

 

 

 

 

 

 

 

 

G. DESCRIPTION OF WORK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

A. DATE OF EMPLOYMENT

 

B. SALARY

 

 

C. TITLE OF POSITION

 

 

 

 

 

 

 

 

 

 

 

FROM (Mo., Yr..)

 

TO(Mo., Yr..)

STARTING

PER

FINAL

PER

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

D. NAME AND ADDRESS OF EMPLOYER

 

 

 

 

E.

NO. HOURS PER WEEK WORKED (If

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other than full time)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. REASON FOR LEAVING

 

 

 

 

 

 

 

 

G. DESCRIPTION OF WORK

 

 

 

 

 

 

 

NOTE: It is important that all periods of County FSA employee service and Civil Service employment be reflected in this application. If you have service of this type which has not already been noted in this application, attach a separate sheet citing each period of such service.

28. CERTIFICATION

I certify that the statements made by me in this application are true, complete, and correct and made in good faith. A false statement on any part of your application may be grounds for not hiring you, or for firing you after you begin work.

SIGNATURE OF APPLICANT

 

 

 

DATE

 

 

 

 

 

 

29. APPROVALS

 

 

 

 

 

 

 

 

 

 

A. MEETS QUALIFICATION STANDARDS

 

 

B. APPROVED FOR EMPLOYMENT

 

 

 

 

 

 

NAME

 

NAME

 

 

 

 

 

 

 

 

 

TITLE

DATE

TITLE

 

 

DATE

 

 

 

 

 

 

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