PMF Success Story Submission Form
PRIVACY ACT STATEMENT AND INSTRUCTIONS:
Author
ity: 5 CFR 362 promulgates Executive Order 13562, placing the Presidential Management Fellows (PMF) Program under the Pathways
Programs. The U.S. Office of Personnel Management (OPM) administers the PMF Program government-wide. The PMF Program is to attract to the
Federal service outstanding men and women from a variety of academic disciplines and career paths, who have a clear interest in, and commitment to,
excellence in the leadership and management of public policies and programs.
Purpose
: This PMF Success Story Submission Form is used to collect success stories from current and former PMFs.
Rout
ine Uses: These stories are to highlight the success of PMFs during and after their fellowship and publish to the PMF website.
Disclo
sure: Use of this form and furnishing this information is optional. All submissions must include the Authorization and Release signature (below).
The PMF Program Office reserves the right to edit, deny, and/or approve any submissions.
Curre
nt/Former Fellows: This form can be found under the “Current PMFs\Resources” section on the PMF website at www.pmf.gov
. Fill out the
information below and send via email to pmf@opm.gov with the subject of “Success Story”. Please include a photo. Photographs should be related to
the submitter and/or story being submitted.
Current/Former PMF First and Last Name:
Work Phone Number (with area code):
Work Email Address:
Agency/Sub-Agency:
Work or Home Mailing Address:
Success Story (please limit to 3-5 paragraphs; add a separate page if additional space is needed):
AUTHO
RIZATION AND RELEASE: I hereby authorize and consent that the U.S. Office of Personnel Management, a Federal Agency, its legal
representatives, successors or assigns, shall have the absolute right to copyright, publish, use, sell or assign any and all photographic portraits or
pictures, or any part thereof, they have taken or made of me or I have submitted to them, or in which I may be included in whole or in part, whether apart
from or in connection with, illustrative or written printed matter, story or news item, for the PMF Success Stories. I hereby waive all claims for any
compensation for such use or for damages. I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising
copy that may be used in connection therewith or the use to which it may be applied. I hereby warrant that I am of full age and have every right to
contract in my own name in the above regard. I state further that I have read the above authorization and release, prior to its execution, and that I am
familiar with the contents thereof.
_______________________________________ _________________
Si
gnature Date (mm/dd/yyyy)
PMFPO Received: PMFPO Posted: Success Story Number:
U.S. Office of Personnel Management OPM Form 1304
Presidential Management Fellows Program November 2014
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signature
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