Sf 171 Form PDF Details

The Sf 171 form is a document used to request information from an agency or organization. This document can be used to request general information or specific data about the agency's programs and services. The form can also be used to identify potential employment opportunities with the agency. The Sf 171 form is typically used by individuals who are interested in working for the government or who are seeking information about government programs and services.

Here, you may find a number of information regarding sf 171 form PDF. You may look at it before submitting the form.

QuestionAnswer
Form NameSf 171 Form
Form Length4 pages
Fillable?Yes
Fillable fields313
Avg. time to fill out31 min 48 sec
Other nameshow to application federal, sf 171 form, sf 171 leave form, form sf 171

Form Preview Example

Released 6/29/00.

Application for Federal Employment - SF 171

Read the instructions before you complete this application. Type or print clearly in dark ink.

Form Approved OMB No. 3206-0012

GENERAL INFORMATION

1

What kind of job are you applying for?

Give title and announcement no. (if any)

2

 

 

 

 

 

 

Social Security Number

3

Sex

 

 

 

 

Male

 

Female

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

Birth date (Month, Day, Year)

5

Birthplace (City and State or Country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6 Name (Last, First, Middle)

Mailing address (include apartment number, if any)

 

City

 

State

ZIP Code

 

7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other names ever used (e.g., maiden name, nickname, etc.)

 

 

 

8

 

 

 

 

 

 

 

Home Phone

9 Work Phone

 

 

 

 

 

Area Code

Number

Area Code

 

Number

 

Extension

 

 

 

 

 

 

 

 

 

Were you ever employed as a civilian by the Federal Government? If "NO", go to

10 Item 11. If "YES ", mark each type of job you held with an "X".

 

Temporary

Career-Conditional

Career

Excepted

What is your highest grade, classification series and job title?

Dates at highest grade: FROM

TO

DO NOT WRITE IN THIS AREA

FOR USE OF EXAMINING OFFICE ONLY

Date entered register

Form reviewed:

 

 

 

 

 

Form approved:

 

 

 

 

 

 

 

 

 

 

 

Option

Grade

Earned

Veteran

Augmented

Rating

Preference

Rating

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

Preference

 

 

 

 

 

 

 

Claimed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5 Points

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Tentative)

 

 

10 Pts. (30% or More Comp. Dis.)

10 Pts. (Less than 30% Comp. Dis.)

Other

10 Points

Initials and Date

Being

Investi-

Disallowed gated

FOR USE OF APPOINTING OFFICE ONLY

Preference has been verified through proof that the separation was

under honorable conditions, and other proof as required.

5-Point

 

10-point - 30% or More

 

10-point - Less Than 30%

 

10-Point -

 

Compensable Disability

 

Compensable Disability

 

Other

Signature and Title

 

Agency

Date

 

 

 

 

 

 

 

 

 

AVAILABILITY

11 When can you start work?

12 What is the lowest pay you will accept? (You will

(Month and Year)

not be considered for jobs which pay less than you

 

indicate.)

 

 

 

 

 

Pay $

Per

 

OR Grade

 

 

 

 

 

 

 

 

13 In what geographic area(s) are you willing to work?

 

 

 

 

14 Are you willing to work:

 

 

 

 

 

YES NO

A.40 hours per week (full-time)?

B.25-32 hours per week (part-time)?

C.17-24 hours per week (part-time)?

D.16 or fewer hours per week (part-time)?

E.An intermittent job (on call/seasonal)?

F.Weekends, shifts, or rotating shifts?

15 Are you willing to take a temporary job lasting:

A.5 to 12 months (sometimes longer)?

B.1 to 4 months?

C.Less than 1 month?

16 Are you willing to travel away from home for:

A.1 to 5 nights each month?

B.6 to 10 nights each month?

C.11 or more nights each month?

MILITARY SERVICE AND VETERAN PREFERENCE

17 Have you served in the United States Military Service? If your only YES NO active duty was training in the Reserves or National Guard,

answer "NO", If "NO", go to item 22.

18 Did you or will you retire at or above the rank of major or lieutenant commander?

THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER

PREVIOUS EDITION USABLE UNTIL 12-31-90

Page 1

MILITARY SERVICE AND VETERAN PREFERENCE (Cont.)

19 Were you discharged from the military service under honorable

YES NO

 

 

conditions? (If your discharge was changed to "honorable" or "general"

 

 

 

by a Discharge Review Board, answer "YES". If you received a clemency

 

 

 

discharge, answer "NO".)

 

 

 

 

If "NO ", provide below the date and type of discharge you received.

 

 

 

 

 

 

 

 

 

Discharge Date

 

Type of Discharge

 

 

(Month, Day, Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

20 List the dates (Month, Day, Year) , and branch for all active duty military service

From

To

Branch of Service

21 If all your active duty was after October 14, 1976, list the full names and dates of all campaign badges or expeditionary medals you received or were entitled to receive.

22 Read the instructions that came with this form before completing this item. When you have determined your eligibility for veteran preference from the instructions, place an "X" in the box next to your veteran preference claim.

NO PREFERENCE

5-POINT PREFERENCE - You must show proof when you are hired.

10-POINT PREFERENCE - If you claim 10-point preference, place an "X" in the

box below next to the basis for your claim. To receive 10-point preference you must also complete a Standard Form 15, Application for 10-Point Veteran Preference, which is available from any Federal Job Information Center. ATTACH THE COMPLETED SF 15 AND REQUESTED PROOF TO THIS APPLICATION.

Non-compensably disabled or Purple Heart recipient.

Compensably disabled, less than 30 percent.

Spouse, widow(er), or mother of a deceased or disabled veteran.

Compensably disabled, 30 percent or more.

NSN 7540-00-935-7150171-110 Standard Form 171 (Rev. 6-88) U.S. Office of Personnel Management

FPM Chapter 295

WORK EXPERIENCE If you have no work experience, write "NONE" in A below and go to 25 on page 3.

23 May we ask your present employer about your character, qualifications, and work record?

A "NO" will not affect our review of your

 

YES

NO

qualifications. If you answer "NO" and we need to contact your present employer before we can offer you a job, we will contact you first.

 

 

 

 

 

 

 

 

 

 

 

READ WORK EXPERIENCE IN THE INSTRUCTIONS BEFORE YOU BEGIN.

. INCLUDE MILITARY SERVICE -- You should complete all parts of the experience

 

 

 

block just

24.

Describe your current or most recent job in Block A and work backwards, describing

as you would for a non-military job, including all supervisory experience. Describe each

 

 

 

each job you held during the past 10 years. If you were unemployed for longer than 3

major change of duties or responsibilities in a separate experience block.

 

 

 

. IF YOU NEED MORE SPACE TO DESCRIBE A JOB -- Use sheets of paper the same size as

 

months within the past 10 years, list the dates and your address(es) in an experience block.

. You may sum up in one block work that you did more than 10 years ago. But, if that

this page (be sure to include all information we ask for in A and B below). On each

 

 

 

work is related to the type of job you are applying for, describe each related job in a

sheet show your name, Social Security Number, and the announcement number or job

 

 

.

separate block.

title.

 

 

INCLUDE VOLUNTEER WORK. (non-paid work) -- If the work (or a part of the work) is

. IF YOU NEED MORE EXPERIENCE BLOCKS, use the SF 171-A or a sheet of paper.

 

like the job you are applying for, complete all parts of the experience block just as

. IF YOU NEED TO UPDATE (ADD MORE RECENT JOBS), use the SF 172 or a sheet of

 

you would for a paying job. You may receive credit for work experience with religious,

 

community, welfare, service, and other organizations.

paper as described above.

 

 

A

Name and address of employer's organization(include ZIP Code, if known)

Datesemployed(givemonth,dayandyear)

Average number of

Number of employees

 

 

 

From:

 

To:

hours per week

you supervise

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary or earnings

 

Your reason for leaving

 

 

 

Starting

$

per

 

 

 

 

 

 

Ending

$

per

 

 

 

 

 

 

 

 

 

 

 

Your immediate supervisor

 

Exact title of your job

 

 

If Federal employment (civilian or military) list series, grade or

 

Name

Area CodeTelephone No.

 

 

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ForAgencyUse(skillcodes,etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

Name and address of employer's organization(include ZIP Code, if known)

Datesemployed(givemonth,dayandyear)

Average

number of

Number of employees

 

 

 

 

 

From:

 

To:

hours per week

you supervised

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Salary or earnings

 

Your reason for leaving

 

 

 

 

 

 

Starting

$

per

 

 

 

 

 

 

 

 

 

 

 

Ending

$

per

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your immediate supervisor

 

Exact title of your job

 

 

If Federal employment (civilian or military) list series, grade or

 

 

 

Name

Area CodeTelephone No.

 

 

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 supervised. 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.

ForAgencyUse(skillcodes,etc.)

Page 2 IF YOU NEED MORE EXPERIENCE BLOCKS, USE SF 171-A (SEE BACK OF INSTRUCTION PAGE).

ATTACH ANY ADDITIONAL FORMS AND SHEETS HERE

EDUCATION

 

 

 

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

 

 

 

 

Write the name and location (city and state) of the last high school you attended or

 

25 equivalency or will graduate within the next nine months, answer "YES ".

 

 

26 where you obtained your GED high school equivalency.

 

 

 

 

 

 

 

 

 

 

 

 

 

If "YES", give month and year graduated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever attended

 

 

 

 

 

If "YES ", continue with 28.

 

 

 

 

 

 

 

 

 

 

 

 

 

or received GED equivalency:

 

 

 

 

 

 

27 college or graduate

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

If "NO", give the highest grade you completed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

If "NO ", go to 31 .

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

school?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28

 

 

NAME AND LOCATION (city, state and ZIP Code) OF COLLEGE OR UNIVERSITY. If you expect to grad-

 

 

 

MONTH AND YEAR

NUMBER OF CREDIT

 

DEGREE

 

 

 

AND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF

 

 

MONTH

 

 

 

 

uate within nine months, give the month and year you expect to receive your degree:

 

 

 

 

 

 

 

ATTENDED

HOURS COMPLETED

 

(e.g. B.A.,

 

 

YEAR OF

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

City

 

State

ZIP Code

 

From

 

To

Semester

Quarter

 

M.A.)

 

 

DEGREE

 

 

 

 

1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29

 

CHIEF UNDERGRADUATE SUBJECTS

 

NUMBER OF CREDIT

30

 

 

 

 

 

 

CHIEF GRADUATE SUBJECTS

 

NUMBER OF CREDIT

 

 

 

 

Show major on the first line

 

HOURS COMPLETED

 

 

 

 

 

 

 

Show major on the first line

 

 

 

 

HOURS COMPLETED

 

 

 

 

 

 

 

 

 

 

 

Semester

Quarter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Semester

 

 

Quarter

 

 

 

 

1)

 

 

 

 

 

 

 

 

 

 

 

1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2)

 

 

 

 

 

 

 

 

 

 

 

2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3)

 

 

 

 

 

 

 

 

 

 

 

 

3)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31

 

If you have completed any other courses or training related to the kind of jobs you are applying for (trade,

vocational, Armed Forces, business) give information below.

 

 

 

 

 

 

 

 

 

 

 

NAME AND LOCATION (city, state and ZIP Code) OF SCHOOL

MONTH AND YEAR

CLASS-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRAINING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTENDED

 

ROOM

 

 

 

 

 

 

SUBJECT(S)

 

COMPLETED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From

 

To

 

HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

School Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

School Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPECIAL SKILLS, ACCOMPLISHMENTS AND AWARDS

32 Give the title and year of any honors, awards or fellowships you have received. List your special qualifications, skills or accomplishments that may help you get a job. Some examples are: skills with computers or other machines; most important publications (do not submit copies); public speaking and writing experience; membership in professional or scientific societies; patents or inventions; etc.

33 How many words per minute can you:

TYPE? TAKE DICTATION?

Agenciesmaytestyour skillsbeforehiringyou.

34

List job-related licenses or certificates that you have, such as: registered nurse; lawyer; radio operator; driver's; pilot's; etc.

 

LICENSE OR CERTIFICATE

DATE OF LATEST LICENSE

STATE OR OTHER

 

OR CERTIFICATE

LICENSING AGENCY

 

 

1)

2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you speak or read a language other than English (include sign

 

 

 

YES

 

 

If "YES", list each language and place an "X" in each column that applies to you.

35 language) ? Applicantsforjobsthatrequirealanguageotherthan

 

 

 

 

 

 

 

If "NO", go to 36.

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

Englishmaybegivenaninterviewconductedsolelyinthatlanguage.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LANGUAGE(S)

 

 

CAN PREPARE AND

CAN SPEAK AND UNDERSTAND

CAN TRANSLATE ARTICLES

CAN READ ARTICLES

 

 

 

 

 

GIVE LECTURES

 

 

 

 

FOR OWN USE

 

 

 

 

 

 

Fluently

 

With Difficulty

Fluently

Passably

Into English

From English

Easily

With Difficulty

 

1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

36

List three people who are not related to you and are not supervisors you listed under 24 who know your qualifications and fitness for the kind of job for which you are applying.

 

 

At least one should know you well on a personal basis.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FULL NAME OF REFERENCE

TELEPHONE NUMBER(S)

PRESENT BUSINESS OR HOME ADDRESS

STATE

ZIP CODE

 

 

 

(Include Area Code)

 

(Number, street and city)

 

 

 

 

 

 

 

 

1)

2)

3)

Page 3

BACKGROUND INFORMATION -- You must answer each question in this section before we can process your application.

37 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

YES NO

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).

38 During the last 10years, were you firedfromanyjobfor any reason, did you quitafterbeingtoldthatyouwouldbefired, or did you

YES

NO

 

 

leave by mutual agreement because of specific problems?

 

 

 

39 Have you everbeen convicted of, or forfeited collateral for anyfelonyviolation? (Generally, a felony is defined as any violation of law

 

 

 

 

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.)

 

 

 

40 Have you everbeen convicted of, or forfeited collateral for anyfirearmsorexplosivesviolation?

 

 

 

 

 

 

 

 

 

 

41 Are you now under charges for anyviolation of law?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

42 During the last10yearshave you forfeited collateral, been convicted, been imprisoned, been on probation, or been on parole? Do not

 

 

include violations reported in 39, 40, or 41, above

 

 

 

43 Have you everbeen convicted by a military court-martial? If no military service, answer "NO"

 

 

 

44 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 plusdefaults on Federally guaranteed or insured loans such as a 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. 39through43 - 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 No.

Date

(Mo./Yr.)

Explanation

 

MailingAddress

 

 

Name of Employer, Police, Court, or Federal Agency

 

 

 

 

 

 

 

City

 

State

ZIP Code

 

 

 

 

 

 

 

 

Name of Employer, Police, Court, or Federal Agency

 

 

 

 

 

 

 

City

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

47 Do any of your relatives work for the United States Government or the United States Armed Forces? 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; 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.

YES NO

Name

Relationship

Department,AgencyorBranchofArmedForces

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.

Iunderstand that any information I give may be investigated as allowed by law or Presidential order.

.

Iconsentto the release of information about my ability and fitness for Federal employment byemployers, schools, law enforcement agencies and other

.

individuals and organizations, to investigators, personnel staffing specialists, and other authorized employees of the Federal Government.

Icertifythat, to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith.

48 SIGNATURE(Signeachapplicationindarkink)

49DATESIGNED(Month,day,year)

Page 4

*U.S. Government Printing Office: 1992 312-071/50114

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Enter the appropriate information in Temporary, Career, Conditional Career, Excepted, Point, point, or, More, Com, pens, able, Disability pointLess, Than, Com, pens, able, Disability Point, Other Signature, and, Title Dates, at, highest, grade, FROM Agency, Date, Month, and, Year Pay, and Per segment.

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The YES, NO Dates, employed, give, month, day, and, year From, Salary, or, earnings, Starting, Ending per, per you, supervise Your, reason, for, leaving Your, immediate, supervisor, Name Area, Code, Telephone, No and Exact, title, of, your, job area needs to be applied to put down the rights or obligations of both parties.

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End by checking the following sections and writing the proper data: Dates, employed, give, month, day, and, year From, Salary, or, earnings, Starting, Ending per, per you, supervised Your, reason, for, leaving Your, immediate, supervisor, Name Area, Code, Telephone, No and Exact, title, of, your, job

sf 171 form Datesemployedgivemonthdayandyear, FromSalaryorearningsStartingEnding, perper, yousupervised, Yourreasonforleaving, YourimmediatesupervisorName, AreaCodeTelephoneNo, and Exacttitleofyourjob blanks to fill out

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