Free Form 13896 (6-2007) - Federal

SES/CDP Application Intake Information
Applicant Information 1. Job title in announcement 3. Name Last name First name Middle name 2. Announcement Number

4. Mailing Address (Use Standard State Postal Codes (abbreviations). If outside the United States of America, and you do not have to have a military address, type or print "OV" in the State field, leaving the ZIP code field blank.) Street City State ZIP Code Country

5. Phone numbers (include area code if within the United States of America) Daytime Education 7. Mark highest level completed Some HS General 8. Are you a U.S. Citizen? HS/GED Associate Evening

6. Email address (if available)

Bachelor

Master

Doctoral

Yes Yes Yes To (mm/yyyy)

No No No

9. Are you eligible for reinstatement in the career SES? If yes, attach copy of Notification of Personnel Action (SF 50) as proof. 10. Were you ever a Federal civilian employee? If yes, fill in the information below showing the highest civilian grade held. Series Other Qualifications Grade From (mm/yyyy)

Job related education, publications, memberships in professional/honor societies, leadership activities, public speaking, etc. - give dates, but do not send documents or certificates.

Privacy Act Notice
This form solicits personal information from individuals applying for Senior Executive Service (SES) positions in the Internal Revenue Service or its SES Candidate Development Program. The authority to collect this information is 5 U.S.C. 301, 3131, 3301 and 3302. We need the information requested on this form to evaluate your qualifications. We may disclose this information to the Office of Personnel Management for review and certification of your Executive Core Qualifications. We may disclose this information to a former employer to confirm SES reinstatement eligibility, tenure of employment, civil service status, or length of service. We may also disclose this information to the Office of Special Counsel or the Equal Employment Opportunity Commission for adjudicating a complaint. You are not required to provide this information, however, failure to furnish the requested information may delay or prevent consideration of the application; providing false information may subject you to penalties.
Form 13896 (6-2007) Catalog Number 50261V Department of the Treasury - Internal Revenue Service