Free SF 171 - Hawaii

Application for Federal Employment--SF 171
GENERAL INFORMATION

Retrieve Data

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Form Approved: OMB No. 3206-0012

Read the instructions before you complete this application. Type or print clearly in dark ink.
DO NOT WRITE IN THIS AREA

1 2 4 6

What kind of job are you applying for? Give title and announcement no. (if any)

FOR USE OF EXAMINING OFFICE ONLY
Social Security Number

3 Sex
Male Female

Date entered register

//
Option Grade

Form reviewed: Form approved: Earned Rating Veteran Preference
No Preference Claimed 5 Points (Tentative)

Birth date (Month, Day, Year)

//
Name (Last, First, Middle)

5 Birthplace (City and State or Country)

Augmented Rating

Mailing address (include apartment number, if any)

City

State

ZIP Code

10 Pts. (30% Or More Comp. Dis.) 10 Pts. (Less Than 30% Comp. Dis.)

7 8 10

Other names ever used (e.g., maiden name, nickname, etc.) Initials and Date Home Phone
Area Code Number

Other 10 Points

9 Work Phone
Area Code Number Extension

//

Disallowed

Being Investigated

FOR USE OF APPOINTING OFFICE ONLY
Preference has been verified through proof that the separation was under honorable conditions, and other proof as required.
10-Point--30% or More Compensable Disability 10-Point--Less Than 30% Compensable Disability

Were you ever employed as a civilian by the Federal Government? If "NO", go to Item 11. If "YES", mark each type of job you held with an "X". Temporary Career-Conditional Career Excepted

5-Point

10-Point--Other

Signature and Title

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

Dates at highest grade: FROM //

TO

AVAILABILITY

MILITARY SERVICE AND VETERAN PREFERENCE (Cont.)

11 13 14

What is the lowest pay you will accept? (You will not be considered for jobs which pay less than you indicate.) Pay $ per OR Grade In what geographic area(s) are you willing to work? When can you start work? (Month and Year)

12

19

Were you discharged from the military service under honorable YES 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)

NO

//
Are you willing to work:

YES
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)?...............

NO

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 military 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.

15

F. Weekends, shifts, or rotating shifts?................... Are you willing to take a temporary job lasting: A. 5 to 12 months (sometimes longer)?.................. B. 1 to 4 months?....................................................

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.

16

C. Less than 1 month?............................................ 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 YES only active duty was training in the Reserves or National Guard, answer "NO". If "NO", go to item 22. ...........................................

NO
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 7540-00-935-7150 171-110
Standard Form 171 (Rev. 6-88) U.S. Office of Personnel Management FPM Chapter 295

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

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

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NO

23 24

YES May we ask your present employer about your character, qualifications, and work record? A "NO" will not affect our review of your 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. Describe your current or most recent job in Block A and work backwards, describing each job you held during the past 10 years. If you were unemployed for longer than 3 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 work is related to the type of job you are applying for, describe each related job in a separate block. INCLUDE VOLUNTEER WORK (non-paid work)--If the work (or a part of the work) is like the job you are applying for, complete all parts of the experience block just as you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other Name and address of employer's organization (include ZIP Code, if known)

INCLUDE MILITARY SERVICE--You should complete all parts of the experience block just as you would for a non-military job, including all supervisory experience. Describe each 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 this page (be sure to include all information we ask for in A and B below). On each sheet show your name, Social Security Number, and the announcement number or job title. IF YOU NEED MORE EXPERIENCE BLOCKS, use the SF 171-A or a sheet of paper. IF YOU NEED TO UPDATE (ADD MORE RECENT JOBS), use the SF 172 or a Dates employed (give month, day and year) Average number of Number of employees hours per week you supervise From: // Salary or earnings Starting $ Ending $ To: Your reason for wanting to leave per per If Federal employment (civilian or military) list series, grade or rank, and, if promoted in this job, the date of your last promotion

A

Your immediate supervisor Name

Exact title of your job Telephone No.

//
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.)

B

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

Dates employed (give month, day and year) Average number of hours per week From: // Salary or earnings Starting $ Ending $ To:

Number of employees you supervise

//
Your reason for leaving per per If Federal employment (civilian or military) list series, grade or rank, and, if promoted in this job, the date of your last promotion

Your immediate supervisor Name

Exact title of your job Telephone No.

//
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.)

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

ATTACH ANY ADDITIONAL FORMS AND SHEETS HERE EDUCATION

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25

Did you graduate from high school? If you have a GED high school equivalency or will graduate within the next nine months, answer "YES".

26 27

Write the name and location (city and state) of the last high school you attended or where you obtained your GED high school equivalency.

YES NO

28

> >

If "YES", give month and year graduated or received GED equivalency: . . . . . . . . . . . . . If "NO", give the highest grade you completed:

YES Have you ever attended college or graduate school? NO
MONTH AND YEAR ATTENDED From To

> >

If "YES", continue with 28. If "NO", go to 31.

NAME AND LOCATION (city, state and ZIP Code) OF COLLEGE OR UNIVERSITY. If you expect to graduate within nine months, give the month and year you expect to receive your degree:
Name City State ZIP Code

NUMBER OF CREDIT TYPE OF MONTH AND HOURS COMPLETED DEGREE YEAR OF (e.g., DEGREE Semester Quarter B.A.,M.A.)

1)

2)

3)

29
1) 2) 3)

CHIEF UNDERGRADUATE SUBJECTS Show major on the first line

NUMBER OF CREDIT HOURS COMPLETED Semester Quarter

30
1) 2) 3)
MONTH AND YEAR ATTENDED From To

CHIEF GRADUATE SUBJECTS Show major on the first line

NUMBER OF CREDIT HOURS COMPLETED Semester Quarter

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 School Name 1) City
CLASSROOM HOURS

SUBJECT(S)

TRAINING COMPLETED

YES NO

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?

34
1) 2)

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 OR CERTIFICATE STATE OR OTHER LICENSING AGENCY

Agencies may test your skills before hiring you.

35

Do you speak or read a language other than English (include sign language)? Applicants for jobs that require a language other than English may be given an interview conducted solely in that language.

YES NO

LANGUAGE(S) 1) 2)

CAN PREPARE AND CAN SPEAK AND UNDERSTAND GIVE LECTURES Fluently With Difficulty Fluently Passably

> >

// //
If "YES", list each language and place an "X" in each column that applies to you. If "NO", go to 36.
CAN TRANSLATE ARTICLES Into English From English CAN READ ARTICLES FOR OWN USE Easily With Difficulty

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) (Include Area Code) PRESENT BUSINESS OR HOME ADDRESS (Number, street and city) STATE ZIP CODE

1)

2)

3)

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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 identity and citizenship at the time you are hired.) If "NO", give the country or countries you are a citizen of :

YES

NO

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).

YES

NO

38 39 40 41 42 43 44 45

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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Have you ever been convicted of, or forfeited collateral for any felony violation? (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.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Have you ever been convicted of, or forfeited collateral for any firearms or explosives violation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Are you now under charges for any violation of law? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 39, 40, or 41, above. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Have you ever been convicted by a military court-martial? If no military service, answer "NO". . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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.) . . . . . . . . . . . . . . . . . . . . . . If "YES" in: 38 - Explain for each job the problem(s) and your reason(s) for leaving. Give the employer's name and address. 39 through 43 - 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

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

YES

NO

46 47

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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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; 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. Name Relationship Department, Agency or Branch of Armed Forces

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. I understand that any information I give may be investigated as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies and other individuals and organizations, to investigators, personnel staffing specialists, and other authorized employees of the Federal Government. I certify that, to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith.

48

SIGNATURE (Sign each application in dark ink)

49
Print Email Form

DATE SIGNED (Month, day, year)

//
U.S. Government Printing Office: 1992 312-071/50009

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