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Fillable Printable OPM Form 1655

Fillable Printable OPM Form 1655

OPM Form 1655

OPM Form 1655

United States Office of Personnel Management Form Approved:
OMB No. 3206-0248
Application for Senior Administrative Law Judge
Description of the Senior Administrative Law Judge (SALJ) Program: The SALJ Program allows retired
Administrative Law Judges (ALJs) to be reemployed on a temporary and intermittent basis to complete hearings of
one or more specified case(s) in accordance with the Administrative Procedure Act of 1946. Upon appointment, and
while reemployed, the retired ALJ is referred to as a SALJ. (See 5 U.S.C. § 3323(b), and 5 CFR 930.201, et seq)
Who Can Apply: Retired Federal ALJs formerly employed by the Federal Government, and currently receiving an
annuity under the Civil Service Retirement System (CSRS) or the Federal Employee Retirement System (FERS).
Retired ALJs are required to demonstrate through proper documentation that they possess a current license to
practice law under the laws of a State, the District of Columbia, the Commonwealth of Puerto Rico, or any other
territorial court established under the Constitution. If eligible, the U.S. Office of Personnel Management (OPM) will
place the retired ALJs name on its SALJ Master List for referral to a hiring agency for possible reemployment. Place-
menton the SALJ Master List is not a guarantee of reemployment.
Instructions: Type or print clearly in black or blue ink. Complete the application and Geographic Preference
Statement for Senior Administrative Law Judge Applicant (OPM Form 1655-A). Submit your application and
requested documentation to: Human Capital Leadership & Merit System Accountability Division,
Administrative Law Judge Program, U.S. Office of Personnel Management, 1900 E Street, NW, Washington,
DC 20415.
1. Name (Last, First, MI) 2. Social Security Number 3. Telephone Numbers
Daytime ( )
Other ( )
4. Address (Street, City, State, ZIP Code) 5. Email Address (if available)
6. Are you a U.S. Citizen?
Yes No
7. Highest Grade and Step/Level and Rate as ALJ
8. Retirement
Date (mm/dd/yyyy) 9. Are you a Civil Service annuitant?
No Yes
CSRS CSA Claim Number:
FERS |
10. Do you meet the licensure requirements un
der
5 CFR 930.201 et seq?
Yes No
If yes, list the state(s) and /or jurisdic
tion(s) where you are
currently licensed to practice law (attach proof of licensure):
11. Since the date of your original appointment as an
ALJ, have you ever
been disciplined or cited for
breach of ethics or unprofessional conduct by, or
been the subject of a complaint to, any court,
administrative agency, bar association, disciplinary
committee, or other professional group?
Yes No
If yes, in which jurisdiction: Please describe the nature and
outcome of the proceeding (if neede
d, please attach a separate
sheet to this form):
12. List your ALJ experience. If desired, attach a resume or OF-612, Optional Application for Federal Employment to this form.
From (mm/yyyy) To (mm/yyyy) Title Grade/Level Employer (Agency) Location (City/State)
13. For which agencies are you interested in conducting hearings?
14. Availability to work:
Part Time Full Time
15. Are you willing to travel?
Yes No
5 U.S.C. § 3323(b)
Page 1
OPM Form 1655
5 CFR 930.201 et seq January 2008
United States Office of Personnel Management Form Approved:
OMB No. 3206-0248
Privacy Act Statement
The information on this form is collected pursuant to 5 U.S.C. § 3323(b) and 5 CFR 930.201 et seq. The
primary use of the information is to determine eligibility for reemployment as a SALJ. The information may be
disclosed to appropriate Federal, State, or local agencies when relevant to civil, criminal, or regulatory
investigations or prosecutions; in judicial or administrative proceedings; to congressional offices; and to Federal
agencies for employment or security reasons. Your Social Security Number (SSN) is requested under the
authority of Executive Order 9397, which requires the SSN for the purpose of uniform, orderly administration of
personnel records. Providing this information is voluntary, however, failure to provide the requested
information will prevent processing of the application. We may confirm information from your records with
prospective nonfederal employers concerning tenure of employment, civil service status, length of service, and
date and nature of action for separation as shown on personnel action forms of specifically identified
individuals.
Public Burden Statement
We estimate the public reporting burden for this collection will vary from 30 to 45 minutes with an average of 15
minutes per response, including time for reviewing instructions, searching existing data sources, gathering
data, and completing and reviewing the information. Send comments regarding the burden estimate or any
other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of
Personnel Management, OPM Forms Officer, Washington, DC 20415-7900. The OMB number, 3206-0248, is
currently valid. OPM may not collect this information and you are not required to respond, unless this number
is displayed. Do not send completed application forms to this address.
Reasonable Accommodation
Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate.
Applicants requiring reasonable accommodation for any part of the hiring process should contact the appointing
agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case
basis.
THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER
I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is
true, correct, complete and made in good faith. I understand that reemployment as a SALJ is subject to
investigation of suitability in accordance with 5 CFR 731.201 through 731.303. In addition, I understand that
reemployment is subject to conflict of interest and security investigation requirements by the appointing agency.
Signature Date
5 U.S.C. § 3323(b)
Page 2
OPM Form 1655
5 CFR 930.201 et seq January 2008
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