Fillable Printable Standard Form 39
Fillable Printable Standard Form 39
Standard Form 39
U.S. Office of Personnel Management
Request for Referral of Eligibles
1. Name of issuing official
2. Certificate of Eligibles control number
3. Date issued (mm/dd/yyyy)
I. AGENCY REQUEST
4. Department or agency name
5. Department or agency organization code
6. Bureau or field office
7. Agency request number
8. Date of request (mm/dd/yyyy)
9. Identify appropriate delegated examining office and address
10a. Number of vacancies
10b. Series
10c. Position title
10d. Grade (salary, if ungraded)
10e. Duty location
11. Type of appointment
Career or career-conditional
Temporary NTE:
Term NTE:
(Provide justification in remarks)
(Provide justification in remarks)
12. Full performance level
(Potential)
13. Date SF 52 or request initiated
14. CTAP/ICTAP cleared
Yes
No
15. Other conditions of employment
(e.g., shift or seasonal work, medical exam, etc.)
16. Reemployment priority list
cleared
Yes
No
17. Indicate maximum number of nights per month the appointee
will be required to be away from home in a travel status.
None1 to 56 to 10
11 or more
18. Date position(s) needs to
be filled (mm/dd/yyyy)
19. Work Schedule
Part-time employment of
Full-time employment
Intermittent employment
Other (specify)
20. Remarks. Provide any special qualification requirements (e.g., selective factors).
21. Address where Certificate of Eligibles is to be sent:
22a. Contact name
22b. Contact telephone number
22c. Contact fax number
22d. Contact e-mail address
II. CERTIFICATION of ELIGIBLES (To Be Completed by DE Office)
Delegated examining office:
The attached Certificate of Eligibles is provided in response to the above request.
This Certificate of Eligibles is valid only for the position(s), grade(s), and duty location(s) shown above.
This Certificate of Eligibles must be returned by___________________________, according to agency policy.
For information concerning this Certificate of Eligibles contact:
III. REPORT
To issuing office: If Certificate of Eligibles is returned unused, please explain why:
Signature of appointing officialName and title of appointing official
Date signed (mm/dd/yyyy)
Standard Form 39
Revised April 2011
Previous editions not usable
U.S. Office of Personnel Management
5 CFR part 332
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Request for Referral of Eligibles
Instructions and Information for Agency Selecting and Appointing Officials
General:
The information on the Certificate of Eligibles is for the United States Government use only. Treat Certificate of Eligibles, including
qualification statements and other attached documents, as privileged information. Return Certificate of Eligibles to the issuing office by the
date indicated in Section II.
Selections from Certificate of Eligibles must be made in compliance with title 5, United States Code, Sections 3318 and 3319 and any
regulations issued by the U.S. Office of Personnel Management. See Guide to Processing Personnel Actions located on OPM's website,
//www.opm.gov/feddata/gppa/gppa.asp, for further instructions on required pre-appointment checks. Additional information on making
selections can be found in title 5, Code of Federal Regulations (CFR) sections 330 subpart F and G,332.404, and 332.406(b)(c)(d).
Explanation of Key Terms and Footnotes
Footnotes or remarks are placed beside a particular eligible’s name on a Certificate of Eligibles or on the eligible’s qualifications statement
to convey information about that person and, as appropriate, to alert the office to necessary actions.
The following key terms may appear adjacent to eligibles listed:
CPS -- 10-point compensable preference based on a
service-connected disability of 30% or more
CP -- 10-point compensable preference based on a service
connected disability of 10% or more, but less than 30%
XP -- 10-point other preference; granted to recipients of the Purple
Heart, persons with a non-compensable service-connected
disability (less than 10%), widow/widower or mother of a
deceased veteran, or spouse or mother of a disabled veteran
TP -- 5-point preference
NV --
Non-Veteran
Completion of Educational Requirements - Many examinations
recognize students who are within nine months of completing their
education as tentatively qualified. Therefore, such eligibles may not
enter on duty until they provide proof of completion of required
education to the appointing official.
Superior Academic Achievement - Students who achieved
superior academic standing based on class standing, grade-point
average, or honor society membership may qualify for superior
academic achievement. Agency must verify such academic
achievement prior to selection.
Certification of Proficiency Claimed - An eligible who claims
typing and/or stenographic proficiency. Agency must verify claims
prior to selection
Reporting
Report appropriate action codes on the Certificate of Eligibles next to the appropriate name of the eligible. Declinations, Communication Returned
Unclaimed, and Failed to Respond codes must be supported by documentation. Action codes for use in reporting are listed below:
Declinations:
DA -- Declined Agency
DD -- Declined
DG -- Declined Grade or Salary
DL -- Declined Location
DP -- Declined for the Position Certified Only
DZ -- Declined for other Reason
Agency Objections:
(Under Delegated Examining Authority)
RM --
Removed from Certificate-Medical (5 CFR part 339)
RQ --
Removed from Certificate - Qualification(5 CFRpart 337 or338)
RS -- Removed from Certificate - Conduct (5 CFR part 731)
Others:
A -- Selected (For each selection, provide the expected date of
appointment.)
CRU -- Communication Returned Unclaimed
FR -- Failed to Respond
NC -- Appointed by Non-Competitive Action
NS -- Not Selected
NN -- Not Contacted
CE -- Career or Career-Conditional Employee*
TE -- Temporary (or Term) Employee
** Already serving under the same appointing official, in the same type
of position, in the same (or higher) grade, at the same duty location.
Position title, grade and duty location must be listed as evidence that
all of the above conditions are present, including the type of
appointment and selecting official, if known.
U.S. Office of Personnel Management
5 CFR part 332
(Back) Standard Form 39
Revised April 2011
Previous editions not usable
