APPLICATION FOR EMPLOYMENT
AS A LOCALLY EMPLOYED STAFF (LES)
(This application is for Field use only)	  POSITION APPLIED FOR:

	
INSTRUCTIONS: The questions on this application should be answered fully and completely. Do not use the abbreviation “n/a” to respond to any question; all questions are applicable and should be given an appropriate response. Making a false statement on this form will result in rejection of your application; if discovered subsequent to your appointment, a false statement is cause for dismissal.	  DATE OF APPLICATION:

1. NAME IN FULL (Enter regularly used surname with other names used following In parenthesis-i.e, Spanish or other double names)
                                    (SURNAME)                                                       (Firstname)                                                                           (Middlename)

	ATTACH
PHOTOGRAPH
TAKEN WITHIN
PAST
12 MONTHS	
2. NAME AT BIRTH, IF DIFFERENT FROM ABOVE

3. HAVE YOU EVER BEEN KNOWN BY ANY OTHER NAMES?                           YES                                   NO
 (If yes, give name and explain circumstances under item 38)

4. PRESENT ADDRESS:

4. TELEPHONE NUMBER:
	5. DATE OF BIRTH (Month, Day,Year)

	6a. PLACE OF BIRTH (City, Country)

		
6b. BARBADOS ID NUMBER:                                                             6c. NATIONAL INSURANCE NUMBER :                                                                  6d. PASSPORT NUMBER :                             	
7. SEX		8. HEIGHT		9. WEIGHT		10. COLOR OF EYES	11. COLOR OF HAIR

	13. MARITAL STATUS		
                           MALE												    SINGLE	  DIVORCED	
                           FEMALE		Ft.	In.			Lbs.						    MARRIED	 SEPARATED	
12. DESCRIBE ANY SPECIAL CHARACTERISTICS OR IDENTIFYING MARKS
	    WIDOWED	  REMARRIED	
	     COMMON LAW SPOUSE	
						14. PREVIOUS ADDRESSES'DURING PAST TEN YEARS						
DATES		STREET AND NUMBER			CITY (District /Province)				COUNTRY		
FROM	TO																		

																			
																			
15. DO YOU HAVE PERMANENT U.S. RESIDENT STATUS?	 YES	 NO - LIST EACH COUNTRY OF WHICH YOU HAVE BEEN A CITIZEN		
DATES				COUNTRY						HOW CITIZENSHIP WAS ACQUIRED		

16a. FULL NAME OF SPOUSE (II wife, maiden name) or Common-Law Spouse

 	b, DATE OF BIRTH

	c. PLACE OF BIRTH (City, Country)

d. PRESENT ADDRESS IN FULL

	e. PRESENT OCCUPATION

f. CITIZENSHIP AT BIRTH
	g. PRESENT CITIZENSHIP
	
17. CHILDREN	
	NAME				DATE OF BIRTH				PRESENT ADDRESS IN FULL		OCCUPATION	

																			
18a. FATHER'S NAME

	b. DATE OF BIRTH

	c. PLACE OF BIRTH (City, Country)

d. PRESENT ADDRESS IN FULL

	e. PRESENT OCCUPATION

	
f. CITIZENSHIP AT BIRTH
	g. PRESENT CITIZENSHIP
	
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HR 001 
DEPT. OF STATE  Revised 10/13/03

19a. MOTHER'S NAME

	b. DATE OF BIRTH

	c. PLACE OF BIRTH (City, Country)

d. PRESENT ADDRESS
	e. PRESENT OCCUPATION
	
f. CITIZENSHIP AT BIRTH
	g. PRESENT CITIZENSHIP
	
	20. RELATIVES (Brothers, sisters and in-laws)						
NAME	RELATIONSHIP	NATIONALITY	OCCUPATION		PRESENT ADDRESS IN FULL	

										

		                               								

		
						.	

21. ARE ANY RELATIVES OR FAMILY MEMBERS NAMED ABOVE EMPLOYED BY AN AGENCY OR REPRESENTATIVE OF A NATIONAL
     OR LOCAL GOVERNMENT? If so, list name, relationship, agency and agency address.	   YES	
	   NO	

											
										
22. DO YOU HAVE ANY PERSONAL BUSINESS OR PROFESSIONAL CONTACTS IN THE UNITED STATES?				   YES	
If so, list name, business or occupation and address.								   NO	

											
23. TRAVEL (If you have ever traveled in any other countries give the dates, duration and purpose of such travel. If travel was in the United States,
                     supply under item 38 additional data. including type of visa. place and date of issuance, date and port of arrival in the United States,
                     places of residence in the United States and the date and port of departure from the United States.)	
COUNTRY	DATES									
							PURPOSE				
	FROM	TO								

											
											
24. MEMBERSHIPS, SOCIETIES, ASSOCIATIONS, CLUBS AND OTHER ORGANIZATIONS OF WHICH YOU ARE NOW OR HAVE BEEN A MEMBER, EXCEPT RELIGIOUS
      OR POLITICAL AFFILIATIONS
        NAME                                                 ADDRESS                                                TYPE                                FROM                    TO                                 OFFICE HELD

       

25. MILITARY SERVICE (Outline military service past or present. giving country of service, branch of service, unit or organization, specialty, highest rank held, dates of
      service, present rank, and date and type of discharge.)	

											
											
26. LIST ANY TITLES, ORDERS OR DECORATIONS BESTOWED UPON YOU								
	TITLES. ORDERS OR DECORATIONS					DATE BESTOWED	

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27. EDUCATION	
NAMES AND LOCATIONS OF EDUCATIONAL INSTITUTIONS ATTENDED			DATES							MAJOR SUBJECTS		
							DEGREES						
		FROM		TO												

																						

		28. LANGUAGES (Name and indicate the extent of your competence)										
				SPEAK					READ			WRITE		UNDERSTAND	
	LANGUAGE													
Good	
Fair	
Excellent	
Good    Fair	
			Excellent	Good	Fair	Excellent	Good	Fair	Excellent					

																						
 29. REFERENCES. LIST THREE COMPETENT AND RESPONSIBLE PERSONS NOT RELATED TO YOU BY BLOOD OR MARRIAGE WHO ARE QUALIFIED TO SUPPLY
        DEFINITE INFORMATION REGARDING YOUR CHARACTER AND ABILITY. (Do not give names of supervisors listed in item 30.)  
(DISCLAIMER: REFERENCES WILL BE CONTACTED FOR CHARACTER VERIFICATION)	
	NAME						ADDRESS IN FULL							OCCUPATION		

																						
30. EMPLOYMENT. (In the space provided below describe every position which you have held since you first began to work. Start with Present Position and work back to the
      first position which you held. Account for all periods of unemployment and state reasons for any unemployment indicated. If not enough space use Continuation Sheet.)	
      
      IF CURRENTLY EMPLOYED MAY WE APPROACH YOUR PRESENT EMPLOYER?                                        YES                          NO	
A. DATES OF EMPLOYMENT (Month, Year)			EXACT TITLE OF YOUR POSITION						SALARY OR EARNINGS		
FROM:	TO:			
		STARTING		P.A.	
     NAME AND FULL ADDRESS OF EMPLOYER					FINAL			P.A..	
	DUTIES:	
 .  NAME AND TITLE OF IMMEDIATE SUPERVISOR
				
  REASON FOR WANTING TO LEAVE
				
B. DATES OF EMPLOYMENT (Month. Year)			EXACT TITLE OF YOUR POSITION

	SALARY OR EARNINGS		
FROM:	TO:				STARTING		P.A.	
   NAME AND FULL ADDRESS OF EMPLOYER				FINAL			P.A.	
				DUTIES
	
   NAME AND TITLE OF IMMEDIATE SUPERVISOR
				
   REASON FOR LEAVING
					
C. DATES OF EMPLOYMENT (Month, Year)			EXACT TITLE OF YOUR POSITION

	SALARY OR EARNINGS		
FROM:	TO:				STARTING		P.A. 	
    NAME AND FULL ADDRESS OF EMPLOYER				FINAL			P.A.	
	DUTIES:
	
   NAME AND TITLE OF IMMEDIATE SUPERVISOR
				
REASON FOR LEAVING					

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'31. SPECIALQUALIFICATIONS AND SKILLS. List any special skills you possess and machines and equipment you can
       use, such as a Photocopier, Fax Machine, PBX switchboard, etc.
	Approximate Number of Words per Minute in:	
	TYPING					
						
	SHORTHAND__________________			
	ANSWER ITEMS 32 THROUGH 36 BY PLACING AN "X" IN THE PROPER COLUMN				YES	NO	
32. HAVE YOU EVER BEEN DISCHARGED OR FORCED TO RESIGN FOR MISCONDUCT OR UNSATISFACTORY SERVICE FROM A POSITION?			
IF ANSWER IS "YES" GIVE DETAILS UNDER ITEM 38.									
33 a. HAVE YOU NOW OR HAVE YOU EVER HAD ANY PHYSICAL LIMITATIONS?...........................………………………………………………………………………………………......................			
     b. ARE YOU NOW UNDER A PHYSICIAN'S CARE AND IF SO, FOR WHAT REASON?.................................................................................................…………………………………....................			
     c. HAVE YOU EVER HAD A NERVOUS DISORDER?.............................................................................................……………………………………………………………………..............................			
     d. HAVE YOU EVER HAD TUBERCULOSIS?......................................................................………………………………………………………………………………………………………................			
     e. WITHIN THE PAST 12 MONTHS, HAVE YOU USED INTOXICATING BEVERAGES TO EXCESS?...................………………………………………..................................................................			
     f. DO YOU HAVE A DRUG OR NARCOTIC ADDICTION?...........................................................................................……………………………………........................................................................			
     g. WERE YOU EVER MEDICALLY DISCHARGED FROM THE ARMED FORCES?...........................................................………………………………………………………………......................
			
 IF ANY OF YOUR ANSWERS TO ANY OF THE ABOVE IS "YES", GIVE PARTICULARS UNDER ITEM 38.						
34. HAVE YOU EVER BEEN ARRESTED OR DETAINED BY ANY POLICE OR MILITARY AUTHORITY?...........................................................................................…………………………………....			
IF SO, NAME THE AUTHORITY, GIVE TIME, PLACE, REASON AND THE DISPOSITION OF COURT ACTION.

						
35. ARE YOU NOW, OR HAVE YOU EVER BEEN, A MEMBER OF THE COMMUNIST PARTY OR ANY COMMUNIST OR FASCIST ORGANIZATION?.....................			
36. ARE YOU NOW OR HAVE YOU EVER BEEN A MEMBER OF ANY ORGANIZATION, ASSOCIATION, MOVEMENT, GROUP, OR COMBINATION OF
      PERSONS WHICH ADVOCATES THE OVERTHROW OF THE CONSTIT{JTIONAL FORM'OF GOVERNMENT OF THE UNITED STATES. OR ANY
      ORGANIZATION, ASSOCIATION. MOVEMENT, GROUP, OR COMBINATION OF PERSONS WHICH HAS ADOPTED A POLICY OF ADVOCATING OR
      APPROVING THE COMMISSION OF ACTS OR FORCE OR VIOLENCE TO DENY OTHER PERSONS THEIR RIGHTS UNDER THE CONSTITUTION OF
     T HE UNITED STATES OR OF SEEKING TO ALTER THE FORM OF GOVERNMENT OF THE UNITED STATES BY UNCONSTITUTIONAL MEANS?			

			
			
37. IF YOUR ANSWER TO ITEMS 35 OR 36 IS "YES", STATE THE NAME OF THE ORGANIZATION, DATES OF MEMBERSHIP OR ASSOCIATION, AND EXTENT OF YOUR
      PARTICIPATION. IF YOU DESIRE TO EXPLAIN THE CIRCUMSTANCES OF YOUR MEMBERSHIP. USE SPACE UNDER ITEM 38 OR ATTACH A SEPARATE PAGE.	
	
        NAME	ADDRESS	TYPE	FROM	TO	OFFICE HELD		

										

38. USE THIS SPACE FOR DETAILED ANSWERS. NUMBER ANSWERS TO CORRESPOND WITH QUESTIONS. ADD ANY INFORMATION NOT COVERED
       ABOVE WHICH MIGHT AFFECT YOUR EMPLOYMENT. USE EXTRA BLANK PAGES, IF NECESSARY.

		
		
PRIVACY ACT STATEMENT
(APPLICABLE ONLY TO APPLICANTS WHO ARE RESIDENT ALIENS OF THE U.S.)
    The Foreign Service Act of 1980, as amended, implies the authority to solicit personal information from individuals due to its relevance to the appointment,
    training, evaluation and assignment processes. This information is used by the Department of State to assist in evaluating your qualifications for employment in
    the Foreign Service. The information you furnish will be reviewed by authorized persons within the Department of State and other agencies at posts abroad as requested.
    Failure to answer all applicable questions on this form may delay consideration of your application and could result in your not receiving full consideration for a position
     in which this information is needed.	
CERTIFICATION	
  BEFORE SIGNING THIS FORM MAKE SURE YOU HAVE ANSWERED ALL QUESTIONS FULLY AND COMPLETELY. A FALSE STATEMENT ON THIS APPLICATION
  IS CAUSE FOR DISMISSAL.	
   I DO SOLEMNLY AFFIRM THAT THE INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

              SIGNATURE:
			
(Name as usually written and which will be used as official signature)			Date			

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