Fillable Printable OPM Form 1304

OPM Form 1304

PMF Success Story S ubmis sion Form

PRIVACY ACT STATEMENT AND 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 Program is to attract t 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 pm[email protected] with the subjec t of “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 PMF First 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 PMF Success 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.

_______________________________________ _________________

gnature Date (mm/dd/yyyy)

OFFICE USE ONLY:

PMFPO Received: PMFPO Posted: Success Story Number:

U.S. Office of Personnel Management OPM F orm 1304

Presidential Management Fellows Program November 2014