Fillable

Released 6/29/00.

Application for Federal Employment - SF 171

Form Approved

OMB No. 3206-0012

Read the instructions before you complete this application. Type or print clearly in dark ink.

GENERAL INFORMATION

DO NOT WRITE IN THIS AREA

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

FOR USE OF EXAMINING OFFICE ONLY

Date entered register

2 Social Security Number

3 Sex

Male

Birth date (Month, Day, Year)

Female

Option

Grade

Birthplace (City and State or Country)

Form reviewed:
Form approved:
Earned
Rating

Augmented
Rating

Veteran
Preference
No
Preference
Claimed

6 Name (Last, First, Middle)

5 Points

(Tentative)

10 Pts. (30%

or More
Comp. Dis.)

Mailing address (include apartment number, if any)

City

State

ZIP Code

10 Pts. (Less

than 30%
Comp. Dis.)

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

Other

10 Points

Initials and Date

Disallowed

8 Home Phone

Area Code

9 Work Phone

Number

Area Code

FOR USE OF APPOINTING OFFICE ONLY

Number

Extension

Were you ever employed as a civilian by the Federal Government? If "NO", go to

10 Item

11. If "YES ", mark each type of job you held with an "X". Temporary

Career-Conditional

Being
Investigated

Career

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

10-Point Other

10-point - Less Than 30%
Compensable Disability

Excepted

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

Agency

Date

TO

Dates at highest grade: FROM

AVAILABILITY

MILITARY SERVICE AND VETERAN PREFERENCE (Cont.)

can you start work?
is the lowest pay you will accept? (You will

11 When

12 What

not be considered for jobs which pay less than you
(Month and Year)
indicate.)

Pay $

Per

OR Grade

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

14 Are you willing to work:

19 Were you discharged from the military service under honorable Discharge Date
(Month, Day, Year)

YES NO

YES NO

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.

Type of Discharge

dates (Month, Day, Year) , and branch for all active duty military service

20 List theFrom

To
Branch of Service

A. 40 hours per week (full-time)?

B. 25-32 hours per week (part-time)?