Free VA Form SF-171 - Application for Fedeal Employment - Federal

Standard Form 171

Application for Federal Employment
Read The Following Instructions Carefully Before You Complete This Application
DO NOT SUBMIT A RESUME INSTEAD OF THIS APPLICATION. TYPE OR PRINT CLEARLY IN DARK INK. IF YOU NEED MORE SPACE for an answer, use a sheet of paper the same size as this page. On each sheet write your name, Social Security Number, the announcement number or job title, and the item number. Attach all additional forms and sheets to this application at the top of page 3. If you do not answer all questions fully and correctly, you may delay the review of your application and lose job opportunities. Unless you are asked for additional material in the announcement or qualification information, do not attach any materials, such as: official position descriptions, performance evaluations, letters of recommendation, certificates of training, publications, etc. Any materials you attach which were not asked for may be removed from your application and will not be returned to you. We suggest that you keep a copy of this application for your use, if you plan to make copies of your application, we suggest you leave items 1, 48 and 49 blank. Complete these blank items each time you apply. YOU MUST SIGN AND DATE, IN INK, EACH COPY YOU SUBMIT. To apply for a specific Federal civil service examination (whether or not a written test is required) or a specific vacancy in a Federal agency: -- Read the announcement and other materials provided. -- Make sure that your work experience and/or education meet the qualification requirements described. -- Make sure the announcement is open for the job and location you are interested in. Announcements may be closed to receipt of applications for some types of jobs, grades, or geographic locations. -- Make sure that you are allowed to apply. Some jobs are limited to veterans, or to people who work for the Federal Government or have worked for the Federal Government in the past. -- Follow any directions on "How to Apply". If a written test is required, bring any material you are instructed to bring to the test session. For example, you may be instructed to "Bring a completed SF 171 to the test." If a written test is not required, mail this application and all other forms required by the announcement to the address specified in the announcement.

Veteran Preference in Hiring (Item 22)
DO NOT LEAVE Item 22 BLANK. If you do not claim veteran preference place an "X" in the box next to "NO PREFERENCE". You cannot receive veteran preference if you are retired or plan to retire at or above the rank of major or lieutenant commander, unless you are disabled or retired from the active military Reserve. To receive veteran preference your separation from active duty must have been under honorable conditions. This includes honorable and general discharges. A clemency discharge does not meet the requirements of the Veteran Preference Act. Active duty for training in the military Reserve and National Guard program is not considered active duty for purposes of veteran preference. To qualify for preference you must meet ONE of the following conditions: 1. Served on active duty anytime between December 7, 1941, and July 1, 1955; (If you were a Reservist called to active duty between February 1, 1955 and July 1, 1955, you must meet condition 2, below.) or 2. Served on active duty any part of which was between July 2, 1955 and October 14, 1976 or a Reservist called to active duty between February 1, 1955 and October 14, 1976 and who served for more than 180 days; or 3. Entered on active duty between October 15, 1976 and September 7, 1980 or a Reservist who entered on active duty between October 15, 1976 and October 13, 1982 and received a Campaign Badge or Expeditionary Medal or are a disabled veteran; or 4. Enlisted in the Armed Forces after September 7, 1980 or entered active duty other than by enlistment on or after October 14, 1982 and: a. completed 24 months of continuous active duty or the full period called or ordered to active duty, or were discharged under 10 U.S.C. 1171 or for hardship under 10 U.S.C. 1173 and received or were entitled to receive a Campaign Badge or Expeditionary Medal; or b. are a disabled veteran. If you meet one of the four conditions above, you qualify for 5-point preference. If you want to claim 5-point preference and do not meet the requirements for 10-point preference, discussed below, place an "X" in the box next to "5-POINT PREFERENCE". If you think you qualify for 10-point preference, review the requirements described in the Standard Form (SF) 15, Application for 10-Point Veteran Preference. The SF 15 is available from any Federal Job Information Center. The 10-point preference groups are: -- Non-Compensably Disabled or Purple Heart Recipient. -- Compensably Disabled (less than 30%). -- Compensably Disabled (30% or more). -- Spouse, Widow(er) or Mother of a deceased or disabled veteran. If you claim 10-point preference, place an "X" in the box next to the group that applies to you. To receive 10-point preference you must attach a completed SF 15 to this application together with the proof requested in the SF 15. collect by using your SSN will be used for employment purposes and also may be used for studies, statistics, and computer matching to benefit and payment files. Information we have about you may also be given to Federal, State and local agencies for checking on law violations or for other lawful purposes. We may send your name and address to State and local Government agencies, Congressional and other public offices, and public international organizations, if they request names of people to consider for employment. We may also notify your school placement office if you are selected for a Federal job. Giving us your SSN or any of the other information is voluntary. However, we cannot process your application, which is the first step toward getting a job, if you do not give us the information we request. Incomplete addresses and ZIP Codes will also slow processing.

Work Experience (Item 24)
Carefully complete each experience block you need to describe your work experience. Unless you qualify based on education alone, your rating will depend on your description of previous jobs. Do not leave out any jobs you held during the last ten years. Under Description of Work, write a clear and brief, but complete description of your major duties and responsibilities for each job. Include any supervisory duties, special assignments, and your accomplishments in the job. We may verify your description with your former employers. If you had a major change of duties or responsibilities while you worked for the same employer, describe each major change as a separate job.

Privacy Act Statement
The Office of Personnel Management is authorized to rate applicants for Federal jobs under sections 1302, 3301, and 3304 of title 5 of the U.S. Code. Section 1104 of title 5 allows the Office of Personnel Management to authorize other Federal agencies to rate applicants for Federal jobs. We need the information you put on this form and associated application forms to see how well your education and work skills qualify you for a Federal job. 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 who may be employed by the Federal Government. We must have your Social Security Number (SSN) to keep your records straight because other people may have the same name and birth date. The SSN has been used to keep records since 1943, when Executive Order 9937 asked agencies to do so. The Office of Personnel Management may also use your SSN to make requests for information about you from employers, schools, banks, and others who know you, but only as allowed by law or Presidential directive. The information we

DETACH THIS PAGE - NOTE SF 171-A ON BACK

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 2 4 6

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

DO NOT WRITE IN THIS AREA FOR USE OF EXAMINING OFFICE ONLY
Date entered register Form reviewed: Form approved: Earned Rating Veteran Preference No Preference Claimed 5 Points (Tentative) 10Pts (30% Or More Comp. Dis.) Augmented Rating

Social Security Number Birth date (Month, Day, Year)

3 5

Sex Male Female Option Grade Birthplace (City and State or Country)

Name (Last, First, Middle) Mailing address (include apartment number, if any) City State ZIP Code

10 Pts. (Less Than 30% Comp. Dis.) Other 10 Points Initials and Date Disallowed Being Investigated

7 8

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

Home Phone

9

Work Phone

Extension

you ever employed as a 10 Were 11. If "YES", mark eachcivilian by the Federal Government? If "NO", go to Item type of job you held with an "X". Temporary Career-Conditional Career Excepted

Preference has been verified through proof that the separation was under honorable conditions, and other proof as required. 10-Point--Less Than 10-Point--30% or 30% Compensable More Compensable 5-Point 10-Point--Other Disability Disability Signature and Title

FOR USE OF APPOINTING OFFICE ONLY

What is your highest grade, classification series and job title? Agency Dates at highest grade: FROM TO Date

AVAILABILITY
start 11 When can youand Year) work? (Month the lowest you 12 What isbe consideredpay jobs will accept? (You will not for which pay less than you indicate.) Pay $ per OR Grade

MILITARY SERVICE AND VETERAN PREFERENCE (Cont.)
military service under honorable 19 Were you discharged from thewas changed to "honorable" or "general" conditions? (If your discharge YES NO 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 (Month, Day, Year) Type of Discharge

13

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

14 Are you willing to work:
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?..................... 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?........................................... 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?............................

YES NO

20 List the dates (Month, Day, Year), and branch for all active duty military svc. From To Branch of Service
active military duty after October 14, 1976, names 21 If all yourall campaign badgeswasexpeditionary medals youlist the full or wereand dates of or received entitled to receive.

15 16

came with this this 22 Read the instructions that your eligibility forform before completing the item. When you have determined veteran preference from 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 7540-00-935-7150 Standard Form 171 (Rev. 6-88) U.S. Office of Personnel Management FPM Chapter 295

MILITARY SERVICE AND VETERAN PREFERENCE

17 Have you served in the United States Military Service? If your
will you retire at or above the rank of major 18 Did you orcommander?.......................................... or lieutenant

only active duty was training in the Reserves or National Guard, answer "NO". If "NO", go to item 22.......................

YES NO

THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER

PREVIOUS EDITION USABLE UNTIL 12-31-90

Page 1

ask your A 23 May we "NO" andpresent employer about your character, qualifications, and work record? job,"NO" will not affect our review. .of your qualifications. If you answer we need to contact your present employer before we can offer you a we will contact you first . . . . EXPERIENCE IN BEFORE YOU BEGIN. 24 READ WORKyour current or mostTHE INSTRUCTIONSand work backwards, describing Describe recent job in Block A 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 organizations.

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

YES

NO

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 sheet of paper as described above. To: 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. Average number of hours per week Number of employees you supervise

A

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

Dates employed (give month, day and year) From: Salary or earnings Starting $ Ending $

Your reason for wanting to leave

Your immediate supervisor Name

Telephone No.

Exact title of your job

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) From: Salary or earnings Starting $ Ending $ To: per per

Average number of hours per week

Number of employees you supervise

Your reason for wanting to leave

Your immediate supervisor Name

Telephone No.

Exact title of your job

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

For Agency Use (skill codes, 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
high school? If you have a GED 25 Did you graduate fromnext nine months, answer "YES". high school equivalency or 26 Write the name and location (city and state) of the last high school you attended or where you obtained your GED high school equivalency. will graduate within the

YES NO

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

27 Have you ever attended college or graduate school?

YES NO

If "YES", continue with 28. If "NO", go to 31.
TYPE OF MONTH AND DEGREE YEAR OF (e.g. B.A.,M.A.) DEGREE

and ZIP Code) OR UNIVERSITY. 28 NAME AND LOCATION (city, state month and yearOF COLLEGEreceive your degree: If you expect to graduate within nine months, give the you expect to
Name City State ZIP Code

MONTH AND YEAR NUMBER OF CREDIT HOURS HOURS COMPLETED COMPLETED From To Semester Quarter

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)

CHIEF GRADUATE SUBJECTS Show major on the first line

NUMBER OF CREDIT HOURS COMPLETED
Semester Quarter

you are applying for 31 If you have completed any other courses or training related to the kind of jobsMONTH AND YEAR (trade, vocational, Armed Forces, business) give information below. TRAINING

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

ATTENDED

From

To

CLASSROOM HOURS

SUBJECT(S)

COMPLETED

YES

NO

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 hours, 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
Agencies may test your skills before hiring you.

DATE OF LATEST LICENSE OR CERTIFICATE

STATE OR OTHER LICENSING AGENCY

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

If "YES", list each language and place an "X" in each column that applies to you. If "NO", go to 36. CAN SPEAK AND UNDERSTAND
Fluently Passably

LANGUAGE(S)

CAN PREPARE AND GIVE LECTURES
Fluently With Difficulty

CAN TRANSLATE ARTICLES
Into English From English

CAN READ ARTICLES FOR OWN USE
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 lease 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)

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 identify 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).

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.

YES

NO

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; mother-in-law; son-in-law; daugher-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

DATE SIGNED (Month, day, year)

Page 4

Standard Form 171-A -- Continuation Sheet for SF 171
1. Name (Last, First, Middle Initial) 3. Job Title or Announcement Number You Are Applying For

Attach all SF 171-A's to your application at the top of page 3.

Form Approved OMB No. 3206-0012 2. Social Security Number 4. Date Completed

ADDITIONAL WORK EXPERIENCE BLOCKS
Name and address of employer's organization (include ZIP Code, if known) Dates employed (give month, day and year) From: Salary or earnings Starting $ Ending $ Your immediate supervisor Name Exact title of your job Area Code Telephone No. 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 To: Average number if hours per week Number of employees you supervise

Your reason for wanting to leave

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.)
Name and address of employer's organization (include ZIP Code, if known) Dates employed (give month, day and year) From: Salary or earnings Starting $ Ending $ Your immediate supervisor Name Exact title of your job Area Code Telephone No. 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 To: Average number if hours per week Number of employees you supervise

Your reason for wanting to leave

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.)
THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER PREVIOUS EDITION USABLE Standard Form 171-A (Rev. 6-88) U.S. Office of Personnel Management, FPM Chapter 295