AO 78 (10/09)
FEDERAL JUDICIAL BRANCH
APPLICATION FOR EMPLOYMENT
If you need additional space, continue under “Remarks” listing item number
1. Name (Last, First, Middle Initial) 2. Phone Number
3. Present Address (Street, City, State, Zip)
4. Email Address
5. Other Names Previously Used for Employment Purposes 6. Date of Birth (complete only for law enforcement positions)
GENERAL
7. Are you a U.S. Citizen?
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YES
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NO If no, give the Country of your citizenship
8. a. Were you ever a federal civilian employee?
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YES
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NO If yes, give highest civilian grade: / /
Pay Plan Grade Step
b. Are you receiving a federal civilian annuity payment?
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YES
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NO
c. Are you receiving federal severance pay?
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YES
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NO If yes, give former agency contact/telephone:
d. Have you received a federal separation incentive payment
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YES
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NO If yes, state mo/yr received and former agency contact/telephone:
in the past 5 years?
9. Do you have any relatives who are Judges, Officers or
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YES
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NO If yes, give their names, positions, and relationships to you.
employees of the United States Courts?
10. Have you ever served on active duty with the military?
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YES
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NO
(If selected, you will need to provide your DD-214 (copy 4), Certificate of
Release or Discharge from Active Duty, so that your service may be
verified and credited)
BACKGROUND INFORMATION
For questions 11, 12, and 13, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any
violation of law committed before your 16
th
birthday, (3) any violation of law committed before your 18
th
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, and (5) any conviction for which the record was expunged under Federal or state
law.
11. During the last 10 years, have you been convicted, imprisoned,
on probation, or on parole? (Include felonies, firearms or explosives
violations, misdemeanors, and all other offenses)
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YES
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NO If yes, provide in Section 19 the date, explanation of violation, place of
occurrence, and name/address of police dept or court.
12. Have you been convicted by a military court-martial in the past
10 years?
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YES
’
NO If yes, provide in Section 19 the date, explanation of violation, place of
occurrence, and name/address of military authority or court.
13. Are you now under charges for any violation of law?
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YES
’
NO If yes, provide in Section 19 the date, explanation of violation, place of
occurrence, and name/address of police dept or court.
14. During the last 10 years, have you been fired from any job for
any reason, did you quit after being told that you would be fired,
did you leave any job by mutual agreement because of specific
problems, or were you debarred from Federal employment by the
Office of Personnel Management or any other Federal agency?
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YES
’
NO If yes, provide in Section 19 the date, explanation of problem, reason for
leaving, and employer’s name/address.
15. 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 of
Federally guaranteed or insured loans (e.g., student loan, home
mortgage loan)).
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YES
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NO If yes, provide in Section 19 the type, length, and amount of
delinquency/default, and steps being taken to correct the error/repay the debt.
EDUCATION
16. a. Do you have a high school diploma or G.E.D. equivalent?
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YES
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NO If yes, Date of Completion
