A. Have you ever served on active duty in the United States military service? (Exclude tours of active duty for training as a reservist or Guardsman.) B. Have you ever been discharged from the armed services under other than honorable conditions? (You may omit any such discharge changed to honorable by a Discharge Review Board or similar authority.)... If "Yes," give details in Item 37. C. Do you claim 5-point preference based on active duty in the armed forces?. Yes No If "Yes," you wi" be required to furnish records to support your claim at the time you are appointed. D. Do you claim 10-point preference?.... If "Yes," check type of preference claimed and complete and attach Standard Form 15. "Claim for 10-point Veteran Preference," together with the proof called for in that form TYPE: Compensable disability Disability E. List Dates, Branch, and Serial or Service Number of All Active Service (Enter "N/A" if not applicable) Wife Widow Mother PLEASE BE SURE TO READ ATTACHED INSTRUCTIONS BEFORE COMPLETING ITEM 20 20. EXPERIENCE (Start with your PRESENT position and work back. Account for periods of unemployment in separate blocks in order.) May inquiry be made of your present employer regarding your character, qualifications, and record of employment?. (A "No" will not affect your consideration for employment opportunities except for HEARING EXAMINER positions.) If Federal service, civilian or military grade Number and kind of employees Kind of business or organization etc.) Page 2 For agency use (skill codes, etc.) If Federal service, civilian or military Number and kind of employees Kind of business or organization etc.) Name of employer (firm, organization, etc.) and address (including ZIP Code, if known) For agency use (skill codes, etc.) IF YOU NEED ADDITIONAL EXPERIENCE BLOCKS USE STANDARD FORM 171-A OR BLANK SHEETS ATTACH SUPPLEMENTAL SHEETS OR FORMS HERE · ANSWER ALL QUESTIONS CORRECTLY AND FULLY 21 A. Special qualifications and skills (skills with machines; patents or inventions; your most important publications (do not submit copies unless requested); your public speaking and publications experience; membership in professional or scientific societies; etc.) G. Other schools or training (for example, trade, vocational, armed forces, or business). Give for each the name and location (city, State; and ZIP Code if known) of school, dates attended, subjects studied, number of classroom hours of instruction per week, certificates, and any other pertinent data, 25. REFERENCES. List three persons who are NOT related to you and who have definite knowledge of your qualifications and fitness for the position for which you are applying. Do not repeat names of supervisors listed under Item 20, EXPERIENCE. Page 3 FULL NAME PRESENT BUSINESS OR HOME ADDRESS BUSINESS OR OCCUPATION ANSWER ITEMS 26 THROUGH 36 BY PLACING AN "X" IN THE PROPER COLUMN 26. Are you a citizen of the United States? "If "No." give country of which you are a citizen: Before answering these questions read Items 27 and 28 in the attached instructions. Are you now, or within the last ten years have you been, a member of: 27. The Communist Party, U.S.A. er any subdivision of the Communist Party, U.S.A.?. 28. An organization that to your present knowledge seeks the overthrow of the constitutional form of government of the United States by force or violence or other unlawful means? If your answer to Item 27 or 28 is "Yes," write your answers to the following questions in Item 37 or on a separate piece of paper: (A) The name of the organization? (B) The dates of your membership? (C) Your understanding of the aims and purposes of the organization at the time of your membership? 29. To insure that you are not placed in a position which might impair your health, or which might be a hazard to you or to others, we need informa. 30. Within the last five years have you been fired from any job for any reason? 31. Within the last five years have you quit a job after being notified that you would be fired?. If your answer to 30 or 31 above is "Yes," give details in Item 37. Show the name and address (including ZIP Code) of employer, approximate date, and reasons in each case. This information should agree with your answers in Item 20, EXPERIENCE. 32. Have you ever been convicted of an offense against the law or forfeited collateral, or are you now under charges for any offense against the law? (You may omit: (1) traffic violations for which you paid a fine of $30.00 or less; and (2) any offense committed before your 21st birthday which was finally adjudicated in a juvenile court or under a Youth Offender law.). 33. While in the military service were you ever convicted by general court-martial?. If your answer to 32 or 33 is "Yes," give details in Item 37. Show for each offense: (1) date; (2) charge; (3) place; (4) court; and (5) action taken. 34. Does the United States Government employ in a civilian capacity or as a member of the Armed Forces any relative of yours (by blood or marriage)? If your answer to 34 13 "Yes," give in liem 37 for such relatives: (1) full name; (2) present address (including ZIP Code); (3) relationship: (4) depart. 36. Do vou receive or do you have a pending application for retirement or retainer pay, pension, or other compensation based upon military, Federal civilian, or District of Columbia Government service? If your answer is "Yes." give details in Item 37. Your Statement cannot be processed until you have answered all questions, including Items 26 through 36 above. Be sure you have placed an "X" to the left of EVERY marker (above, either in the "Yes" or the "No" column. 37. Space for detailed answers. Indicate Item number to which answers apply. Item No. If more space is required, use full sheets of paper approximately the same size as this page. Write on EACH sheet your name, birth date, and announcement or position title. Attach all sheets to this Statement at the top of Page 3. ATTENTION THIS STATEMENT MUST BE SIGNED Read the following paragraph carefully before signing this Statement A false answer to any question in this Statement may be grounds for not employing you, or for dismissing you after you begin work, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Sec. 1001). All statements are subject to investigation, Induding a check of your Angerprints, police records, and former employers. All the Information you give will be considered in reviewing your Statement and is subject to investigation. A false answer to Items 27 or 28 could deprive you of your right to an annuity when you reach retirement age in addition to the penalties described above. PEACE CORPS VOLUNTEER DATA FILES TITLE: SELECT PROGRAM ATTACHMENT 9 PROGRAM: No. 334 The purpose of this program is to produce three extract tapes from the master file. Illogical records may be corrected or rejected. An error listing is produced for illogical output records. INPUT: MASTER FILE The master file is output from the update program, 14CB03. The record length is 699 bytes. A block is 3 records. Tape labels are standard. The record layout is displayed in attachment A. OUTPUT: SELECT REPORT FILE The record length is 125 bytes. A block is 20 records. Tape labels are standard. Only one output buffer area is used. The file layout is displayed in attachment B. The first two bytes of the record are always "01". PROGRAM ANALYSIS FILE The record length is 125 bytes. A block is 20 records. Tape labels are standard. The file layout is the same as the select report record layout displayed in attachment B. The first two bytes of the record are always "02". COUNTRY CONDENSED FILE The record length is 285 bytes. A block is 10 records. Tape labels are standard. The first 125 bytes have the same layout as the select report record layout displayed in attachment B. The rest of the file layout is displayed in attachment C. The first two bytes in the record are always "03". ERROR LISTING The print file may be assigned to the printer or to a tape drive (i.e. it is spoolable). No page control is used and no header lines are printed. |