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Clearance Form
Ty Hallock
2023-11-06T18:13:48+00:00
Clearance Form
Formatted Resume
DATE
MM slash DD slash YYYY
TO
SUBJECT
PROPOSED CANDIDATE
SSN
Date of Birth
MM slash DD slash YYYY
Place of Birth
Citizenship Status
Non-Key Position
Skill Category
Availability
Education
Position (Date)
Relevant Experience
Specific Experience Months/ Years
General Experience Months/ Years
Total
Proposed Position
Education
Colleges Attended
Present Position
Company
Position Title
Immediate Supervisor
Date of Employment
Number and type of personnel supervised
Duties and Responsibilities
Skills utilized
Preceding Position 1
Company
Position Title
Date of Employment
Immediate Supervisor
Number and type of personnel supervised
Duties and Responsibilities
Skills utilized
Preceding Position 2
Company
Date of Employment
Immediate Supervisor
Number and type of personnel supervised
Duties and Responsibilities
Skills utilized
Preceding Position 3
Company
Position Title
Date of Employment
Immediate Supervisor
Number and type of personnel supervised
Duties and Responsibilities
Skills utilized
Technical References
Name
Telephone
Position Title
Employer
Relationship to Proposed Individual
Declaration from Federal Employment
General Information
Social Security Number
Are you a U.S. citizen?
Other Names Ever Used
Phone Numbers (Day)
Phone Numbers (Night)
Selective Service Registration
7a. Were you born a male after December 31, 1959?
7b. Have you registered with the Selective Service System?
7c. If "NO," describe your reason(s) in items 16.
Military Service
8. Have you ever served in the United States Military?
Branch
From (MM/DD/YYYY)
MM slash DD slash YYYY
To (MM/DD/YYYY)
MM slash DD slash YYYY
Type of Discharge
Background Information
9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole? (Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.
10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the miliatry authority or court involved.
11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.
12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.
13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.
Additional Questions
14. Do any of your relatives work for the agency or government organization to which you are submitting this form? (Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relativeworks.
15.Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?
Continuation Space / Agency Optional Questions
16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).
Certifications / Additional Questions
17a. Applicant's Signature
Date
MM slash DD slash YYYY
17b. Appointee's Signature
Date
MM slash DD slash YYYY
18. Appointee (Only respond if you have been employed by the Federal Government before) Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.
18a. When did you leave your last Federal job?
Date
MM slash DD slash YYYY
18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?
18c. If you answered "YES" to item 18b, did you later cancel the waver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.
eQIP Applicant Listing
Submittal Date
MM slash DD slash YYYY
Company Name
Contract Number
CPOC Name
Phone Number
COR-COTR Name
Phone Number
Contract Personnel
SSN
Last Name
First Name
Full Middle Name*
Suffix
City of Birth
State of Birth (2 Letter)
Country (if not USA)**
Country (if not USA)**
Email Address
Attachments
SSN
Max. file size: 64 MB.
IDs
Max. file size: 64 MB.
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contact_id
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