This form contains 55 fields organized into 14 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Additional Explanations
Item 16 Continuation Space Text
Provide detailed responses to items 7 through 15 and 18c in the space below or on attached sheets, and be sure to include your name, Social Security Number, item number, and ZIP Codes for all addresses.
Applicant Information
Applicant’s Signature Date Text
Enter the date (MM/DD/YYYY) when the applicant signs the certification in item 17a.
Appointee Information
Appointee’s Signature Date Text
Enter the date (MM/DD/YYYY) when the appointee signs the certification in item 17b.
Appointing Officer Information
Appointment or Conversion Date Text
Provide the date on which the appointing officer’s appointment or conversion occurred, in MM/DD/YYYY format.
Certification
Applicant's digital signature Signature
Provide your digital signature to certify the truthfulness of your responses.
Appointee's digital signature Signature
Provide the appointee's digital signature to certify the truthfulness of their responses.
Citizenship Status
U.S. Citizen – Yes RadioButton
Check this box if you are a U.S. citizen.
U.S. Citizen – No RadioButton
Check this box if you are not a U.S. citizen.
Country of Citizenship Text
Enter the name of the country where you hold citizenship. Fill only if the 'Are you a U.S. citizen?' is 'No'.
Depends on: U.S. Citizen – No
Contact Information
Day Phone Number Text
Enter your daytime phone number, including area code.
Night Phone Number Text
Enter your evening or night phone number, including area code.
Criminal History
Conviction history in last 7 years – Yes RadioButton
Check this box if you have been convicted, imprisoned, on probation, or on parole during the last 7 years.
Conviction history in last 7 years – No RadioButton
Check this box if you have not been convicted, imprisoned, on probation, or on parole during the last 7 years.
Military court-martial conviction in past 7 years – Yes RadioButton
Check if you have been convicted by a military court-martial in the past 7 years.
Military court-martial conviction in past 7 years – No RadioButton
Check if you have not been convicted by a military court-martial in the past 7 years or if you had no military service.
Currently Under Charges – Yes RadioButton
Check this box if you are currently under charges for any violation of law.
Currently Under Charges – No RadioButton
Check this box if you are not currently under charges for any violation of law.
Employment History
Fired from any job in the past 5 years – Yes RadioButton
Check this box if you have been fired from any job in the past 5 years for any reason, left a job by mutual agreement because of specific problems, or were debarred from Federal employment by the Office of Personnel Management or any other Federal agency.
Fired from any job in the past 5 years – No RadioButton
Check this box if you have not been fired from any job in the past 5 years, did not leave a job by mutual agreement because of specific problems, and were not debarred from Federal employment by the Office of Personnel Management or any other Federal agency.
Date of Last Federal Job Separation Text
Provide the date you left your last Federal job in MM/DD/YYYY format.
Financial History
Delinquent on Federal Debt – Yes RadioButton
Check this box if you are delinquent on any Federal debt, including delinquencies arising from Federal taxes, loans, overpayment of benefits, or other debts to the U.S. Government.
Delinquent on Federal Debt – No RadioButton
Check this box if you are not delinquent on any Federal debt.
Insurance Information
Basic Life Insurance Waiver – Yes RadioButton
Check this box if you waived basic life insurance or any type of optional life insurance when you last worked for the Federal Government.
Basic Life Insurance Waiver – No RadioButton
Check this box if you did not waive basic life insurance or any type of optional life insurance when you last worked for the Federal Government.
Basic Life Insurance Waiver – Do Not Know RadioButton
Check this box if you do not know whether you waived basic life insurance or any type of optional life insurance when you last worked for the Federal Government.
Did you later cancel the waiver(s)? – Yes RadioButton
Check this box if you later canceled your life insurance waiver(s) after waiving coverage in item 18b. Fill only if the 'Did you waive Basic Life Insurance or any type of optional life insurance?' is 'Yes'.
Depends on: Basic Life Insurance Waiver – Yes
Did you later cancel the waiver(s)? – No RadioButton
Check this box if you did not cancel your life insurance waiver(s) after waiving coverage in item 18b. Fill only if the 'Did you waive Basic Life Insurance or any type of optional life insurance?' is 'Yes'.
Depends on: Basic Life Insurance Waiver – Yes
Did you later cancel the waiver(s)? – Do Not Know RadioButton
Check this box if you are not sure whether you later canceled your life insurance waiver(s). Fill only if the 'Did you waive Basic Life Insurance or any type of optional life insurance?' is 'Yes'.
Depends on: Basic Life Insurance Waiver – Yes
Military Service
Registered with the Selective Service System – Yes RadioButton
Check this box if you have registered with the Selective Service System. Fill only if the 'Were you born a male after December 31, 1959?' is 'Yes'.
Depends on: Born male after December 31, 1959 – Yes
Registered with the Selective Service System – No RadioButton
Check this box if you have not registered with the Selective Service System. Fill only if the 'Were you born a male after December 31, 1959?' is 'Yes'.
Depends on: Born male after December 31, 1959 – Yes
Served in the United States military – Yes RadioButton
Check this box if you have served in the United States military.
Served in the United States military – No RadioButton
Check this box if you have never served in the United States military.
First Military Service Branch Text
Enter the name of the branch of the United States military in which you first served. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
First Military Service Start Date Text
Provide the month, day, and year when you began your first period of active duty. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
First Military Service End Date Text
Provide the month, day, and year when you ended your first period of active duty. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
First Military Service Discharge Type Text
Specify the type of discharge you received at the end of your first period of active duty. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Second Military Service Branch Text
Enter the branch of the United States military in which you served during your second period of active duty. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Second Military Service From Date Text
Provide the date you began your second period of active military service in MM/DD/YYYY format. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Second Military Service To Date Text
Provide the date you ended your second period of active military service in MM/DD/YYYY format. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Second Military Service Type of Discharge Text
Enter the type of discharge you received at the end of your second period of active military service. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Third Military Service Branch Text
Provide the branch of the United States military in which you served for your third period of active duty. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Third Military Service From Date Text
Enter the start date of your third period of active military service in MM/DD/YYYY format. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Third Military Service To Date Text
Enter the end date of your third period of active military service in MM/DD/YYYY format. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Third Military Service Discharge Type Text
Provide the type of discharge you received for your third period of military service. Fill only if the 'Have you ever served in the United States military?' is 'Yes'.
Depends on: Served in the United States military – Yes
Personal Information
Full Name Text
Provide your full legal name in the order of first, middle (enter “Initial only” if you have only initials or “No Middle Name” if you do not have a middle name), last, and any suffix (e.g., Jr., Sr.).
Social Security Number Text
Enter your nine-digit Social Security Number in the standard format (e.g., 123-45-6789).
Place of Birth Text
Enter the city and state (or country if born outside the United States) where you were born.
Date of Birth Text
Enter your date of birth in month/day/year format (MM/DD/YYYY).
Other Names Ever Used Text
Provide any other names you have ever used, such as a maiden name, nickname, or alias.
Born male after December 31, 1959 – Yes RadioButton
Check this box if you were born a male after December 31, 1959.
Born male after December 31, 1959 – No RadioButton
Check this box if you were not born a male after December 31, 1959.
Relatives Work for Agency Question – Yes RadioButton
Check this box if any of your relatives work for the agency or government organization to which you are submitting this form.
Relatives Work for Agency Question – No RadioButton
Check this box if none of your relatives work for the agency or government organization to which you are submitting this form.
Retirement Information
Retirement Pay Question: Yes RadioButton
Check this box if you currently receive or have ever applied for retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service.
Retirement Pay Question: No RadioButton
Check this box if you do not currently receive and have never applied for retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service.