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Registered User
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GetCaretPos
tbkwin.dll
pageFromClient
HorizontalDisplayRes
VerticalDisplayRes
kernel
globalAlloc
globalFree
globalLock
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globalAlloc
globalLock
HorizontalDisplayRes
VerticalDisplayRes
hautoshift
You are using an EGA Video Adapter. This program was designed for use on VGA systems and may not print properly on your system.
hautoshift
hautoshift
hautoshift
SF 171, Page 1
import
Export
Print Report
Print Pages
Printer Setup
Select all
Select Page
show hotwords
SaveAs
&Print
&Data for Form SF 171 Using Preprinted Form
Print
&Form SF 171 and Data
Print
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Page &1
Page &2
Page &3
Page &4
Page &5 Continuation
Page 1
&Info
&Form Instructions
&Quick Tips
&Program Help
&About
Add Con&tinuation Sheet
&Delete Continuation Sheet
&Insert New Work Experience
Delete &Existing Work Experience
&Export Data
&Import Data
Add Continuation Sheet
Delete Continuation Sheet
Insert New Work Experience
Delete Existing Work Experience
Page &
, Continuation
Page 1
nag screen
agree
sf171.ico
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pagename
counter
displayflag
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Hautoshift
VDisplayPageUnits
HDisplayPageUnits
lpMem
tname
evalflag
daysused
Showhighlights
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buttons
counter
Hidehighlights
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buttons
fields
counter
buttonyes
bnameNo
bnameYes
buttonno
bnameNo
bnameNo
bnameNo
bnameYes
bnameno
buttonyes2
bnameNo
bnameYes
buttonno2
bnameNo
bnameNo
bnameNo
bnameYes
bnameno
ExportData
This utility will save the data from this SF171 to a text file (SF171.EXP) on your A drive. Use this utility to back up your data or as a means to transfer data from this version of the program to a future version of the program. If you wish to continue, place a formatted floppy disk into your A drive. Use the Import Function to load data into form.
Cancel
filename
a:\sf171.exp
filename
SF171VERSION3~
filename
filename
Firstletter
writesub
Firstletter
writesub
Firstletter
writesub
Firstletter
writesub
Firstletter
writesub
Firstletter
writesub
Firstletter
writesub
Firstletter
writesub
filename
filename
filename
Firstletter
writesub
Firstletter
writesub
Firstletter
writesub
The data from this SF171 form has been exported to your A drive.
pcounter
maxnumber
firstletter
FILENAME
WRITESUB
filename
counter
counter
maxnumber
filename
filename
tempstring
COUNTER
MAXNUMBER
FIRSTLETTER
FILENAME
ImportData
This utility will import data from your A drive. Insert the floppy disk containing the data file (SF171.EXP) into your A drive.
Continue
Cancel
Continue
cancel
filename
a:\sf171.exp
filename
filename
SF171Version3
This disk does not contain the proper file
filename
Firstletter
5readsub
Firstletter
5readsub
Firstletter
5readsub
Firstletter
5readsub
Firstletter
5readsub
Firstletter
5readsub
Firstletter
5readsub
Firstletter
5readsub
filename
Firstletter
5readsub
Firstletter
5readsub
Firstletter
5readsub
The data from this SF171 form has been imported.
filename
pcounter
importlastpage
maxnumber
firstletter
FILENAME
importflag
temp11
readsub
filename
firstletter
counter
ADDCONTINUATIONSHEET
firstletter
counter
counter
counter
maxnumber
pagename
TEMP9
COUNTER
MAXNUMBER
FIRSTLETTER
FILENAME
programhelp
readme.wri
FormInstructions
instruct.wri
QuickTips
Right Mouse Button or Page Down Key: Next Page
Page Up Key: Previous Page
Tab Key: Next Field
Shift and Tab Key: Previous Field
If your printer cannot print white text on a black background, set Title Boxes to Gray in the View Menu
rightbuttonup
SF 171,
pagename
PSetup
DataForFormSF171UsingPreprintedForm
_AskPages
'PSetup
Set the left margin in inches, from 0 to 0.5 (default is 0.35)
cancel
the margin must be between 0 and 0.5
Set the top margin in inches, from 0 to 0.5 (default is 0.25)
cancel
the top margin must be between 0 and 0.5
ahidehighlights
for agency use only
for agency use only
blankform
page 1
blankform
page 2
blankform
page 3
blankform
page 4
blankform
page 5
ahidehighlights
for agency use only
for agency use only
blankform
page 1
blankform
page 2
blankform
page 3
blankform
page 4
blankform
page 5
showhighlights
counter
returnpage
printpages
FormSF171AndData
_AskPages
'PSetup
ahidehighlights
ahidehighlights
showhighlights
sysuspend
counter
printpages
returnpage
AskPages
The print function is disabled after 30 days of evaluation
Which Page(s) do you want to print? (example: 1,2,4 or All)
cancel
printpages
evalflag
sysCaretPosition
GetCaretPos
pageFromClient
lpMem
getCaretLoc
sysCaretPosition
textfrompoint
keyup
field
sysCaretPosition
lastfield
caretloc
BottomBorder
RightBorder
yoffset
xoffset
pageheight
pagewidth
VDisplayPageUnits
HDisplayPageUnits
displayflag
hautoshift
Page1
5pagesub
Page2
5pagesub
Page3
5pagesub
Page4
5pagesub
Page5Continuation
5pagesub
Page6Continuation
5pagesub
Page7Continuation
5pagesub
Page8Continuation
5pagesub
Page9Continuation
5pagesub
pagesub
SF 171,
pagename
DeleteContinuationSheet
You cannot delete Page 5. If you want to erase the data, use <Delete Existing Work Experience> from the Edit Menu.
Are you sure you want to delete page
and all of its contents???
Page &
, Continuation
Clear
COUNTER
PAGENAME
5PAGESUB
Page
, Continuation
COUNTER
COUNTER
COUNTER
COUNTER
COUNTER
5pagesub
pagename
counter
AddContinuationSheet
Only 5 continuation sheets are allowable with this version of the program
Do you wish to create a continuation sheet, Page &
cancel
Paste
Page &
, Continuation
Page
, Continuation
SF 171,
COUNTER
pagename
importflag
newpageflag
leavebook
kernel
tbkwin.dll
globalUnlock
globalFree
lpMem
InsertNewWorkExperience
Do you wish to insert a new job description at A on page 2, and shift existing jobs from A to B, B to C etc.?
Job description L will be deleted, and replaced by job description K
addcontinuationsheet
This function will allow you to delete an existing job description and shift the old jobs up. This function will be available in the final version of the program.
counter2
counter
DeleteExistingWorkExperience
A or B
Which job description,
, do you wish to delete?
A or B
A or B
A or B
A or B
You need to select either
deletepage
deletepage
counter2
counter
DeletePage
SetTitleBoxesToGray
Set Title Boxes To Gray
Set Title boxes To Black
whitetext
page
whitetext
page
for agency use only
page
for agency use only
page
counter
SetTitleBoxesToBlack
Set Title Boxes To Gray
Set Title boxes To Black
whitetext
page
whitetext
page
for agency use only
page
for agency use only
page
counter
:PRINTLAYOUT
Arial
System
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171, Page 4
uation
171, Page 4
uation
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, Page 4
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;H-@;
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171, Page 4
uyQsDAmx
mes New Roman
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171, Page 4
171, Page 1
uation
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Times New Roman
Times New Roman
Arial
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171, Page 1
uation
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171, Page 4
171, Page 1
171, Page 4
171, Page 2
Times New Roman
System
SF 171, Page 1
Page 1
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blankform
Application for Federal Employment -- SF 171
What kind of job are you applying for? Give Title and announcement no. (if any)
Standard Form 171 (Rev. 6-88)
U.S. Office of Personnel Management
FPM Chapter 295
NSN 7540-00-935-7150 171-11000
List the dates (Month, Day, Year), and branch for all active duty military service.
When can you start work? (Month and Year)
What is the lowest pay you will accept? (You will not be considered for jobs which pay less than you indicate)
Female
Were you discharged from the military service under honorable
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
(Month, Day, Year)
Being
Investigated
A. 40 hours per week (full-time)?. . . . . . . . . . . . . . . . . . . . . . . . . .k (on-call/seasonal)? . . . . . . E. er hours per week (on-call/seasonal)? . . . . . . E. er hours per week (on-call/seasonal)? . . . . . . E. nal)? . . . . . . E. nal)? . . . . . . E. seasonal)? . . . . . . E.
Have you served in the United States Military Service? If your only active duty was training in the Reserves or National Guard, answer "NO". If "NO", go to item 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Did you or will you retire at or above the rank of major or lieuten- ant commander? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
FOR USE OF EXAMINING OFFICE ONLYc@
FOR USE OF APPOINTING OFFICE ONLY
Date entered register
Form reviewed:
Form approved:
Option
Grade
Earned Rating
Veteran Preference
Augmented Rating
"B ~$
Preference
Claimed
5 Points
(Tentative)
10 Pts. (30%
Or More
Comp. Dis.)
10 Pts. (Less
Than 30%
Comp. Dis)
Other
10 Points
Disallowed
Initials and Date
Preference has heen verified through proof that the separation
was under honorable conditions, and other proof as required.
5-Point
10-Point--30% or More
Compensable Disability
10-Point--Less Than 30%
Compensable Disability
10-Point--Other
Signature and Title
Agency
V"J+V"
Type of Discharge
~'Y+~'
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Branch of Service
If all your active military duty was after October 14, 1976, list the full names and dates of campaign badges or expeditionary medals you received or were entitled to receive.....
.,h+J.
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.
Non-compensably disabled or Purple Heart recipient.
Compensably disabled, less than 30 percent.cipient.
Spouse, widow(er), or mother of a deceased or disabled veteran.
Compensably disabled, 30 percent or more.recipient.
THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER
PREVIOUS EDITION USABLE UNTIL 12-31-90
]9;+]9
Page1
PREVIOUS EDITION USABLE UNTIL 12-31-90
U.S. Office of Personnel Management
FPM Chapter 29555l Management
FPM Chapter 295
$Y=f-
FPM Chapter 29571 (Rev. 6-88)
U.S. Office of Personnel Management
FPM Chapter 295
Dates at highest grade: FROM TOOOOOOOOOOOO
TOtes at highest grade: FROM TOOOOOOOOOOOO
OR Grade
per OR Grade OR Grade
Pay $ per OR Grade
Form Approved
OMB No. 3206-0012
DO NOT WRITE IN THIS AREA
whitetext
GENERAL INFORMATION
AVAILABILITY
MILITARY SERVICE AND VETERAN PREFERENCE (Cont.)
MILITARY SERVICE AND VETERAN PREFERENCE
FPM Chapter 295
Read the instructions before you complete this application. Type or print clearly in dark ink.
Page 1
'9!O)G"
)9!/+G"
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4bnameyes
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4bnameyes
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4bnameyes
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4bnameyes
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4bnameyes
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4bnameyes
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4bnameyes
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4bnameyes
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4bnameyes
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4bnameyes
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bnameyes
4bnameyes
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bnameYes
buttonyes
bnameyes
4bnameyes
bnameYes
buttonyes
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bnameYes
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bnameyes
4bnameyes
bnameYes
buttonyes
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bnameyes
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"b38"
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"b40"
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"b37"
"b39"
"b40"
"b41"
"b42"
buttonup
buttonup
"b37"
"b38"
"b40"
"b42"
Request "A Standard Form 15, Application
10-Point Veteran Preference, which
available
Federal Job Information Center must be attached."
f"OK"
buttonup
buttonup
A Standard Form 15, Application for 10-Point Veteran Preference, which is available from any Federal Job Information Center must be attached.
"b37"
"b38"
"b39"
"b42"
Request "A Standard Form 15, Application
10-Point Veteran Preference, which
available
Federal Job Information Center must be attached."
f"OK"
buttonup
buttonup
A Standard Form 15, Application for 10-Point Veteran Preference, which is available from any Federal Job Information Center must be attached.
8 Ib*
"b37"
"b38"
Request "A Standard Form 15, Application
10-Point Veteran Preference, which
available
Federal Job Information Center must be attached."
f"OK"
buttonup
buttonup
A Standard Form 15, Application for 10-Point Veteran Preference, which is available from any Federal Job Information Center must be attached.
"b37"
"b38"
"b39"
"b40"
Request "A Standard Form 15, Application
10-Point Veteran Preference, which
available
Federal Job Information Center must be attached."
f"OK"
buttonup
buttonup
A Standard Form 15, Application for 10-Point Veteran Preference, which is available from any Federal Job Information Center must be attached.
'9!O)G"
4bnameyes
bnameYes
buttonyes
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bnameYes
buttonyes
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)9!/+G"
4bnameno
buttonno
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o'TAj
n(&Bj
"n(lB
fields
setyellow
enterfield
enterfield
setyellow
startdate
nag screen
SF 171 For Windows
Version 1.10000000
Copyright (C) 1992 by Finish Line Software
All rights reserved.
This is an unregistered version of the program that may be used for evaluation for a period of 30 days.
Agree
"nag screen"
buttonup
buttonup
nag screen
I Agree To Terms of Use
Registered User
To register, and receive the latest version of the program, send $20.00 to:
Tom Murrell
17106 Laoana
Eagle River, Alaska 99577
ncidental, consequential, or similar damages) claimed by you or any other person or entity as a result of the use of this program. This includes rejection of a job application, loss of job opportunities, time, money, data or other resources.
daysleft
Evaluation Days Remaining
Page 2
e"Insert New Work Experience"
e"Delete Existing
ackground
enterbackground
leavebackground
enterbackground
Insert New Work Experience
Delete Existing Work Experience
leavebackground
Insert New Work Experience
Delete Existing Work Experience
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blankform
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 at you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other organizations.
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 at you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other organizations...the work (or a part of the work) is like the job you are applying for, complete all parts of the experience block just at you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other organizations.
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 at you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other organizations.plete all parts of the experience block just at you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other organizations...the work (or a part of the work) is like the job you are applying for, complete all parts of the experience block just at you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other organizations.
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.ience 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 at you would for a paying job. You may receive credit for work experience with religious, community, welfare, service, and other organizations.
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..ze as this page (be sure to include all information we as 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 TO UPDATE (ADD MORE RECENT JOBS), use the SF 172 or a sheet of paper as described above. include all information we as for in A and B below). On each sheet show your name, Social Security Number, and the announcement number or job title.....
Ending $$
From:
Name and address of employer's organization (include ZIP Code, if known)
Dates employed (give month, day and year)
Average Number of hours per weekS%
Salary or earnings
Starting $
Your reason for wanting to leave
hours per week
you supervised
Number of employees
Description of work: Describe your specific duties, responsibilities and accomplishments in this job, including the job title(s) of any employees you supervise. If you describe more than one type of work (for example, carpentry and painting, or personnel and budget), write the approximate percentage of time you spent doing each.
Your immediate supervisor
Area Codesssssssss
Telephone No.
Exact title of your job
rank, and if promoted in this job, date of your last promotion rank, and, if promoted in this job the date of your last promotionn
Ending $$
From:
Name and address of employer's organization (include ZIP Code, if known)
'$ +'$
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Dates employed (give month, day and year)
8"b%
Average Number of hours per week-2
Salary or earnings
Starting $
E$|)&%
Your reason for leaving to leave
hours per week
you supervised
Number of employees
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.
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Your immediate supervisor
Area Codesssssssss
Telephone No.
Exact title of your job
~' +A(
rank, and if promoted in this job, date of your last promotion rank, and, if promoted in this job the date of your last promotionn
If Federal employment (civilian or military) list series, grade or rank, and, if promoted in this job the date of your last promotionn
If Federal employment (civilian or military) list series, grade or rank, and, if promoted in this job the date of your last promotionn
Page 2
9 + :
IF YOU NEED MORE EXPERIENCE BLOCKS, USE SF 171-A (SEE BACK OF INSTRUCTION PAGE).
whitetext
WORK EXPERIENCE If you have no work experience, write "NONE" in A below and go to 25 on page 3.
Page 2
buttons
4bnameyes
bnameYes
buttonyes
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4bnameno
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S(k+R)
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setyellow
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setyellow
S(k+R)
+ k+
+ k+
+ \+
for agency use only
For Agency Use (skill codes, etc.)
+ \+
+ \+*!
For Agency Use (skill codes, etc.)
Page 1
Page 3
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whitetext
EDUCATION
SPECIAL SKILLS, ACCOMPLISHMENTS, AND AWARDS
REFERENCES S, ACCOMPLISHMENTS, AND AWARDS
NUMBER OF CREDIT HOURS COMPLETEDi
ATTACH ANY ADDITIONAL FORMS AND SHEETS HERE
TRAINING
COMPLETED
Semester
Quarter
NUMBER OF CREDIT HOURS COMPLETED%
TELEPHONE NUMBER(S)
(Include Area Code)
PRESENT BUSINESS OR HOME ADDRESS
(Number, street and city)
FULL NAME OF REFERENCEE
ZIP CODE
Fluently
With Difficulty
Fluently
Passably
Easily
From English
Into English
With Difficulty
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..
Did you graduate from high school? If you have a GED high school equivalency or will graduate within the next nine months, answer "YES".
Write the name and location (city and state) of the last high school you attended or where you obtained your GED high school equivalency.
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CHIEF UNDERGRADUATE SUBJECTS
Show major on the first line
NAME AND LOCATION (city, state and ZIP Code) OF SCHOOL
School NameCATION (city, state and ZIP Code) OF SCHOOL
State
ZIP Code
SUBJECT(S)eCATION (city, state and ZIP Code) OF SCHOOL
School NameCATION (city, state and ZIP Code) OF SCHOOL
State
ZIP Code
2D0 2
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 socities; patents or inventions; etc.
How many words per
minute can you:
TYPE? TAKE DICTATION????
List job-related licenses or certificates that you have, such as: registered nurse; lawyer; radio opertaor; driver's; pilot's; etc.
LICENSE OR CERTIFICATE
DATE OF LATEST LICENSE OR CERTIFICATE
STATE OR OTHER LICENSING AGENCY
If "YES", list each language and place an "X" in each column that applies to you.
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If "NO", go to 36.
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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.
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LANGUAGE(S)
Page 3
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::
State
ZIP Code
TYPE OF
DEGREE
(e.g. B.A., M.A.)
NUMBER OF CREDIT HOURS COMPLETEDAF
Have you ever attended college or graduate school?
If "YES", continue with 28.
If "NO" go to 31.e with 28.
CHIEF GRADUATE SUBJECTS
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MONTH AND YEAR ATTENDED 28.
Semester
Quarter
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If you have completed any other courses or training related to the jobs you are applying for (trade, vocational, Armed Foces, business) give information below.........
Are you deliquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits or other debts to the U.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgatge loans) . . . . . . . . . . . . . . . . . ...... . . . . . . . . . . . . . . . . . .
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 1 year, except for violations called misdemeanors under State law which are punishable by imprisonment of two years or less.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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) traffice 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).........SC 1001).........01).
l I certify that, to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith. in order to be elegble for Federal employment. You will be required to certify as to your status at the time of appointment.
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:
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.
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Explanation
Mailing Address
Name of employer, Police, Court, or Federal Agency
State
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ZIP Code
Name of employer, Police, Court, or Federal Agency
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ZIP Code
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? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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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; 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.
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Relationship
Department, Agency or Branch of Armed Forces
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SIGNATURE (sign each application in dark ink)
DATE SIGNED (Month, day, year)
YOU MUST SIGN THIS APPLICATION. Read the following carefully before you sign.
l A false statement on any part of this 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)...................... section 1001).
l 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...
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l I understand that any information I give may be investigated as allowed by law or Presidential order.em or hafe a valid exemption in order to be elegble for Federal employment. You will be required to certify as to your status at the time of appointment.
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l 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..
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BACKGROUND INFORMATION--You must answer each question in this section before we can process your application.
SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION his section before we can process your application.
Page 4
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Page 1
Page 5, Continuation
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l Attach all SF 171-A's to your application at the top of page 3..
1. Name (Last, First, Middle Initial)
3. Job Title or Announcement Number You Are Applying For
2. Social Security Number
4. Date Completed
Form Approved
OMB No. 3206-0012G
From:
Name and address of employer's organization (include ZIP Code, if known)
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Dates employed (give month, day and year)
Average Number of hours per week
Salary or earnings
Starting $
Your reason for leaving to leave]
hours per week
you supervised
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Number of employees
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.
Your immediate supervisor
Area Codesssssssss
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 promotionn
THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER
PREVIOUS EDITION USABLE
PREVIOUS EDITION USABLE
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Standard Form 171-A (Rev. 6-88)
U.S. Office of Personnel Management
FPM Chapter 295
rank, and if promoted in this job, date of your last promotion rank, and, if promoted in this job the date of your last promotionn
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From:
Name and address of employer's organization (include ZIP Code, if known)
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Average Number of hours per week
Salary or earnings
Starting $
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hours per week
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Number of employees
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.
Your immediate supervisor
Area Codesssssssss
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 promotionn
rank, and if promoted in this job, date of your last promotion rank, and, if promoted in this job the date of your last promotionn
U.S. Office of Personnel Management FPM Chapter 295
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FPM Chapter 295
Continuation Sheet for SF 171ation Sheet for SF 1711