Last Name
First Name
Permanent Mailing Address
Current U.S. State/Postal Territory OR Canadian Province of Residence (if applicable)
Alabama Alaska Alberta Arizona Arkansas Armed Forces Africa, Canada, Europe, Middle East Armed Forces Americas Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Current Country of Residence
Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ashmore Australia Austria Azerbaidjan Bahamas Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cartier Island Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland Former USSR France French Guyana French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe (French) Guam Guatemala Guinea Guinea Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique (French) Mauritania Mauritius Mayotte Mexico Micronesia Moldavia Monaco Mongolia Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia (French) New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Polynesia (French) Portugal Qatar Reunion (French) Romania Russian Federation Rwanda S. Georgia & S. Sandwich Islands Saint Helena Saint Kitts & Nevis Anguilla Saint Lucia Saint Pierre and Miquelon Saint Tome and Principe Saint Vincent & Grenadines Samoa San Marino Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Tadjikistan Taiwan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu UK US USA Minor Outlying Islands Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands (British) Virgin Islands (USA) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
Current Phone Number
-- Work Cell Home
Current Email
-- Work Personal
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
-- 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 50+
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
-- 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 50+
Foreign Language #1
Afrikaans Akan Twi Akposso Albanian Amashi Amharic Arabic (Spec Dialet) Arabic (Syrian) Arabic Egyptian Arabic-Eastern Arabic-Gulf Arabic-Modern Arabic-Western Armenian-East Armenian-West Assamese Aymara Azerbaijani Bakweri Bamileke Basque Bassa (Cameroons) Baule Beja Bemba/Cibemba Bengali Berber Bini Bosnian Bubi Bulgarian Burmese Byelorussian Cambodian-Khmer Catalan Chamorro Chinese (Amoy) Chinese (Hakka) Chinese (T Ung) Chinese (Taiwanese) Chinese-Canton Chinese-Fuchow Chinese-Mandar Chinese-Swaton Chinyanja/Nyanja Chokwe Croatian Czech Danish Djerma/Songhai Duala Dutch Efik English Estonian Ewe Ewondo Fanagalo Fang/Bulu Fijian Finnish Flemish Flemish Or Dutch Fon Fr.Or Ger.Or Italian French Fula/Toucouleur Ga Gaelic Galla Georgian German German (Swiss) Greek Guarani Gujarati Haitian Creole Hassaniya Hausa Hebrew Hindi Hungarian Iban Icelandic Igbo Ijaw Ila-Tonga Ilocano Indonesian Italian Jamaican Patois Japanese Javanese Kabre Kannada Kanouri Kapingamarangi Kashmiri Kazakh Khmer Kikongo/Kongo Kikuyu Kimbundu Kinyarwanda/Rwanda Kirghiz Kirundi Kirundi/Rundi Kissi Kituba-Munukutuba Korean Kpelle Krio Kru Kumbo Kurdish Kusaie Lamba Lang Pronunciation Language Other Lao Latvian Lingala Lithuanian Loma Luba (Kasai) Luganda/Ganda Lunda Luo Macedonian Malagasy Malay Malayalam Maltese Mandingo-Bambara Mandingo-Dioula Mandingo-Malinke Marathi Marshallese Masai Mauritius Creole Maya Mende Mongolian More Morthlockese Mpongwe Ndebele Nepali/Nepalese Norwegian Nubian Nyamwezi/Sukuma Oriya Palauan Panjabi/Punjabi Papiamento Pashto Persian - Tajiki Persian-Afghan Persian-Iranian Pidgin (Wescos) Pilipino/Tagalog Pizar Malay Polish Ponapean Portuguese Pulap Quechua Romanian Russian Ryukyuan/Okinawan Samoan Sango Sara Serbian Serbo-Croatian Serer Shona Sindhi Singhalese Slavic Slovak Slovenian Somali Soninke Sorani Sotho/Sesutho Spanish Susu Swahili/Kiswahili Swati Swedish Tahitian Taki-Taki Tamil Telugu Temne Tetun Thai Tibetan Tigre Tigrinya Tok Pisin Trukese Tshwa/Tswa Tsonga Tswana/Setswana Tumbuka Turkish Turkmen Ukrainian Ulithi Umbundu Urdu Uzbek Vai Vietnamese-Std Visayan/Cebuano Welsh Woleai Wolof Xhosa Yakut Yao (Malawi & Mozam) Yappese Yiddish Yoruba Zulu
What is your level of proficiency for the following areas: Reading/Writing/Speaking
-- Excellent Good Fair Poor -- Excellent Good Fair Poor -- Excellent Good Fair Poor
Foreign Language #2
Afrikaans Akan Twi Akposso Albanian Amashi Amharic Arabic (Spec Dialet) Arabic (Syrian) Arabic Egyptian Arabic-Eastern Arabic-Gulf Arabic-Modern Arabic-Western Armenian-East Armenian-West Assamese Aymara Azerbaijani Bakweri Bamileke Basque Bassa (Cameroons) Baule Beja Bemba/Cibemba Bengali Berber Bini Bosnian Bubi Bulgarian Burmese Byelorussian Cambodian-Khmer Catalan Chamorro Chinese (Amoy) Chinese (Hakka) Chinese (T Ung) Chinese (Taiwanese) Chinese-Canton Chinese-Fuchow Chinese-Mandar Chinese-Swaton Chinyanja/Nyanja Chokwe Croatian Czech Danish Djerma/Songhai Duala Dutch Efik English Estonian Ewe Ewondo Fanagalo Fang/Bulu Fijian Finnish Flemish Flemish Or Dutch Fon Fr.Or Ger.Or Italian French Fula/Toucouleur Ga Gaelic Galla Georgian German German (Swiss) Greek Guarani Gujarati Haitian Creole Hassaniya Hausa Hebrew Hindi Hungarian Iban Icelandic Igbo Ijaw Ila-Tonga Ilocano Indonesian Italian Jamaican Patois Japanese Javanese Kabre Kannada Kanouri Kapingamarangi Kashmiri Kazakh Khmer Kikongo/Kongo Kikuyu Kimbundu Kinyarwanda/Rwanda Kirghiz Kirundi Kirundi/Rundi Kissi Kituba-Munukutuba Korean Kpelle Krio Kru Kumbo Kurdish Kusaie Lamba Lang Pronunciation Language Other Lao Latvian Lingala Lithuanian Loma Luba (Kasai) Luganda/Ganda Lunda Luo Macedonian Malagasy Malay Malayalam Maltese Mandingo-Bambara Mandingo-Dioula Mandingo-Malinke Marathi Marshallese Masai Mauritius Creole Maya Mende Mongolian More Morthlockese Mpongwe Ndebele Nepali/Nepalese Norwegian Nubian Nyamwezi/Sukuma Oriya Palauan Panjabi/Punjabi Papiamento Pashto Persian - Tajiki Persian-Afghan Persian-Iranian Pidgin (Wescos) Pilipino/Tagalog Pizar Malay Polish Ponapean Portuguese Pulap Quechua Romanian Russian Ryukyuan/Okinawan Samoan Sango Sara Serbian Serbo-Croatian Serer Shona Sindhi Singhalese Slavic Slovak Slovenian Somali Soninke Sorani Sotho/Sesutho Spanish Susu Swahili/Kiswahili Swati Swedish Tahitian Taki-Taki Tamil Telugu Temne Tetun Thai Tibetan Tigre Tigrinya Tok Pisin Trukese Tshwa/Tswa Tsonga Tswana/Setswana Tumbuka Turkish Turkmen Ukrainian Ulithi Umbundu Urdu Uzbek Vai Vietnamese-Std Visayan/Cebuano Welsh Woleai Wolof Xhosa Yakut Yao (Malawi & Mozam) Yappese Yiddish Yoruba Zulu
What is your level of proficiency for the following areas: Reading/Writing/Speaking
-- Excellent Good Fair Poor -- Excellent Good Fair Poor -- Excellent Good Fair Poor
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 Antarctica Africa
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)
-- less than 1 01 02 03 04 05 06 07 08 09 10 11 12 more than 12
Date Available for Deployment (Washington DC)
Number of Months Available (Washington DC)
-- less than 1 01 02 03 04 05 06 07 08 09 10 11 12 more than 12
What Security Clearance do you currently have?
-- Confidential Secret Top Secret Top Secret/SCI
What Agency issued your current clearance?
-- Department of State Central Intelligence Agency Department of Defense Department of Justice Other Please Specify
Do you currently have a USG (world-wide Class 1) issued medical clearance?
Yes No