Fillable Geographic Preference Statement For Senior Administrative Law Judge Applicant, OPM Form 1655-A (U.S. Office of Personnel Management)

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Geographic Preference Statement For Senior Administrative Law Judge Applicant, OPM Form 1655-A (U.S. Office of Personnel Management)

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United S
tates Office of P
ersonnel Management
Geographic Preference Statement for
Senior Administrative Law Judge Applicant
OPM For
m 1655-A
September 2018
Form A
pproved:
OMB No. 3206-0248
5 U.S.C. §
3323(b)
5 CFR 930.201 et seq
Instructions: Typ
e or print clearly in black or blue ink. In the boxes below, indicate with an "X" each location
where you would be available to serve as a Senior Administrative Law Judge (SALJ). You may show availability
for any locations listed. You will be considered only for positions where you have indicated your availability.
Submit form to: Administrative Law Judge Program Office, U.S. Office of Personnel Management, 1900 E
Street, NW, Washington, DC 20415.
Name (Last, First, MI)
Address (Street, City, State, Zip Code)
All Locations
Check this box only if
you are interested in
all locations.
All L
ocations
Wash
ington, DC,
Metro Area
(Rockville, MD;
Alexandria, VA;
Arlington, VA;
Falls Church, VA;
Washington, DC)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indi
ana
Iowa
Kansas
Kentucky
Lou
isiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North C
arolina
North Dakota
Ohio
Oklahoma
Oregon
Penns
ylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
United States Office of Personnel Management Form Approved:
OMB No. 3206-0248
Privacy Act Statement
The information on this form is collected pursuant to 5 U.S.C. § 3323(b) and 5 CFR 930.201 et seq. This completed
form allows us to refer your application to Federal agencies that have SALJ positions where you may want to work.
In addition, this record may be used to develop statistics and studies concerning our SALJ Program. Supplying this
information is voluntary, but if you do not provide it you may lose job opportunities because we may not be able to
properly refer your application.
Public Burden Statement
We estimate the public reporting burden for this collection will vary from 15 to 25 minutes, including time for
reviewing instructions, searching existing data sources, gathering data, and completing and reviewing the
information. Send comments regarding the burden estimate or any other aspect of the collection of information,
including suggestions for reducing this burden, to the U.S. Office of Personnel Management (OPM), Administrative
Law Judge Program Office, ALJ Program Manager, Washington, DC 20415-7900. The OMB number, 3206-0248,
is currently valid. OPM may not collect this information and you are not required to respond, unless this number is
displayed. Do not send completed application forms to this address
.
Reasonable Accommodation
Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate.
Applicants requiring reasonable accommodation for any part of the hiring process should contact the appointing
agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis
.
THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER
Signature Date
5 U.S.C. § 3323(b) OPM Form 1655-A
5 CFR 930.201 et seq September 2018
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Geographic Preference Statement For Senior Administrative Law Judge Applicant, OPM Form 1655-A (U.S. Office of Personnel Management)

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Completed 28 July 2020

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