15. Special Circumstances (See Instructions)
FOREIGN SERVICE FAMILY RESERVE CORPS (FSFRC)
MEMBERSHIP APPLICATION
Do you fall into one of these categories? (Select one)
If you answered "None of the above" to the question above, you are NOT eligible to apply.
Fields highlighted yellow are mandatory. Email completed form to FSFRC@state.gov
12. Estimated Time of Departure (ETD) from Post (mm-dd-yyyy)11. Current Clearance/Certification Level (Will be verified)
If other, specify:
6. Current Mailing Address 7. Permanent Personal Email Address (Not state.gov)
8. Applicant's Last Day in Current Position (mm-dd-yyyy)
9. Current or Most Recent Post of Assignment 10. Current or Most Recent Position Held (As listed on SF-50)
2. Applicant's Employee ID or Last 4 of SSN1. Applicant's Name (Last, First, MI) (As listed on SF-50)
4. Sponsoring Employee's Agency3. Sponsoring Employee's Name (Last, First, MI)
APPLICANT CERTIFICATION
13. Type your initials only on those items that apply below. Do not use X or N/A. By initialing, I certify the following:
INITIALS
(a) I am a U.S.citizen.
I am the spouse or domestic partner (as defined in 3 FAM 1610) of a sponsoring employee (i.e., a direct-hire Foreign Service, Civil
Service, or uniformed service member.
(b)
I am currently employed with Department of State (DOS) under a Family Member Appointment (FMA) or Temporary Appointment
(TEMP), or I am currently in INWS status after having been appointed under an FMA.
(c)
I am a current Civil Service (CS) DOS employee who is listed on the travel orders of a sponsoring employee and departing for a post
abroad at a U.S. Mission under Chief of Mission authority, or at an office of the American Institute of Taiwan (AIT). I am departing my CS
position on ______________________ (enter date) to accompany my sponsoring employee overseas (see statement below).
(d)
(f) I am currently employed under a Personal Services Agreement (PSA) or Personal Services Contract (PSC).
I was formerly a FSFRC Member before my conversion into a Department of State domestic CS position. I am departing my current CS
position on ______________________ and request re-instatement consideration into the FSFRC.
(e)
I am the spouse or domestic partner of a third-party contractor or individual working under a PSA or PSC stationed abroad at a U.S.
Mission under Chief of Mission authority, or at an office of the AIT.
(g)
(h) I am currently receiving a U.S.G. retirement annuity/pension from a career in the Foreign Service or Civil Service.
(i) I am a Foreign Affairs Foreign Service Generalist/Specialist in Leave without Pay (LWOP) status.
(j) I am a DOS or other agency CS employee in Leave without Pay (LWOP) status.
(k) I am a DOS or other agency CS employee in extended LWOP status with agreement to return to duty with originating Agency/bureau.
14. Membership Certification
I understand that FSFRC membership will not guarantee me a local or temporary assignment nor does it grant me an automatic security clearance. I also understand that I
may withdraw my FSFRC membership at any time, and that my FSFRC appointment may be terminated at any time, regardless of the expiration (Not to Exceed) date
specified on the Notification of Personnel Action (SF-50), for reasons outlined in 3 FAM (Termination of FSFRC Membership). As a member of the FSFRC, I will be a
Department of State employee even if not in a local or temporary assignment, and I am subject to standards of conduct and ethics requirements applicable to DOS
employees. As a Department employee, I will be subject to the reporting requirements found in 12 FAM 270 (Security Reporting Requirements) and 12 FAM 262 (Security
Awareness and Contact Reporting).
I have attached the Agency Employee Travel Orders (TMFour for DOS employees), as required for initialed item D above.
APPLICANT INFORMATION
16. Applicant's Signature (NOTE: Your signature must include /s/ before your typed name. Forms without the /s/
designation cannot be accepted for processing. Example: /s/Jane Doe.)
Date (mm-dd-yyyy)
DS-5137-A
09-2017
Page 1 of 2
U.S. Department of State
5. Sponsoring Employee's Email Address
(Select)
(Select)
click to sign
signature
click to edit
INSTRUCTIONS - Foreign Service Family Reserve Corps (FSFRC) Membership Application
PURPOSE
The FSFRC Membership Application is to be used by existing Department of State employees currently appointed under a Family Member
Appointment or Temporary Appointment, or currently in INWS status, to apply for membership in the FSFRC.
Highlighted fields are mandatory.
1. Enter your full name as it appears on your SF-50.
2. Enter your Employee ID (found in box 44 on your SF-50) or the last four digits of your Social Security Number.
3. Provide your sponsoring employee's name.
4. Enter your sponsoring employee's employing Agency.
5. Enter your sponsoring employee's email address.
6. Enter a permanent mailing address (do not use pouch address). This will be used for future correspondence through the USPS.
7. Enter your permanent personal contact email address. This should not be a state.gov email address as it may be used to contact you when you
are not actively working in a local assignment. You may wish to add FSFRC@state.gov to your email address book.
8. If applicable, enter your last day in your current position (mm-dd-yyyy).
9. Enter the post where you are currently or previously employed.
10. Enter your current or most recent position title (as found in either box 7 or 15 on your SF-50).
11. Select the choice that corresponds with your current clearance or certification level.
12. Enter your sponsoring employee's estimated date of departure from post.
13. Read each statement and initial those that apply to you.
14. Read the membership certification statement. Required documentation for those applicants who initial Certification Statement (d) only.
15. Special Circumstances: Use this box to include information that may not be covered elsewhere on the form. For instance, if you held a higher
level clearance within the last 2 years, include the clearance level, position title, post, and the dates employed under the position; If you completed
Item d in the Certification section as a domestic CS employee, please provide contact info of your Bureau/EX HR Specialist; If you recently had a
name change that may not be reflected on your last SF-50, etc.
16. Sign and date the form. Your signature must include /s/ before your typed name. Forms without the /s/ designation cannot be accepted for
processing. Example: /s/Jane Doe.
17. Page 2 to be completed by HR Shared Services only.
Highlighted fields are mandatory.
Page 2 of 2DS-5137-A
PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Sections 303, 309, and 311 of the Foreign Service Act of 1980, as amended (Appointment and Hiring); and Section
201 of the Foreign Service Act of 1980, as amended (Management of the Foreign Service).
PURPOSE: The information collected in this form will be used to document your declination to apply for the Foreign Service Family Reserve Corps (FSFRC).
Social Security Numbers will be used to verify identity.
ROUTINE USES: The information on this form may be shared with a member of Congress in response to an inquiry made at your request or with law enforcement as
required by law. More information on the Routine Uses for the system can be found in System of Records Notice State-31, Human Resource Records.
DISCLOSURE: Disclosure of this information, including the Social Security Number, is voluntary. Failure to apply or decline membership in the FSFRC will result in
termination of employment.
AUTHORITIES: The information is sought pursuant to Sections 303, 309, and 311 of the Foreign Service Act of 1980, as amended (Appointment and Hiring); Executive
Order (E.O.) 13526, Sec. 5.4(d); E.O. 10450 (Security Requirements); E.O. 12968, Sections 3.3 and 2.1(b)(2); 5 C.F.R. § 731 (suitability); Homeland Security Presidential
Directive (HSPD-12) "Policy for a Common Identification Standard for Federal Employees and Contractors"; and Section 201 of the Foreign Service Act of 1980, as
amended (Management of the Foreign Service).
PURPOSE: The information collected in this form will be used to establish and maintain the Foreign Service Family Reserve Corps (FSFRC), to allow for the Department to
meet its need for a workforce capable of rapid assignment to positions overseas, including sensitive positions.
Social Security Numbers will be used to verify identity and to confirm existing security clearances.
ROUTINE USES: The information on this form may be shared with a member of Congress in response to an inquiry made at your request or with law enforcement as
required by law. More information on the Routine Uses for the system can be found in System of Records Notices State-31, Human Resource Records and State-36,
Security Records.
DISCLOSURE: Disclosure of this information, including the Social Security Number, is voluntary. Failure to provide the information requested on this form may result in
delays in considering an application or in an application not receiving full consideration for the position.
HR/SS USE ONLY
22. Notification Mailed to Employee
17. Date Received (mm-dd-yyyy)
18. Eligibility Requirements Met?
Yes No
19. FSFRC Category Approved by DS
1 2 3
20. Date Submitted for Verification (mm-dd-yyyy) 21. Date Verification Received (mm-dd-yyyy)
23. Date SF-50 Processed (mm-dd-yyyy)
Date (mm-dd-yyyy)
24. FSFRC Coordinator Signature
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome