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Fillable Printable OPM Form 1304

Fillable Printable OPM Form 1304

OPM Form 1304

OPM Form 1304

PMF Success StoryS ubmis sion Form
PRIVACY ACT STATEMENTAND INSTRUCTIONS:
Author
ity:5 CFR 362 promulgates Executive Order 13562, placing the Presidential Management Fellows (PMF) Program under the Pathways
Programs. The U.S. Office of Personnel Management (OPM) administers the PMF Program government-wide. The PMF Programis to attractt o the
Federal servic e outstanding men and women from a variety of academic disciplines and career paths, who have a cl ear interest i n, and commitment to,
excellence in the leaders hi p and management of public policies and programs .
Purpose
:This PMF Success Story Submission Form is used to collect success stories from current and former PMFs.
Rout
ine Uses:T hese s t ori es are to highl i ght the success of PMFs during and after their fellowship and publis h to the PMF website.
Disclo
sure:Use of t his form and furnishing t his inf ormation is optional. All submissi ons must incl ude the Aut horizati on and Release s ignature (belo w).
The PMF Program Office reserves the right to edit, deny, and/or approve any submissions.
Curre
nt/Former Fellows:This form can be found under the “Current PMFs\Resources” section on the PMF website at www.pmf.gov
. Fill out the
informat ion below and send via e mail to pmf@opm.govwith the subjec tof “Success S tory”. Please incl ude a photo. Phot ographs should be related t o
the submitter and/ or story being submitt ed.
Current/Former PMFFirst and Last Name:
Work Phone Number (with area code):
Work Email Address:
Agency/Sub-Agency:
Work or Home Mailing Address:
Success Story (please limit to 3-5 paragraphs; add a separat e page if additio nal sp ace is n eeded) :
AUTHO
RIZATION AND RELEASE:I hereby authorize and consent that the U.S. Office of Personnel Management, a Federal Agency, its legal
representatives, successors or assigns, shall have the absolute right to copyright, publish, use, sell or assign any and all photographic portraits or
pictures, or any part t hereof, they have taken or made of me or I have submitt ed to them, or in which I m ay be included i n whole or in part, whether apart
from or in connection with, illustrative or written printed matter, story or news item, for the PMFSuccess Stories. I hereby waive all claims for any
compensation f or such use or for dam ages. I hereby waive any right that I may have to inspect and/or approve the finished pr oduct or the advertis ing
copy that may be used in connection therewith or the use to which it may be applied. I hereby warrant that I am of full age and have every right to
contract in m y own name in the above regard. I state further that I have read the above authorization and release, prior to its execution, and that I am
familiar with the contents thereof.
________________________________________________________
Si
gnatureDate (mm/dd/yyyy)
OFFICE USE ONLY:
PMFPO Received:PMFPO Posted:Success Story Number:
U.S. Office of Personnel ManagementOPM F orm1304
Presidential Management Fellows ProgramNovember2014
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