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APPLICATION FOR EMPLOYMENT WITH THE FEDERAL AVIATION ADMINISTRATION INSTRUCTIONS READ AND FOLLOW THESE INSTRUCTIONS CAREFULLY. IF YOUR FORM IS NOT COMPLETED CORRECTLY, WE WILL BE UNABLE TO PROCESS YOUR APPLICATION AND UNABLE TO CONSIDER YOU FOR EMPLOYMENT. · You must enter your Social Security Number (SSN) on the bottom of each page of this form. This assures that the pages are processed together. Executive Order 9397 authorized the solicitation of your SSN for use as an identifier in personnel records management, thus assuring proper identification of applicants throughout the selection and employment process. The information we collect by using your SSN will be used for employment purposes and may also be used for studies, statistics, and computer matching to benefit or payment files. Furnishing your SSN or any of the other information specified in the vacancy announcement is voluntary. However, failure to do so will prevent the processing of your application and will prevent consideration for employment. DO NOT submit a resume or Application for Federal Employment (SF-171 or OF-612) in lieu of completing this application form. You must certify the application form by reading, answering, signing, and dating the "SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION" questions, or your application form will not be processed. For statistical purposes, please complete the "RACE AND NATIONAL ORIGIN IDENTIFICATION" form (the last page of this form). This information is voluntary. Failure to provide it will not affect your consideration for employment. It does assure that our employment practices are free from prohibited discrimination and provide equal employment opportunities for all.

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· Please make and retain a copy of FAA Form 52569 for your records. · Please remove this instruction sheet before submitting your application.

Mail your completed application form to: Aviation Careers Division AMH300 FAA MM Aeronautical Center P.O. Box 26650 Oklahoma City, OK 73126-0650

FAA Form CAPS Cover Sheet 11/00

RETIRED MILITARY AIR TRAFFIC CONTROL SPECIALIST U.S. DEPARTMENT OF TRANSPORTATION FEDERAL AVIATION ADMINISTRATION

AT-2152

APPLICATION FOR EMPLOYMENT WITH THE FEDERAL AVIATION ADMINISTRATION FAA-AAT-01-RMC01-52569
SSN _________-________-________ Day Phone (_____) _____-________ Name ________________________________________________________
Last Street First MI

Address _______________________________________________________ ______________________________
City

Night Phone (_____) _____-________ Date of Birth ______/______/_______

______
Ste Country

________-______
Zip

Place of ______________________ Birth City

_______
Ste

______________________

SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION YOU MUST COMPLETE THIS PORTION OF THE FORM IN ORDER TO BE CONSIDERED FOR FEDERAL AVIATION ADMINISTRATION EMPLOYMENT NOTE: You must sign the application and answer each question below. If these four questions are not answered "YES," your application cannot be considered. Read the following carefully before you sign this form:
· I understand that a false statement on any part of this application may be grounds for not hiring me or for firing me after I begin work. I also understand that I may be punished by fine or imprisoned for falsification of my employment application (18 USC 1001)._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes I understand that information I give may be investigated as allowed by law or Presidential order. _ _ _ _ _ _ _ _ _ 0 Yes

0 No 0 No

· ·

I consent to the release of information concerning my background, ability, and fitness for employment with the Federal Aviation Administration by employers, schools, law enforcement agencies, other individuals and organizations to investigators, personnel staffing specialists, and other authorized employees of the Federal Aviation Administration. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes I certify that, to the best of my knowledge and belief, ALL of the information provided on this application is true, accurate, and complete, and that this application for employment with the Federal Aviation Administration is made in good faith. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes

0 No

·

0 No

_________________________________________________
(Signature) Privacy Act and Public Burden Statements

___________________________
(Month) (Day) (Year)

Public Law 104-50 allows the Federal Aviation Administration (FAA) to rate applicants for employment. We need the information on this application questionnaire to see how well your education and work skills qualify you for employment with the FAA. We also need information on matters such as citizenship and military service to see whether you are affected by laws we must follow in deciding whom the Federal government may employ. Executive Order 9397 authorizes the solicitation of your Social Security Number (SSN) for use as an identifier in personnel records management to assure proper identification of applicants throughout the selection and employment process. The information we collect on this questionnaire, including your SSN, will be used for employment purposes, and it may also be used for statistical studies or computer matching with other government files. Furnishing your SSN or any of the other information requested in the vacancy announcement is voluntary; however, failure to provide this information will prevent the processing of your application and will prevent your consideration for employment. The nature of the information received is confidential, and authorized officials will handle it appropriately. This information becomes part of a Privacy Act System of Records as identified in 5CFR 552a, under OPM/GOVT-1: General Personnel Records. We estimate it will take you 60 minutes to complete this form, including the time required to read the instructions, provide the requested information, and review your responses. Send comments regarding this estimate or any other aspect of the collection of information, including suggestions for reducing the burden, to the Federal Aviation Administration, Office of Human Resource Management, 800 Independence Avenue, SW, Washington D.C. 20591.

FAA Form 52569 (11/00)

1

Read each question carefully. Darken the circle for the ONE answer that best describes you. Multiple or blank responses will result in that question receiving the least credit. Section 1: APPLICANT INFORMATION 1. I am a citizen of the United States, Guam, American Samoa, U.S. Virgin Islands, or Puerto Rico. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes 0 No 0 No 0 No 0 No 0 No 0 No 0 No

2. I have advocated or knowingly associated with a group advocating the overthrow of the United States Government or I have participated in a strike against the United States Government. _ 0 Yes 3. I am currently a permanent civilian employee of the Federal Aviation Administration. _ _ _ _ _ 4. I am currently a permanent civilian employee or I have been a permanent civilian employee of a Federal agency. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 5. I am currently a temporary civilian employee of a Federal agency. _ _ _ _ _ _ _ _ _ _ _ _ _ _ 6. I am able to communicate orally and in writing in the English language. ___________ 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes

7. I am able to communicate orally and in writing in a language other than English. _ _ _ _ _ _ _ Section 2: MILITARY SERVICE 1. I have served on active duty in the United States military service. _ _ _ _ _ _ _ _ _ _ _ _ _ 2. I am claiming 5-point veteran preference based on my active duty military service. NOTE: Must submit a copy of your DD-214. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 3. I am claiming 10-point veteran preference as the spouse, widow, widower or natural mother of a disabled or deceased veteran. NOTE: Must submit SF-15 with required proof. _ _ _ _ _ _ 4. I am claiming 10-point veteran preference as a Purple Heart recipient or have a serviceconnected disability of less than 10%. NOTE: Must submit SF-15 with required proof. _ _ _ 5. I am claiming 10-point veteran preference based on a service-connected disability rated at 10% or more, but less than 30%. NOTE: Must submit SF-15 with required proof. _ _ _ _ _ 6. I am claiming 10-point veteran preference based on a service-connected disability rated at 30% or more. NOTE: Must submit SF-15 with required proof. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 7. I retired or will be retiring from military service at or above the rank of major (0-4) or its equivalent. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 8. I retired or will retire on (mm/dd/yyyy) _________________________________________. 9. I retired or will retire from (branch of service) ___________________________________. 10. My military rank and ID are/were _____________________________________________. 11. My last duty station is/was (city, state and country) __________________________________. 12. My current or last work phone number is/was ___________________________________. 13. My current or former supervisor's name is/was __________________________________. 14. My current or former supervisor's phone number is/was ___________________________. SSN: _______-______-__________ FAA Form 52569 (11/00)

0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes 0 Yes

0 No 0 No 0 No 0 No 0 No 0 No 0 No

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Section 3: GEOGRAPHIC PREFERENCES

Darken ONE circle in the first column to indicate your primary geographic choice. You may then select up to two secondary geographic choices by darkening ONE or TWO circles in the second column. As long as there are adequate numbers of qualified applicants available for a particular region, applicants who have designated that region as a primary choice will be referred. If there are insufficient primary geographic choice applicants in a region, additional applicants who selected that region as a secondary geographic choice may be referred.

PRIMARY GEOGRAPHIC CHOICE - Select one SECONDARY GEOGRAPHIC CHOICES - Select up to two regions 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Alaskan Region Central Region Eastern Region Great Lakes Region New England Region Northwest Mountain Region Southern Region Alaska Iowa, Kansas, Missouri, Nebraska Delaware, District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia, West Virginia Illinois, Indiana, Michigan, Minnesota, North Dakota, Ohio, South Dakota , Wisconsin Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont Colorado, Idaho, Montana, Oregon, Utah, Washington, Wyoming Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Puerto Rico, Virgin Islands Arkansas, Louisiana, New Mexico, Oklahoma, Texas Arizona, California, Hawaii, Nevada, American Samoa, Guam, Marshall Islands

0 0

0 0

Southwest Region Western-Pacific Region

SSN: _______-______-__________

FAA Form 52569 (11/00)

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Section 4: DIRECTLY RELATED EXPERIENCE INSTRUCTIONS:
Position - start with most recent position and location Supervisor - enter Y if you performed only supervisory duties; enter N if you concurrently supervised and controlled air traffic
Position and Location Supervisor (Y or N)

Facility Type - if Radar enter R, if VFR enter V Dates - dates employed in this position Fully Certified or Facility Rated - enter Y for Yes or N for No or NA for Not Applicable

Military Rank

Facility ID

Facility Type (V or R)

Dates Fr: _____/_____/_______ To: _____/_____/_______

Fully Certified or Facility Rated

Date Fully Certified or Facility Rated

1.

____/____/_____

2.

Fr: _____/_____/_______ To: _____/_____/_______

____/____/_____

3.

Fr: _____/_____/_______ To: _____/_____/_______

____/____/_____

4.

Fr: _____/_____/_______ To: _____/_____/_______

____/____/_____

5.

Fr: _____/_____/_______ To: _____/_____/_______

____/____/_____

6.

Fr: _____/_____/_______ To: _____/_____/_______

____/____/_____

7.

Fr: _____/_____/_______ To: _____/_____/_______

____/____/_____

8.

Fr: _____/_____/_______ To: _____/_____/_______

____/____/_____

9.

Fr: _____/_____/_______ To: _____/_____/_______

____/____/_____

NOTE: If your duty station was at a command that had co-located Radar and VFR facilities, please specify which option you worked. If you need additional space, use a separate sheet of paper.
SSN: _______-______-__________ FAA Form 52569 (11/00) 4

Section 5: OTHER RELATED EXPERIENCE A. 0 0 0 0 0 0 0 0
0

Darken the circle of any of the following in which you have experience. Foreign Civilian Air Traffic Controller Contract Tower Air Traffic Controller Department of Defense Civilian Air Traffic Controller Military Air Traffic Controller at FAA Facility Former FAA Air Traffic Controller Non-Radar Approach Control Air Traffic Supervisor Air Traffic Facility Manager Certified Tower Operator Ground Control Intercept Ground Control Approach Military Radar Unit Weather Observer Base Operations Flight Dispatcher (Commercial) Ramp Controller Dispatcher Private Pilot License Date: ______/______/______ Commercial Pilot License Date: ______/______/______ Instrument Rating Date: ______/______/______ Certified Flight Instructor Date: ______/______/______ Staff Work (aviation-related) - Must be full performance level · Quality Assurance Duty Station: ___________________________ From: ____/____/______ To: ____/____/______ Duty Station: ___________________________ From: ____/____/______ To: ____/____/______ Duty Station: ___________________________ From: ____/____/______ To: ____/____/______ · ICAO Duty Station: ___________________________ From: ____/____/______ To: ____/____/______ Duty Station: ___________________________ From: ____/____/______ To: ____/____/______ Duty Station: ___________________________ From: ____/____/______ To: ____/____/______ Darken the circle of any of the following for the type of airspace you have handled. Class B Airspace Class C Airspace Class D Airspace Airport Radar Surveillance Area (ARSA) Terminal Radar Surveillance Area (TRSA) Darken the circle of any of the following for the types of aircraft you have controlled. Rotorcraft Prop Turbo Prop Jet Turbo Jet
FAA Form 52569 (11/00) 5

0 0 0 0 0 0 0 0 0 0 0 0 0

B. 0 0 0 0 0 C. 0 0 0 0 0

SSN: _______-______-__________

Section 6: EDUCATION AND TRAINING

A.

Darken the appropriate circle of any aviation-related degrees you have received. Degree College or University ___________________________ ___________________________ ___________________________ ___________________________ Date Completed Degree ____/____/______ ____/____/______ ____/____/______ ____/____/______ Major ______________________ ______________________ ______________________ ______________________

0 0 0 0

Associate Bachelors Masters Ph.D.

B. If you have you completed any aviation-related courses (other than those already indicated in A above) complete the following. This includes FAA aviation-related courses. Course Title 1. 2. 3. 4. 5. 6. _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ Date Completed ________/_______/________ ________/_______/________ ________/_______/________ ________/_______/________ ________/_______/________ ________/_______/________

Section 7: AWARDS If you have received a Letter of Commendation and/or a Commendation Ribbon related to your work as an air traffic controller, darken the appropriate circle, enter the date (mo/day/yr), and give reason for the award or ribbon. Letter of Commendation 0 0 0 0 0 Commendation Ribbon 0 0 0 0 0

Date ___/___/____ ___/___/____ ___/___/____ ___/___/____ ___/___/____

Reason __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________

SSN: _______-______-__________

FAA Form 52569 (11/00)

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RACE AND NATIONAL ORIGIN IDENTIFICATION
(Please read the instructions and Privacy Act Statement before completing form).

NAME: _________________________________________________________________________________
Last First MI

The categories below provide descriptions of race and national origins. Read the Definition of Category descriptions and then blacken the circle next to the category with which you identify yourself. If you are of mixed race and/or national origin, select the category with which you most closely identify yourself. Please mark only one circle. Name of Male Female Category Definition of Category 0 0 American Indian or Alaskan Native Asian or Pacific Islander A person having origins in any of the original peoples of North America, and who maintains cultural identification through community recognition or tribal affiliation. A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. For example, this area includes China, India, Japan, Korea, the Philippine Islands, and Samoa. A person having origins in any black racial groups of Africa. This does not include persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins. A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins. This does not include persons of Portuguese culture or origin. A person having origins in any of the original peoples of Europe, North America, or the Middle East. This does not include persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins.
Privacy Act and Public Burden Statements
Solicitation of this information is authorized by section 2000e-16 of title 42, which requires that agency employment practices be free from discrimination and provide equal employment opportunities for all, and by the Uniform Guidelines on Employee Selection Procedures (1978), 43 FR 38297 et seq. (August 25, 1978), which requires agencies to examine their employee selection procedures to identify any adverse impact those procedures have on women and minorities. Solicitation of this information is in accordance with Department of Commerce Directive 15, "Race and Ethnic Standards for Federal Statistics and Administrative Reporting." This information will be used to make statistical determinations under the Federal Equal Opportunity Recruitment Program (5 USC 7201) and affirmative action programs under section 717 of the title VII of the Civil Rights Act of 1964 as amended. The furnishing of this data is voluntary; however, collection of the information is essential to the design and maintenance of effective recruitment and preemployment processing programs which will provide the best possible employment opportunities to all candidates. You are requested to furnish your social security number (SSN) under the authority of Executive Order 9397 (November 22, 1943), which requires agencies to use the SSN for the sake of economy and orderly administration in the maintenance of personnel records. Furnishing of the SSN is voluntary; however, failure to provide the SSN may result in inaccurate statistical records. The public reporting burden for completing this form is estimated to vary from 1 to 3 minutes with an average of 2 minutes. The estimate includes time for reviewing instructions, gathering data needed, and completing and reviewing entries. Send comments regarding the burden estimate or any other aspect of this form, including suggestions for reducing the burden to: Federal Aviation Administration, Office of Human Resource Management, 800 Independence Avenue, SW, Washington D.C. 20591.

0

0

0

0

Black, not of Hispanic origin Hispanic

0

0

0

0

White, not of Hispanic origin

SSN: _______-______-__________

FAA Form CAPS RNO (3/99)

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