Fillable Printable Request For Preliminary Employment Data

Request For Preliminary Employment Data

)ROG

5HTXHVWIRU3UHOLPLQDU\(PSOR\PHQW'DWD

6DIHJXDUG7KH&RQILGHQWLDO1DWXUH2I7KH' DWD2Q7KLV5HTXHVW

6WDQGDUG)RUP

5HYLVHG$XJXVW

862IILFHRI3HUVRQQHO0DQDJHPHQW

'DWH2I7KLV5HTXHVW

Type or print the name and address of the activity to which this

request is being sent and your return address at the bottom.

To Whom It May Concern:

The person named below is tentatively selected for an appointment

in this agency. Please complete this form using the instructions on

page 4 and mail to the address at the bottom of this form.

3DUW ,   7 R EH&RPSOHWHG%\ $FWLYLW\5HTXHVWLQJ,QIRUPDWLRQ

  1DPHRI  7HQWDWLYH6HOHFWHH /DVW)LUVW0LGGOH

 6RFLDO6HFXULW\1XPEHU

 'DWHR I %LUWK

$7LWOHRI3RVLWLRQIRU:KLFK7HQWDWLYHO\6HOHFWHG %3D\3ODQDQG2FFXSDWLRQ&RGH

&  *UDGHRU/HYHO

$JHQF\LQ:KLFK3RVLWLRQLV/RFDWHG(QWHU&RGH)URP%ORFNRQ6) 3HUVRQQHO2IILFHWKDW6HUYLFHVWKH3RVLWLRQ(QWHU&RGH)URP%ORFNRQ6)

 (QWU\RQ 'XW\ (2''DWH'HVLUHGE\  WKLV$FWLYLW\

$1DPHRI3HUVRQ5HTXHVWLQJ,QIRUPDWLRQ

% 5HTXHVWHUV7LWOH

)ROG

&  5HTXHVWHUV6LJQDWXUH '  'DWH6LJQHG (5HTXHVWHUV7HOHSKRQH1XPEHULQFOXGH$UHD&RGH

  $GGLWLRQDO'DWD5HTXHVWHG

Please Return This Completed Request To:

3$*(

3UHYLRXV(GLWLRQLV8VDEOH

161

86

<HV

<HV 1R

3DUW,,,7REH&RPSOHWHG%\$FWLYLW\*LYLQJ,QIRUPDWLRQ

(Complete the following and provide any additional data requested in Item 9, Part I. Follow the instructions on page 4.)

6HFWLRQ$  ,GHQWLILFDWLRQ6KRZQRQ3HUVRQQHO5HFRUGV

 1DPH /DVW)LUVW0LGGOH

 6RFLDO6HFXULW\1XPEHU

 'DWHRI%LUWK

6HFWLRQ%  6 )   'DWD

$(PSOR\PHQW6WDWXV

&XUUHQWO\RQ WKH5ROOVRI7KLV$JHQF\

6HSDUDWHG6SHFLI\'DWH 6HSDUDWLRQ,QFHQWLYH3DLG

% /RFDWLRQRI23)053)

2Q)LOHLQ7KLV2IILFH

2Q)LOHLQ$QRWKHU2IILFH

1DPHDQG$GGUHVV2I 7KDW

6HQWWR135&6SHFLI\'DWH

2IILFH

3RVLWLRQ7LWOH

3D\3ODQ 2FF&RGH *UDGHRU/HYHO 6WHSRU5DWH 7RWDO6DODU\ 3D\%DVLV

$%DVLF3D\

%/RFDOLW\$GM &5HWHQWLRQ$OORZ '6XSY\'LIIHUHQWLDO ($YDLODELOLW\3D\ )$82

1DPHDQG/RFDWLRQRI3RVLWLRQV2UJDQL]DWLRQ

9HWHUDQV3UHIHUHQFH

)(*/,&RGHDQG&RYHUDJH,I&RGH%HQWHUGDWHRIZDLYHUFDQFHOODWLRQ

7HQXUH

93IRU5,)

$QQXLWDQW 3D\5DWH 5HWLUHPHQW3ODQ 6HUYLFH&RPS

:RUN6FKHGXOH 3RVLWLRQ

,QGLFDWRU 'HWHUPLQDQW 'DWH/HDYH

2FFXSLHG

'XW\6WDWLRQ $JHQF\&RGH 3HUV2IILFH&RGH

6HFWLRQ& 2WKHU3HUVRQQHO'DWD

<HDU'HJUHH$WWDLQHG

&LWL]HQVKLS

(GXFDWLRQ/HYHO $FDGHPLF'LVFLSOLQH 9HWHUDQV6WDWXV

2WKHU

6HFWLRQ' 5HWLUHPHQW'DWD

$%UDQFKRI6HUYLFH %  5HWLUHG5DQN

& &KHFN2QHDQG6SHFLI\'DWH

7UDQVIHUUHGWR

5HWLUHG )OHHW5HVHUYH

' &UHGLWDEOH0LOLWDU\6HUYLFH

$&LYLOLDQ5HWLUHPHQW'DWH %5HWLUHPHQW6\VWHP3D\LQJ$QQXLW\

<HDUV 0RQWKV

)UR]HQ6HUYLFH

)(56&RYHUDJH

<HDUV 0RQWKV

&RYHUHG$XWRPDWLFDOO\ 1HYHU&RYHUHG

(OHFWHG)(56

6HFWLRQ(*UDGHDQG3D\'DWD

  'DWH(QWHUHG&XUUHQW*UDGH   'DWHRI/DVW:LWKLQ*UDGH  ,I:*,:DV'HQLHG'DWHRI   'DWHRI/DVW4XDOLW\6WHS,QFUHDVH

DQG6WHS5DWH ,QFUHDVH:*, 'HQLDO 46,

$ +LJKHVW3UHYLRXV*UDGH &  6DODU\IRU7KDW*UDGH6WHS

%  'DWHV+HOG

6WHS+HOG

)URP 7R

' :DV6DODU\%DVHGRQ $,VWKH$SSOLFDQW1RZRQ*UDGH5HWHQWLRQ"

<HV&LWH$XWKRULW\

6SHFLDO$XWKRULW\"

1R*RWRLWHP

&'DWH7ZR<HDU3HULRGRI*UDGH5HWHQWLRQ ,VWKH$SSOLFDQW1RZRQ3D\5HWHQWLRQ"

% 5HWDLQHG3D\3ODQ*UDGHDQG6WHSRU5DWH

%HJDQ

)URP 7R

5DWLQJVRI5HFRUG

$,I1RW/LVWHG$ERYH+LJKHVW6DODU\+HOGRQ D)HGHUDO$SSRLQWPHQW %  'DWHV+HOG

6HFWLRQ)3HUIRUPDQFH'DWD

/HYHO 3DWWHUQ 3HULRG /HYHO 3DWWHUQ 3HULRG /HYHO 3DWWHUQ 3HULRG

/HYHO 3DWWHUQ 3HULRG

3$*(

6HFWLRQ*   $SSRLQWPHQW'DWD

  1DWXUHRI$FWLRQ12$IRU % $XWKRULW\IRU7KDW$SSRLQWPHQW

& 'DWH

 ,IWKH(PSOR\HHLV1RZ&DUHHURU+DV+HOG&DUHHU $SSRLQWPHQWLQWKH

% 1DWXUHRI$FWLRQDQG$XWKRULW\IRU$SSRLQWPHQW7KDW%HJLQ7KDW

&RPSHWLWLYH6HUYLFH'DWHV6HUYHGWR $WWDLQ&DUHHU7HQXUH

)URP 7R

 ,IWKH(PSOR\HH+DV1RW+HOGD&DUHHU$SSRLQWPHQW'DWHRI0RVW

$XWKRULW\IRU7KDW$SSRLQWPHQW

5HFHQW&DUHHU&RQGLWLRQDO$SSRLQWPHQW

6HFWLRQ+3UREDWLRQ'DWD

$ 7KH(PSOR\HHLV1RZ6HUYLQJ$Q ,QLWLDO$SSRLQWPHQW3HULRG7KDW %  +DV$OUHDG\&RPSOHWHG,QLWLDO$SSRLQWPHQW3UREDWLRQ3HULRG

%HJDQRQ 0RQWK'D\<HDU

(QGLQJ

 2WKHU3UREDWLRQDU\3HULRGV

6XSHUYLVRU\

0DQDJHULDO

6(6

'DWH%HJDQ 'DWH&RPSOHWHG

1RW&RPSOHWHG ([HPSW

6HFWLRQ,  8QIDYRUDEOH'DWD

 'RHV23)053)&RQWDLQ5HPRYDO6XVSHQVLRQ'LVFKDUJHRU&KDQJHWR

  ,V7KHUH8QIDYRUDEOH,QIRUPDWLRQLQ2WKHU

)LOHVHJ/HWWHUVRI:DUQLQJ

$GPRQLVKPHQW5HSULPDQG6XLWDELOLW\RU

/HWWHURI 'HFLVLRQRQ  DQ$GYHUVH$FWLRQ"

<HV

'RQW

1R<HV

%HJLQQLQJ

,I<HVWR4XHVWLRQRU1DPHRI3HUVRQWR&RQWDFWIRU0RUH % 7HOHSKRQH1XPEHU,QGLFDWH'61 

DQG

&RPPHUFLDO  6KRZ$UHD&RGH

,QIRUPDWLRQ

6HFWLRQ-)(+%'DWD

 (QUROOPHQW6WDWXV

&DQFHOOHG

(QUROOHG

6KRZ'DWH

:DLYHG6KRZ'DWH:DLYHG6KRZ'DWH

,QHOLJLEOH

6KRZ&RGH

6HFWLRQ.6HFXULW\'DWD

$ 0RVW5HFHQW,QYHVWLJDWLRQ

1$&

%, /%,

1$&,

6%, 0%,

35,

% 'DWH,QYHVWLJDWLRQ&RPSOHWHG

'  /HYHOR I&XUUHQW&OHDUDQFH

& 2WKHU7\SHRI,QYHVWLJDWLRQ([SODLQ

$ ,I,QYHVWLJDWLRQLV3HQGLQJ6KRZW\SH'DWH,QLWLDWHGDQG$JHQF\&RQGXFWLQJ,W

& 7HOHSKRQH1XPEHU,QGLFDWH'61 

DQG &RPPHUFLDO   6KRZ $UHD &RGH

% 1DPHRI6HFXULW\2IILFHUWR&RQWDFWIRU0RUH,QIRUPDWLRQ

6HFWLRQ/6HUYLFH 2EOLJDWLRQ

$ 'RHV(PSOR\HH+DYHDQ2EOLJDWLRQWR5HPDLQLQ*RYHUQPHQW6HUYLFHIRUD6SHFLIF3HULRG%HFDXVHRI

% 'DWH2EOLJDWLRQ([SLUHV

7UDLQLQJ5HFHLYHG"

1R <HV([SODLQ

$ 'RHV(PSOR\HH+DYHDQ2EOLJDWLRQ%HFDXVHRI D5HFUXLWPHQWRU5HORFDWLRQ%RQXVD*RYHUQPHQW3DLG

% 'DWH2EOLJDWLRQ([SLUHV

0RYHRUD6WXGHQW/RDQ5HSD\PHQW"

<HV([SODLQ

6HFWLRQ0 (PSOR\HH3D\UROODQG7KULIW6DYLQJV3ODQ'DWD

$(PSOR\HHV3D\UROO2IILFH$GGUHVV % 3D\UROO2IILFH1XPEHU'LJLW,GHQWLI\LQJ1XPEHU

& 3HUVRQWR&RQWDFWIRU/HDYHDQG3D\,QIRUPDWLRQ

' 7HOHSKRQH1XPEHULQGLFDWH'61

DQG

FRPPHUFLDO  6KRZ$UHD&RGH

$ <HDU7R'DWH%DVLF3D\ % <HDU7R'DWH(DUQLQJV



$V2I'DWH



$V2I'DWH

  <HDU7R'DWH),&$'HGXFWLRQV  <HDU7R'DWH),&$'HGXFWLRQV  <HDU7R'DWH)+,70HGLFDUH'HGXFWLRQV



$V2I'DWH



$V2I'DWH

 ,V (PSOR\HH&XUUHQWO\RQ/:23"

$ 'RHV(PSOR\HH+DYH

% ,I<HV6KRZ1XPEHURI

%HJLQLQJ'DWH

<HV 17('DWH

<HV

3$*(

Weeks and Beginning Date.

 7KULIW6DYLQJV3ODQ

&RGH &RGH

0RQWK <HDU 0RQWK <HDU

<(6

$ 7636HUYLFH

&RPSXWDWLRQ'DWH

% 7639HVWLQJ & 7636WDWXV

' 7636WDWXV'DWH

( 'RHV(PSOR\HH+DYHD/RDQ"

'D\ 'D\

12 &LUFOH2QH

) ,I<HV3URYLGHWKH)ROORZLQJ,QIRUPDWLRQIRU(DFK/RDQ

&LUFOH2QH

$FFRXQW1XPEHU $FFRXQW1XPEHU

3HU:HHNO\ %LZHHNO\ 0RQWKO\

3D\PHQW$PRXQW 3D\PHQW$PRXQW

3HU:HHNO\ %LZHHNO\ 0RQWKO\

 763$OORFDWLRQ

$3HUFHQWDJHRI %DVLF3 D\



%:KROH'ROODU$PRXQW

25

&

)81'*297

6(&85,7,(6



'

)

)81'),;('

,1&20(,1'(;



(

&

)81'&20021

672&.,1'(;



)727$/



$1DPHDQG6LJQDWXUHRI2IILFLDO&HUWLI\ LQ J 763,QIRUPDWLRQ

% 'DWH6LJQHG

6HFWLRQ1/RVLQJ$JHQF\5HOHDVH'DWD

$ ,V(2''DWHLQ3DUW, ,WHP   $FFHSWDEOH"

& 1DPHRI3HUVRQWR&DOO7R'LVFXVV5HOHDVH'DWH

$ 1DPHRI3HUVRQ*LYLQJ,QIRUPDWLRQ

&  7LWOH

' 6LJQDWXUHDQG'DWH6LJQHG

Instructions for Activity

Requesting Information

Use the SF 75 to obtain pre-employment information when the

applicant's Official Personnel Folder (OPF) or Merged Records

Personnel Folder (MRPF) is not available for review. This most

often occurs when the applicant works for a different agency,

when the applicant works in the same agency but receives

personnel service from another office, when the applicant's

OPF/MRPF is on file in another agency even though the

applicant is not employed there, or when the applicant's

OPF/MRPF has been retired to the National Personnel Records

Center (NPRC) but the last employer has most of the information

needed.

Use the information provided on the SF 75 to: (1) verify

information on the applicant's application; (2) make decisions

regarding the applicant's eligibility for appointment, pay and

benefits; and (3) to complete the processing necessary.

The SF 75 may

not

be used for any other purposes (such as to

obtain references or to voucher a prospective employee). Be

sure to request SF 75 information sufficiently in advance of the

projected date of the action to enable the office that receives the

form to complete and return it or to provide the information by

telephone before the effective date of the employment action.

You may request SF 75 information by telephone or be mail.

When requesting the information by mail, complete Part I and

circle the items in Part II that are needed. If additional

information is required (e.g., dates of a detail, the number of

hours an intermittent employee has been in pay and duty status,

etc.), list it in Item 9 of Part I.

After you receive the SF 75 information, follow your agency's

procedures to refer the form to the personnel specialist who will

effect the appointment

% ,I8QDFFHSWDEOH6KRZ(DUOLHVW3RVVLEOH5HOHDVH'DWH

' 7HOHSKRQH1XPEHU,LQGLFDWH'61

DQG

FRPPHUFLDO  6KRZ$UHD&RGH

% $GGUHVV%XLOGLQJ 6WUHHW&LW\6WDWH=,3&RGH

( 7HOHSKRQH1XPEHU,QGLFDWH'61 

DQG

FRPPHUFLDO  6KRZ$UHD&RGH

Instructions for Activity

Providing Information

The name of the person on whom information is requested is in

Part I, Item 1, of this form. Use the most recent SF 50 on which

the data appear to complete Part II, Sections A and B. Use the

OPF/MRPF, Employment Performance Folder (EPF), and the

agency information systems that include adverse action, and

agency security/suitability files to complete Part II. Contact the

Payroll office to complete this Part as well. Review both the right

(long-term records) side of the OPF/MRPF and left (temporary

records).

Instructions for Filing the SF 75

Agencies must prepare an accounting of disclosure for release of

information outside the agency, unless the agency as the

employee's prior written consent to release the information. This

should be done for each system of records used to prepare the

information. The accounting of disclosure for OPF information

should be put on the right side of the OPF/MRPF. The

accounting of disclosure need only be a statement that "SF 75

information on (name of employee) was disclosed to (name and

address of agency) on (date)." If the gaining office has the

employee's written consent to get pre-employment information

from the current agency, no accounting of disclosure is

necessary. Example: OF 306 includes a section where

applicant consents to release of information about ability and

fitness by employers, etc.

3$*(

has the

Print Form

Save Form

Clear Form