Governance and Participation

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NOTE: PLEASE HIT THE SUBMIT BUTTON ONLY ONCE. A CONFIRMATION OF SUCCESS IS NOT POSTED UPON RECEIPT.

Last Name
First Name
Permanent Mailing Address
Current U.S. State/Postal Territory OR Canadian Province of Residence (if applicable)
Current Country of Residence
Current Phone Number
Current Email
Current Office of Employment
Employment Status (check all that apply)	Direct Hire (DH) Personal Service Contract (PSC) When Actually Employed (WAE) Student Program Institutional Contract RASA/PASA Other, Please Specify
Past Employment (check all that apply)	USG NGO IO Other, Please Specify
Years of USG Experience
Additional Skills or Qualifications you wish to highlight
Sector	GOVERNANCE & PARTICIPATION (note: if this is incorrect please access the appropriate form from the previous page)
Capability (refer to ETM)	Disposition of Armed and Other Security Forces, Intelligence Services and Belligerents Territorial Security Public Order and Safety Protection of Indigenous Individuals, Infrastructure and Institutions Protection of Reconstruction and Stabilization Personnel and Institutions Security Coordination Public Information and Communications
Years of R/S Experience
Foreign Language #1
What is your level of proficiency for the following areas: Reading/Writing/Speaking
Foreign Language #2
What is your level of proficiency for the following areas: Reading/Writing/Speaking
Regional Experience (check all that apply-Note that the definitions for regions and countries located therein are explained by the Under Secretary for Political Affairs at the U.S. Department of State)	East Asia/Pacific Europe Near East Asia South Asia Western Hemisphere AntarcticaAfrica
Most Recent Country of R/S Experience
R/S Training
Reference
Educational Background (List additional relevant Degrees/Certificates or training course)
How many weeks advance notice do you require for deployment?
Date Available for Deployment (overseas)
Number of Months Available (overseas)
Date Available for Deployment (Washington DC)
Number of Months Available (Washington DC)

What Security Clearance do you currently have?
What Agency issued your current clearance?	Please Specify
Do you currently have a USG (world-wide Class 1) issued medical clearance?	Yes No

NOTE: PLEASE HIT THE SUBMIT BUTTON ONLY ONCE. A CONFIRMATION OF SUCCESS IS NOT POSTED UPON RECEIPT.

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