Free 117... - Federal

Supplemental Qualifications Statement

Form Approved OMB No. 3206-003

LIST OF COLLEGE COURSES AND CERTIFICATION OF SCHOLASTIC ACHIEVEMENT
Complete and submit this form with your Application for Federal Employment or as instructed
1. Name: (Last, First, MI) 2. Birth Date (Month, day, year) 3. Social Security Number

4. Position for which you are applying (Include options, if any) 5. List the undergraduate and/or graduate college degrees you have received or expect to receive (Give name of degree, name of college or university granting degree and date received or to be received)

6. State your major undergraduate course(s) of study

6a. State your major graduate course(s) of study.

PART 1 - COLLEGE COURSES List below by appropriate academic field (e.g., biology, mechanical engineering, economics, sociology, etc.) all courses you have taken (including those failed) which appear to satisfy the qualification requirements of positions for which you are applying. List graduate and undergraduate courses separately. Credits for each category should be totaled to determine if you meet the minimum course requirements. Indicate Academic Field:
DESCRIPTIVE TITLE Completion Date Grade Sem Qtr Class Room

Indicate Academic Field:
DESCRIPTIVE TITLE Completion Date Grade Sem Qtr Class Room

TOTAL U.S. Office of Personnel Management

TOTAL OPM-1170/17

Indicate Academic Field:
DESCRIPTIVE TITLE Completion Date Grade Sem Qtr Class Room

Indicate Academic Field:
DESCRIPTIVE TITLE Completion Date Grade Sem Qtr Class Room

TOTAL

TOTAL

Indicate Academic Field:
DESCRIPTIVE TITLE Completion Date Grade Sem Qtr Class Room

Indicate Academic Field:
DESCRIPTIVE TITLE Completion Date Grade Sem Qtr Class Room

TOTAL

TOTAL

Indicate Academic Field:
DESCRIPTIVE TITLE Completion Date Grade Sem Qtr Class Room

Indicate Academic Field:
DESCRIPTIVE TITLE Completion Date Grade Sem Qtr Class Room

TOTAL

TOTAL PART II - PRIVACY ACT STATEMENT AND CERTIFICATION

The Office of Personnel Management is authorized by section 1302 of Chapter 12 (Special Authority) and sections 3301 and 3304 of Chapter 33 (Examination, Certification, and Appointment:) of Title 5 of the U.S. Code to collect the information on this form. Executive Order 9397 (Numbering System for Federal Accounts Relating to Individual Persons) authorizes the collection of your Social Security Number (SSN). Your SSN is used to identify this form with your basic application. It may be used for the same purposes as stated on the application. The information you provide will be used primarily to determine your qualifications for Federal employment. Other possible uses or disclosures of the information are: 1. To make requires for information about from any source; (e.g., former employers or schools).that would assist an agency in determining whether to hire you. 2. To refer your application to prospective Federal Employers and, with your consent, to others (e.g., State and local governments) for possible employment. 3. To a Federal, State, or local agency for checking on violations of law or other lawful purposes in connection with hiring or retaining you on the job, or issuing you a security clearance; 4. To the courts when the Government is party to a suit; and 5. When lawfully required by Congress, the Office of Management and Budget, or the General Services Administration. Providing the information requested on this form, including your SSN is voluntary. However, failure to do so may result in your not receiving an accurate rating, which may hinder your chances for obtaining Federal employment. PUBLIC BURDEN INFORMATION: Public burden reporting for this collection of information is estimated to take approximately 40 minutes per response, including time for review instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Reports and Forms Management Office, U.S. Office of Personnel Management, 1900 E Street N.W., Room CHP 500 Washington, D.C. 20415; and to the Office of Management and Budget, Paperwork Reduction Project (3200-0038), Washington, D.C. 20503.

ATTENTION - THIS STATEMENT MUST BE SIGNED Read the following paragraph carefully before signing this statement A false answer to any question in this Statement can be grounds for not employing you, or for dismissing you after you begin work, and may be punishable by fine or imprisonment (US Code, Title 18, Sec 1001). All statements are subject to investigation, including a check of your fingerprints, police records, and former employers. All the information you give will be considered in reviewing your Statement and is subject to investigation

CERTIFICATION I CERTIFY that all of the statements made in this Statement are true, complete, and correct to the best of my knowledge and belief, and are made in good faith .

Signature (Sign in ink)

Date Signed

COMPLETE PART III ON THE NEXT PAGE IF YOU CLAIM SUPERIOR ACADEMIC ACHIEVEMENT

PART III - SCHOLASTIC ACHIEVEMENT

NOTE: This part is for the use of college students and graduates who may qualify for some GS-7 positions on the basis of undergraduate scholastic achievement, as provided in an open job announcement. the appropriate job announcement for complete requirements.Proof of scholastic achievement under one of these See provisions should not be submitted with your application, but will be required by the hiring agency at the time of appointment. If you do not wish to qualify on this basis or if you do not meet the scholastic requirements for the position, do not complete this part. In any case, YOU MUST SIGN YOUR NAME AFTER THE CERTIFICATION STATEMENT AT THE BOTTOM OF PAGE 3.

A. COLLEGE OR CLASS STANDING. Must be in upper third of your graduating class in the college or university, or major subdivision such as School of Engineering, School of Business Administration, etc. NUMBER IN CLASS ______ YOUR STANDING ______

Proof of class standing should be in the form of a statement in writing from the institution's registrar, the dean of your course of study, or other appropriate official. This statement of class standing must be based on a suitable measure of your academic performance, such as the results of a comprehensive examination or an overall faculty assessment, and must indicate the basis of the judgment. Class standing must be based on your standing in your college or university or the first major subdivision (e.g., the School of Business Administration, the College of Arts and Sciences, etc.). Subdivisions below this level, i.e., a single academic department within a large university, such as the English Department or the Accounting Department, are not recognized as major subdivisions for this purpose.

B. COLLEGE-GRADE POINT AVERAGE. Your grade-point average (GPA) should be recorded in the manner that is most beneficial to you, using one of the methods below. Your grade-point average must be expressed in terms of a value on a 4.0 scale based on 4 years, the last 2 years, or courses completed in the major field of study.* If computing your GPA, indicate the method used and period covered by checking the appropriate boxes in item 2and in item 3 below, and compute your average in the space provided below on this page. 1. GPA as recorded on final transcript _________ (Transcript must cover at least the last 2 years) 2. (Check One) 3. (Check One) _____ _____ Average of undergraduate courses At time of filing * _____ _____ Average in major field of study _____ Last 2 years

All 4 years

* You may be rated provisionally eligible if you are a senior student, provided you have the required average in the junior year. You will be required to submit evidence at the time of appointment that you maintained the required average during your senior years. In computing your grade-point average, round to the first decimal place (e.g., 2.95 = 3.0. 2.94 = 2.9, 3.45 = 3.5, etc.). If your college uses a different system, explain below, or on an attachment, how it compares with the grade-point average on a 4.0 scale. If more than 10 percent of your courses were graded on a pass/fail system rather than on a traditional rating system, you can usually claim credit under the scholastic achievement provision based only on class standing or membership in a national honor society. The exception is if you can document that only your freshman-year courses (25 percent or less of your total credits) were credited on a pass/fail or similar system.

NO. OF SEMESTER OR QUARTER HOURS AT 4.0 ("A") NO. OF SEMESTER OR QUARTER HOURS AT 3.0 ("B") NO. OF SEMESTER OR QUARTER HOURS AT 2.0 ("C") NO. OF SEMESTER OR QUARTER HOURS AT 1.0 ("D") NO. OF SEMESTER OR QUARTER HOURS AT 0.0 ("F") TOTAL (1)

________ ________ ________ ________ ________ ________

X X X X X

4 = ______________ 3 = ______________ 2 = ______________ 1 = ______________ 0 = ______________ ______________

TOTAL (2)

COMPUTED GRADE-POINT AVERAGE Total (2) divided by Total (1)

___________________

C. HONOR SOCIETY MEMBERSHIP. Must be one of the national scholastic honor societies meeting the minimum requirements of the Association of College Honor Societies (other than freshman scholarship honor societies). Name of honor society and date you were elected to membership ___________________________________________________________