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?
YES
NO If no, give the Country of your citizenship
8. a. Were you ever a federal civilian employee?
YES
NO If yes, give highest civilian grade: / /
Pay Plan Grade Step
b. Are you receiving a federal civilian annuity payment?
YES
NO
c. Are you receiving federal severance pay?
YES
NO If yes, give former agency contact/telephone:
d. Have you received a federal separation incentive payment
YES
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
YES
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?
YES
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)
YES
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?
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?
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?
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)).
YES
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?
YES
NO If yes, Date of Completion
Page 2 of 5
b. Name and location of colleges or universities
attended (including law schools)
Dates Attended
Credit Hours
Degree Date Received
Grade Point
Average and/or
scholastic standing
Quarter Semester
16. c. Other schools or training attended (list name/location of school, dates attended, subject studied, certificates received, and other pertinent data):
JOB RELATED SKILLS, AWARDS, SPECIAL ACCOMPLISHMENTS
17. List any skills (e.g., language, computer, keyboarding speed), honors, awards, or special accomplishments (e.g., memberships in professional/honor societies, leadership
activities, performance awards) that you believe are relevant to your ability to perform the job:
APPLICANTS FOR LEGAL POSITIONS
18. a. Are you admitted to the Bar?
YES
NO If yes, list the Bar(s) to which admitted and date(s) of admission. If no, skip to
18b.
Is your Bar membership
ACTIVE
INACTIVE
b. What was your scholastic standing in law school?
UPPER ½
UPPER a
UPPER ¼
c. Were you a member of an editorial board of law review or a
YES
No
moot court participant?
19. REMARKS (Use this space for continuation of answers. List the item number being explained.)
Page 3 of 5
WORK EXPERIENCE
(Start with your present position and work back 10 years. Include any military service. Use additional page if necessary.)
A
Dates of Employment (mm/dd/yyyy)
Number of hours
worked per week:
Exact Title of Your Position
From: To:
Salary or Earnings
Pay Plan/Grade
(If in federal Service)
Place of Employment
Starting $ Per City
Final $ Per State
Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor
Business Telephone: (Area Code and Phone Number)
Reason for Leaving
Description of Work
B
Dates of Employment (mm/dd/yyyy)
Number of hours
worked per week:
Exact Title of Your Position
From: To:
Salary or Earnings
Pay Plan/Grade
(If in federal Service)
Place of Employment
Starting $ Per City
Final $ Per State
Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor
Business Telephone: (Area Code and Phone Number)
Reason for Leaving
Description of Work
Page 4 of 5
C
Dates of Employment (mm/dd/yyyy)
Number of hours
worked per week:
Exact Title of Your Position
From: To:
Salary or Earnings
Pay Plan/Grade
(If in federal Service)
Place of Employment
Starting $ Per City
Final $ Per State
Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor
Business Telephone: (Area Code and Phone Number)
Reason for Leaving
Description of Work
D
Dates of Employment (mm/dd/yyyy)
Number of hours
worked per week:
Exact Title of Your Position
From: To:
Salary or Earnings
Pay Plan/Grade
(If in federal Service)
Place of Employment
Starting $ Per City
Final $ Per State
Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor
Business Telephone: (Area Code and Phone Number)
Reason for Leaving
Description of Work
Page 5 of 5
APPLICANT CERTIFICATION
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 firing me after I begin work,
and may be punishable by fine or imprisonment. I understand that any information I give may be investigated.
SIGNATURE DATE SIGNED
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