Page 3 of 3DS-174
SECTION 4: WORK EXPERIENCE (Continued)
SECTION 5: CITIZENSHIP
Are you a U.S. citizen listed on the travel orders or approved OF-126 (or other agency equivalent) of a direct hire FS, CS or uniformed service
member assigned (not TDY) to this U.S. Mission and under Chief of Mission authority, or to an office of the American Institute in Taiwan?
If no, proceed to Section 6.
If yes, select all that apply:
Yes No
I am a member of the Foreign Service Family Reserve Corps (FSFRC). (SF-50 required)
I am a preference eligible U.S. Veteran. I have not invoked my preference at this Post. (DD214 required)
I am a preference eligible U.S. Veteran. I have invoked my preference at this Post. I have worked in (enter Agency/job)
I am Foreign Service on Leave Without Pay (LWOP).
I am Civil Service on LWOP with Bureau-specific reemployment rights.
SECTION 6: DECLARATION
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
separation/dismissal after I begin work, and may be punishable by fine or imprisonment according to this country's law or U.S. law. I
understand that any information I voluntarily provide on or attached to this application may be investigated.
AUTHORITIES The information is sought pursuant to The Foreign Service Act of 1980, as amended, and 22 U.S.C. 2669(c). Your social security number (SSN) maybe
used to confirm the identity and employment eligibility of the individual, pursuant to Executive Order 9397, as amended.
PURPOSE The information solicited on this form will be used to establish your eligibility and qualifications for job vacancies at U.S. Missions.
ROUTINE USES The information may be shared with other federal agencies to the extent relevant and necessary for that agency to make employment decisions and to a
Congressional Office in response to your written request. More information on Routine Uses can be found in System of Records Notices State-31, Human Resource
Records, and OPM/GOVT-5, Recruiting, Examining, and Placement Records.
DISCLOSURE Disclosure of this information, including your social security number, is voluntary. Failure to provide the requested information may result in your application
not receiving full consideration or being delayed for consideration.
BURDEN Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time required for searching existing data
sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this
information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations
for reducing it, please send them to: HR/OE, SA-22, 1800 G Street, NW, Washington, DC 20006.
PRIVACY AND PAPERWORK REDUCTION ACT STATEMENTS
(For U.S. Citizens and Legal Permanent Residents of the U.S.)
Hours per WeekYearly Salary (Local currency) From (mm-yyyy) To (mm-yyyy)
Supervisory Responsibilities?
Yes No
Supervisor Name
Main Duties and Responsibilities
Reason for leaving
Employer Name, Address and Phone Number
Job Title
EQUAL OPPORTUNITY EMPLOYER
The U.S. Mission provides equal opportunity and fair and equitable treatment in employment to all people without regard to race, color, religion, sex, national origin, age,
disability, political affiliation, marital status, protected genetic information, or sexual orientation.
The EEO complaint procedure is not available to individuals who believe they have been denied equal opportunity based upon marital status or political affiliation.
Individuals with such complaints should avail themselves of the appropriate grievance procedures, remedies for prohibited personnel practices, and/or courts for relief.
