Fill and Sign the Claims Regarding Conduct on or After Dec 1 2007 Dli Mn Form

AO 78 (10/09) FEDERAL JUDICIAL BRANCH APPLICATION FOR EMPLOYMENT If you need additional space, continue under “Remarks” listing item number 1. Name (Last, First, Middle Initial) 2. Phone Number 3. Present Address (Street, City, State, Zip) 4. Email Address 5. Other Names Previously Used for Employment Purposes 6. Date of Birth (complete only for law enforcement positions) GENERAL 7. Are you a U.S. Citizen? ’ YES ’ NO If no, give the Country of your citizenship 8. a. Were you ever a federal civilian employee? ’ YES ’ NO If yes, give highest civilian grade: / Pay Plan / Grade Step b. Are you receiving a federal civilian annuity payment? ’ YES ’ NO c. Are you receiving federal severance pay? ’ YES ’ NO If yes, give former agency contact/telephone: d. Have you received a federal separation incentive payment ’ YES ’ NO If yes, state mo/yr received and former agency contact/telephone: ’ YES ’ NO If yes, give their names, positions, and relationships to you. ’ YES ’ NO (If selected, you will need to provide your DD-214 (copy 4), Certificate of Release or Discharge from Active Duty, so that your service may be verified and credited) in the past 5 years? 9. Do you have any relatives who are Judges, Officers or employees of the United States Courts? 10. Have you ever served on active duty with the military? BACKGROUND INFORMATION For questions 11, 12, and 13, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law. 11. During the last 10 years, have you been convicted, imprisoned, on probation, or on parole? (Include felonies, firearms or explosives violations, misdemeanors, and all other offenses) ’ YES ’ NO If yes, provide in Section 19 the date, explanation of violation, place of occurrence, and name/address of police dept or court. 12. Have you been convicted by a military court-martial in the past 10 years? ’ YES ’ NO If yes, provide in Section 19 the date, explanation of violation, place of occurrence, and name/address of military authority or court. 13. Are you now under charges for any violation of law? ’ YES ’ NO If yes, provide in Section 19 the date, explanation of violation, place of occurrence, and name/address of police dept or court. 14. During the last 10 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? ’ YES ’ NO If yes, provide in Section 19 the date, explanation of problem, reason for leaving, and employer’s name/address. 15. Are you delinquent on any Federal debt? (Include delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans (e.g., student loan, home mortgage loan)). ’ YES ’ NO If yes, provide in Section 19 the type, length, and amount of delinquency/default, and steps being taken to correct the error/repay the debt. EDUCATION 16. a. Do you have a high school diploma or G.E.D. equivalent? ’ YES ’ NO If yes, Date of Completion Page 2 of 5 b. Name and location of colleges or universities attended (including law schools) Dates Attended Credit Hours Quarter Semester Degree Date Received Grade Point Average and/or scholastic standing 16. c. Other schools or training attended (list name/location of school, dates attended, subject studied, certificates received, and other pertinent data): JOB RELATED SKILLS, AWARDS, SPECIAL ACCOMPLISHMENTS 17. List any skills (e.g., language, computer, keyboarding speed), honors, awards, or special accomplishments (e.g., memberships in professional/honor societies, leadership activities, performance awards) that you believe are relevant to your ability to perform the job: APPLICANTS FOR LEGAL POSITIONS 18. a. Are you admitted to the Bar? ’ YES ’ NO If yes, list the Bar(s) to which admitted and date(s) of admission. If no, skip to 18b. ’ ACTIVE ’ INACTIVE b. What was your scholastic standing in law school? ’ UPPER ½ ’ UPPER a c. Were you a member of an editorial board of law review or a ’ YES Is your Bar membership ’ UPPER ¼ ’ No moot court participant? 19. REMARKS (Use this space for continuation of answers. List the item number being explained.) Page 3 of 5 WORK EXPERIENCE (Start with your present position and work back 10 years. Include any military service. Use additional page if necessary.) A Dates of Employment (mm/dd/yyyy) From: Number of hours worked per week: Exact Title of Your Position To: Pay Plan/Grade (If in federal Service) Salary or Earnings Place of Employment Starting $ Per City Final $ Per State Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor Business Telephone: (Area Code and Phone Number) Reason for Leaving Description of Work B Dates of Employment (mm/dd/yyyy) From: Number of hours worked per week: Exact Title of Your Position To: Pay Plan/Grade (If in federal Service) Salary or Earnings Place of Employment Starting $ Per City Final $ Per State Name and Address of Employer (firm, organization, etc.) Business Telephone: (Area Code and Phone Number) Reason for Leaving Description of Work Name and Title of Immediate Supervisor Page 4 of 5 C Dates of Employment (mm/dd/yyyy) From: Number of hours worked per week: Exact Title of Your Position To: Pay Plan/Grade (If in federal Service) Salary or Earnings Place of Employment Starting $ Per City Final $ Per State Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor Business Telephone: (Area Code and Phone Number) Reason for Leaving Description of Work D Dates of Employment (mm/dd/yyyy) From: Number of hours worked per week: Exact Title of Your Position To: Pay Plan/Grade (If in federal Service) Salary or Earnings Place of Employment Starting $ Per City Final $ Per State Name and Address of Employer (firm, organization, etc.) Business Telephone: (Area Code and Phone Number) Reason for Leaving Description of Work Name and Title of Immediate Supervisor Page 5 of 5 APPLICANT CERTIFICATION I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete and made in good faith. I understand that false or fraudulent information on or attached to this application may be grounds for not hiring me, or firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated. SIGNATURE DATE SIGNED Print Save As... Reset