Form OPM-1170 List of College Courses and Certification of Scholastic

Supplemental Qualifications Statement

Form Approved
OMB No. 3206-003

LIST OF COLLEGE COURSES AND CERTIFICATION OF SCHOLASTIC ACHIEVEMENT
Complete and submit this form with your Application for Federal Employment or as instructed
1. Name: (Last, First, MI)

2. Birth Date (Month, day, year)

3. Social Security Number

4. Position for which you are applying (Include options, if any)
5. List the undergraduate and/or graduate college degrees you have received or expect to receive (Give name of degree, name of college or
university granting degree and date received or to be received)

6. State your major undergraduate course(s) of study

6a. State your major graduate course(s) of study.

PART 1 - COLLEGE COURSES
List below by appropriate academic field (e.g., biology, mechanical engineering, economics, sociology, etc.) all courses you have taken
(including those failed) which appear to satisfy the qualification requirements of positions for which you are applying. List graduate and
undergraduate courses separately. Credits for each category should be totaled to determine if you meet the minimum course requirements.
Indicate Academic Field:
DESCRIPTIVE TITLE

Completion
Date

Indicate Academic Field:
Grade

TOTAL
U.S. Office of Personnel Management

Sem

Qtr

Class
Room

DESCRIPTIVE TITLE

Completion
Date

Grade

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Class
Room

TOTAL
OPM-1170/17

Indicate Academic Field:
DESCRIPTIVE TITLE

Completion
Date

Indicate Academic Field:
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Class
Room

TOTAL

TOTAL

Completion
Date

Grade

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Indicate Academic Field:
DESCRIPTIVE TITLE

DESCRIPTIVE TITLE

Completion
Date

Indicate Academic Field:
Grade

Sem

Qtr

Class
Room

DESCRIPTIVE TITLE

TOTAL

Completion
Date

Indicate Academic Field:
DESCRIPTIVE TITLE

Indicate Academic Field:

Completion
Date

Grade

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TOTAL

DESCRIPTIVE TITLE

Completion
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Room

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PART II - PRIVACY ACT STATEMENT AND CERTIFICATION

The Office of Personnel Management is authorized by section 1302 of Chapter 12 (Special Authority) and sections 3301 and 3304 of Chapter 33 (Examination, Certification, and
Appointment:) of Title 5 of the U.S. Code to collect the information on this form.
Executive Order 9397 (Numbering System for Federal Accounts Relating to Individual Persons) authorizes the collection of your Social Security Number (SSN). Your SSN is used to
identify this form with your basic application. It may be used for the same purposes as stated on the application.
The information you provide will be used primarily to determine your qualifications for Federal employment. Other possible uses or disclosures of the information are:
1. To make requires for information about from any source; (e.g., former employers or schools).that would assist an agency in determining whether to hire you.
2. To refer your application to prospective Federal Employers and, with your consent, to others (e.g., State and local governments) for possible employment.
3. To a Federal, State, or local agency for checking on violations of law or other lawful purposes in connection with hiring or retaining you on the job, or issuing you a security clearance;
4. To the courts when the Government is party to a suit; and
5. When lawfully required by Congress, the Office of Management and Budget, or the General Services Administration.
Providing the information requested on this form, including your SSN is voluntary. However, failure to do so may result in your not receiving an accurate rating, which may hinder your
chances for obtaining Federal employment.
PUBLIC BURDEN INFORMATION:
Public burden reporting for this collection of information is estimated to take approximately 40 minutes per response, including time for review instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to Reports and Forms Management Office, U.S. Office of Personnel Management, 1900 E Street N.W., Room
CHP 500 Washington, D.C. 20415; and to the Office of Management and Budget, Paperwork Reduction Project (3200-0038), Washington, D.C. 20503.

ATTENTION - THIS STATEMENT MUST BE SIGNED
Read the following paragraph carefully before signing this statement
A false answer to any question in this Statement can be grounds for not employing you, or for dismissing you after you begin work, and may be punishable by fine
or imprisonment (US Code, Title 18, Sec 1001). All statements are subject to investigation, including a check of your fingerprints, police records, and former
employers. All the information you give will be considered in reviewing your Statement and is subject to investigation

CERTIFICATION
I CERTIFY that all of the statements made in this Statement
are true, complete, and correct to the best of my knowledge
and belief, and are made in good faith.

Signature (Sign in ink)

Date Signed

COMPLETE PART III ON THE NEXT PAGE IF YOU CLAIM SUPERIOR ACADEMIC ACHIEVEMENT

PART III - SCHOLASTIC ACHIEVEMENT

NOTE: This part is for the use of college students and graduates who may qualify for some GS-7 positions on the basis of undergraduate scholastic achievement, as
provided in an open job announcement.
See the appropriate job announcement for complete requirements.Proof of scholastic achievement under one of these
provisions should not be submitted with your application, but will be required by the hiring agency at the time of appointment. If you do not wish to qualify on this
basis or if you do not meet the scholastic requirements for the position, do not complete this part. In any case, YOU MUST SIGN YOUR NAME AFTER THE
CERTIFICATION STATEMENT AT THE BOTTOM OF PAGE 3.

A. COLLEGE OR CLASS STANDING. Must be in upper third of your graduating class in the college or university, or major subdivision
such as School of Engineering, School of Business Administration, etc.
NUMBER IN CLASS ______

YOUR STANDING ______

Proof of class standing should be in the form of a statement in writing from the institution’s registrar, the dean of your course of study, or other appropriate official.
This statement of class standing must be based on a suitable measure of your academic performance, such as the results of a comprehensive examination or an overall
faculty assessment, and must indicate the basis of the judgment. Class standing must be based on your standing in your college or university or the first major
subdivision (e.g., the School of Business Administration, the College of Arts and Sciences, etc.). Subdivisions below this level, i.e., a single academic department
within a large university, such as the English Department or the Accounting Department, are not recognized as major subdivisions for this purpose.

B. COLLEGE-GRADE POINT AVERAGE. Your grade-point average (GPA) should be recorded in the manner that is most beneficial to
you, using one of the methods below. Your grade-point average must be expressed in terms of a value on a 4.0 scale based on 4 years, the
last 2 years, or courses completed in the major field of study.* If computing your GPA, indicate the method used and period covered by
checking the appropriate boxes in item 2and in item 3 below, and compute your average in the space provided below on this page.
1. GPA as recorded on final transcript _________ (Transcript must cover at least the last 2 years)
2. (Check One)

_____

Average of undergraduate courses

_____

3. (Check One)

_____

At time of filing *

All 4 years

_____

Average in major field of study
_____

Last 2 years

* You may be rated provisionally eligible if you are a senior student, provided you have the required average in the junior year. You will be required to submit
evidence at the time of appointment that you maintained the required average during your senior years.
In computing your grade-point average, round to the first decimal place (e.g., 2.95 = 3.0. 2.94 = 2.9, 3.45 = 3.5, etc.). If your college uses a different system, explain
below, or on an attachment, how it compares with the grade-point average on a 4.0 scale.
If more than 10 percent of your courses were graded on a pass/fail system rather than on a traditional rating system, you can usually claim credit under the scholastic
achievement provision based only on class standing or membership in a national honor society. The exception is if you can document that only your freshman-year
courses (25 percent or less of your total credits) were credited on a pass/fail or similar system.

NO. OF SEMESTER OR QUARTER HOURS AT 4.0 (“A”)

________

X

4 = ______________

NO. OF SEMESTER OR QUARTER HOURS AT 3.0 (“B”)

________

X

3 = ______________

NO. OF SEMESTER OR QUARTER HOURS AT 2.0 (“C”)

________

X

2 = ______________

NO. OF SEMESTER OR QUARTER HOURS AT 1.0 (“D”)

________

X

1 = ______________

NO. OF SEMESTER OR QUARTER HOURS AT 0.0 (“F”)

________

X

0 = ______________

________

TOTAL (2)

TOTAL (1)

COMPUTED GRADE-POINT AVERAGE
Total (2) divided by Total (1)

______________

___________________

C. HONOR SOCIETY MEMBERSHIP. Must be one of the national scholastic honor societies meeting the minimum requirements of the
Association of College Honor Societies (other than freshman scholarship honor societies).
Name of honor society and date you were elected to membership ___________________________________________________________