U.S. Department of State OMB APPROVAL NO.
1405-0189
APPLICATION FOR EMPLOYMENT AS A
EXPIRES: 03/31/2016
LOCALLY EMPLOYED STAFF OR FAMILY MEMBER ESTIMATED BURDEN: 1
Hour
(This application is for positions recruited by the U.S. Mission under the
Office of Overseas Employments Interagency Local Employment Recruitment Policy)
POSITION
1. Position Title 2. Grade
3. Vacancy Announcement Number 4. Date Available for Work (mm-dd-yyyy)
PERSONAL INFORMATION
5. Last Name(s)/Surnames First Name
Middle Name
6. Other Names Used
7. Current Address 8. Phone Numbers
Day
Evening
Mobile
9. E-mail Address
10. Are you a U.S. Citizen?
Yes No
11. Do you have permanent U.S. Resident status (green card)?
Yes No
If yes, provide number.
12a. U.S. Social Security Number (for U.S. Citizens/Permanent U.S. Residents)
and/or
12b. Country Identification Number
13. Are you legally eligible to work in this country?
Yes No
If yes, Mission HR may require verification of eligibility. Please attach copies of all documentation that confirms your
legal eligibility to work in this country (e.g., work permit, residency permit).
14. If hired, are there accommodations the Mission needs to provide so that you can perform all the essential
functions and duties of the position? Yes No
If yes, please explain.
15. If you are applying for a position that includes driving a U.S. Government vehicle, do you have a current and
valid drivers license?
Yes No Not Applicable
If yes, Class/Type of License
If yes, have you operated a vehicle without incident for the past three years?
Yes No
16. What days are you available to work as part of a regularly scheduled work week? (Check all that
apply.)
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Sunday Monday Tuesday Wednesday Thursday Friday
Saturday
17. Do any of your relatives or members of your household work for the United States Government?
Yes No
If yes, provide the details below. If you need more space, use an additional sheet of paper. (See
Instructions for Completing the DS-174 for the definition of relatives and members of household.)
Name Relationship Agency, Position, and Location
U.S. CITIZEN ELIGIBLE FAMILY MEMBER (USEFM) AND U.S. VETERANS HIRING PREFERENCE
18. Are you claiming preference in hiring under U.S. law, including the Foreign Service Act of 1980,
based upon your status as either a U.S. Citizen Eligible Family Member (USEFM) or U.S. Veteran? See
Instructions for Completing the DS-174 for additional information about the USEFM and U.S. Veterans
hiring preference. (Check only one.)
Yes, I am a U.S. Citizen EFM and also a U.S. Veteran Yes, I am a U.S. Veteran
Yes, I am a U.S. Citizen EFM No, I am neither a U.S.
Citizen EFM, nor a U.S. Veteran
Have you invoked this preference for a prior position at this post/Mission? Yes No
If yes, which agency? Date (mm-dd-yyyy)
If claiming eligibility for U.S. Veteran preference, you must attach a copy of your most recent DD-214,
Certificate of Release or Discharge from Active Duty. If claiming conditional eligibility for U.S. Veterans
preference, you must submit proof of conditional eligibility.
EDUCATION
19. Graduate School Dates Did you Degree/Diplom Major Subject
Name of School, City, State Attended graduat a
or Country (mm-yyyy) e?
From Yes
To No
Undergraduate Dates Did you Degree/Diplom Major Subject
College/University Attended graduat a
Name of School, City, State or (mm-yyyy) e?
Country
From Yes
To No
High School/GED or Country Dates Did you If no, highest grade level completed.
Equivalent Attended graduat
Name of School, City, State or (mm-yyyy) e?
Country
From Yes
To No
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Other, e.g. Technical/Vocational Dates Did you Certificate/Diplo Major Subject
School Attended graduat ma
Name of School, City, State or (mm-yyyy) e?
Country
From Yes
To No
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LANGUAGES
20. List your languages, the appropriate competency levels, and your primary/first spoken/native
language using the language standards below. You may only identify one primary/first spoken/native
language.
Language Indicators
Level I Basic Knowledge
Level II Limited Knowledge
Level III Good Working Knowledge
IV Fluent
Level V Professional Translator/Interpreter
Language Level To: Speak Read Write
Primary -
WORK EXPERIENCE
Include all work experience, paid and voluntary. Start with your present or most recent work experience.
When describing work, list specific duties/responsibilities and accomplishments. Include supervisory
responsibilities and the number of employees supervised. Go into as much detail as possible for work
experience that directly relates to the advertised position. Include all periods of unemployment and the
reason. (Use additional pages, as needed.)
21a. WORK EXPERIENCE
21a. Job Title (If U.S. Government, include the series and grade)
From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Hours per Week
Currency
Employers Name and Address Supervisors Name and Contact Information
Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes May HR contact your supervisor? Yes
No No
If yes, your
Describe how major
many people did you supervise?
duties/responsibilities and accomplishments.
Reason(s) for Leaving (Do not write N/A or not applicable.)
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21b. WORK EXPERIENCE
21b. Job Title (If U.S. Government, include the series and grade)
From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Hours per Week
Currency
Employers Name and Address Supervisors Name and Contact Information
Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes May HR contact your supervisor? Yes
No No
If yes, your
Describe how major
many people did you supervise?
duties/responsibilities and
accomplishments.
Reason(s) for Leaving (Do not write N/A or not applicable.)
21c. WORK EXPERIENCE
21c. Job Title (If U.S. Government, include the series and grade)
From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Hours per Week
Currency
Employers Name and Address Supervisors Name and Contact Information
Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes May HR contact your supervisor? Yes
No No
If yes, how
Describe many
your people
major did you supervise?and
duties/responsibilities
accomplishments.
Reason(s) for Leaving (Do not write N/A or not applicable.)
21d. WORK EXPERIENCE
21d. Job Title (If U.S. Government, include the series and grade)
From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Hours per Week
Currency
Employers Name and Address Supervisors Name and Contact Information
Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes May HR contact your supervisor? Yes
No No
If yes, your
Describe how major
many people did you supervise?
duties/responsibilities and accomplishments.
Reason(s) for Leaving (Do not write N/A or not applicable.)
LICENSE, SKILLS, TRAINING, MEMBERSHIP, AND RECOGNITION
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22. List professional licenses, certifications, typing/keyboard skills, computer skills, formal and online training, and
other skills and abilities you consider relevant to the position. Include the license or certification number and attach
a copy if the license or certification is a requirement of the position. If licensed in the U.S., please list the state of
issuance. If licensed in another country, please list the province/state/region and country of issuance. (Use
additional pages, as necessary.)
23. List professional organizations, associations, awards, honors, fellowships, and publications you consider
significant.
REFERENCES
24. List three personal references who are not relatives or former supervisors who can speak knowledgeably of your
work performance.
Name Address Telephone Occupation
SIGNATURE AND CERTIFICATION
25. I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is
true, correct, complete, and made in good faith. I understand that false or fraudulent information on or attached to
this application may be grounds for not hiring me, or for termination/dismissal after I begin work, and may be
punishable by fine or imprisonment according to this countrys law or U.S. law. I understand that any information I
voluntarily provide on or attached to this application may be investigated.
Signature Date (mm-dd-yyyy)
CONTINUATION WORK EXPERIENCE
21. Job Title (If U.S. Government, include the series and grade)
From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Hours per Week
Currency
Employers Name and Address Supervisors Name and Contact Information
Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes May HR contact your supervisor? Yes
No No
If yes, your
Describe how major
many people did you supervise?
duties/responsibilities and accomplishments.
Reason(s) for Leaving (Do not write N/A or not applicable.)
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CONTINUATION WORK EXPERIENCE
21. Job Title (If U.S. Government, include the series and grade)
From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Hours per Week
Currency
Employers Name and Address Supervisors Name and Contact Information
Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes May HR contact your supervisor? Yes
No No
If yes, your
Describe how major
many people did you supervise?
duties/responsibilities and accomplishments.
Reason(s) for Leaving (Do not write N/A or not applicable.)
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