52569 Application for Emplyment with the Federal Aviation Admi

APPLICATION FOR EMPLOYMENT WITH THE FEDERAL AVIATION ADMINISTRATION
INSTRUCTIONS
READ AND FOLLOW THESE INSTRUCTIONS CAREFULLY. IF YOUR FORM IS NOT
COMPLETED CORRECTLY, WE WILL BE UNABLE TO PROCESS YOUR APPLICATION
AND UNABLE TO CONSIDER YOU FOR EMPLOYMENT.
•

You must enter your Social Security Number (SSN) on the bottom of each page of this form. This
assures that the pages are processed together. Executive Order 9397 authorized the solicitation
of your SSN for use as an identifier in personnel records management, thus assuring proper
identification of applicants throughout the selection and employment process. The information we
collect by using your SSN will be used for employment purposes and may also be used for
studies, statistics, and computer matching to benefit or payment files. Furnishing your SSN or any
of the other information specified in the vacancy announcement is voluntary. However, failure to
do so will prevent the processing of your application and will prevent consideration for
employment.

•

DO NOT submit a resume or Application for Federal Employment (SF-171 or OF-612) in lieu
of completing this application form.

•

You must certify the application form by reading, answering, signing, and dating the
"SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION" questions, or your
application form will not be processed.

•

For statistical purposes, please complete the "RACE AND NATIONAL ORIGIN IDENTIFICATION"
form (the last page of this form). This information is voluntary. Failure to provide it will not affect
your consideration for employment. It does assure that our employment practices are free from
prohibited discrimination and provide equal employment opportunities for all.

• Please make and retain a copy of FAA Form 52569 for your records.
• Please remove this instruction sheet before submitting your application.

Mail your completed application form to:
Aviation Careers Division AMH300
FAA MM Aeronautical Center
P.O. Box 26650
Oklahoma City, OK 73126-0650

FAA Form CAPS Cover Sheet 11/00

RETIRED MILITARY AIR TRAFFIC CONTROL SPECIALIST

AT-2152

U.S. DEPARTMENT OF TRANSPORTATION
FEDERAL AVIATION ADMINISTRATION
APPLICATION FOR EMPLOYMENT WITH THE FEDERAL AVIATION ADMINISTRATION
FAA-AAT-01-RMC01-52569
SSN _________-________-________

Name

________________________________________________________

Day Phone

Address _______________________________________________________

Last

(_____) _____-________

First

MI

Street

Night Phone (_____) _____-________
Date of Birth ______/______/_______

______________________________

______

City

Ste

Place of ______________________
Birth
City

_______

________-______
Zip

______________________

Ste

Country

SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION
YOU MUST COMPLETE THIS PORTION OF THE FORM IN ORDER TO BE CONSIDERED FOR FEDERAL
AVIATION ADMINISTRATION EMPLOYMENT
NOTE: You must sign the application and answer each question below. If these four questions are not
answered "YES," your application cannot be considered. Read the following carefully before you sign this
form:
•

I understand that a false statement on any part of this application may be grounds for not hiring me or for
firing me after I begin work. I also understand that I may be punished by fine or imprisoned for falsification
of my employment application (18 USC 1001)._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes

0 No

•

I understand that information I give may be investigated as allowed by law or Presidential order. _ _ _ _ _ _ _ _ _

0 Yes

0 No

•

I consent to the release of information concerning my background, ability, and fitness for employment
with the Federal Aviation Administration by employers, schools, law enforcement agencies, other
individuals and organizations to investigators, personnel staffing specialists, and other authorized
employees of the Federal Aviation Administration. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes

0 No

I certify that, to the best of my knowledge and belief, ALL of the information provided on this application
is true, accurate, and complete, and that this application for employment with the Federal Aviation
Administration is made in good faith. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Yes

0 No

•

_________________________________________________
(Signature)

___________________________
(Month)

(Day)

(Year)

Privacy Act and Public Burden Statements
Public Law 104-50 allows the Federal Aviation Administration (FAA) to rate applicants for employment. We need the information on this application
questionnaire to see how well your education and work skills qualify you for employment with the FAA. We also need information on matters such as
citizenship and military service to see whether you are affected by laws we must follow in deciding whom the Federal government may employ.
Executive Order 9397 authorizes the solicitation of your Social Security Number (SSN) for use as an identifier in personnel records management to assure
proper identification of applicants throughout the selection and employment process. The information we collect on this questionnaire, including your SSN,
will be used for employment purposes, and it may also be used for statistical studies or computer matching with other government files. Furnishing your
SSN or any of the other information requested in the vacancy announcement is voluntary; however, failure to provide this information will prevent the
processing of your application and will prevent your consideration for employment. The nature of the information received is confidential, and authorized
officials will handle it appropriately. This information becomes part of a Privacy Act System of Records as identified in 5CFR 552a, under OPM/GOVT-1:
General Personnel Records.
We estimate it will take you 60 minutes to complete this form, including the time required to read the instructions, provide the requested information, and
review your responses. Send comments regarding this estimate or any other aspect of the collection of information, including suggestions for reducing the
burden, to the Federal Aviation Administration, Office of Human Resource Management, 800 Independence Avenue, SW, Washington D.C. 20591.

FAA Form 52569 (11/00)

1

Read each question carefully. Darken the circle for the ONE answer that best describes you. Multiple
or blank responses will result in that question receiving the least credit.
Section 1: APPLICANT INFORMATION
1. I am a citizen of the United States, Guam, American Samoa, U.S. Virgin Islands, or Puerto
Rico. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

0 Yes

0 No

2. I have advocated or knowingly associated with a group advocating the overthrow of the United
States Government or I have participated in a strike against the United States Government. _ 0 Yes

0 No

3. I am currently a permanent civilian employee of the Federal Aviation Administration. _ _ _ _ _

0 Yes

0 No

4. I am currently a permanent civilian employee or I have been a permanent civilian employee of
a Federal agency. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

0 Yes

0 No

5. I am currently a temporary civilian employee of a Federal agency. _ _ _ _ _ _ _ _ _ _ _ _ _ _

0 Yes

0 No

6. I am able to communicate orally and in writing in the English language.

0 Yes

0 No

0 Yes

0 No

1. I have served on active duty in the United States military service. _ _ _ _ _ _ _ _ _ _ _ _ _

0 Yes

0 No

2. I am claiming 5-point veteran preference based on my active duty military service.
NOTE: Must submit a copy of your DD-214. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

0 Yes

0 No

3. I am claiming 10-point veteran preference as the spouse, widow, widower or natural mother of
a disabled or deceased veteran. NOTE: Must submit SF-15 with required proof. _ _ _ _ _ _

0 Yes

0 No

4. I am claiming 10-point veteran preference as a Purple Heart recipient or have a serviceconnected disability of less than 10%. NOTE: Must submit SF-15 with required proof. _ _ _

0 Yes

0 No

5. I am claiming 10-point veteran preference based on a service-connected disability rated at
10% or more, but less than 30%. NOTE: Must submit SF-15 with required proof. _ _ _ _ _

0 Yes

0 No

6. I am claiming 10-point veteran preference based on a service-connected disability rated at
30% or more. NOTE: Must submit SF-15 with required proof. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

0 Yes

0 No

7. I retired or will be retiring from military service at or above the rank of major (0-4) or its
equivalent. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

0 Yes

0 No

___________

7. I am able to communicate orally and in writing in a language other than English. _ _ _ _ _ _ _
Section 2: MILITARY SERVICE

8. I retired or will retire on (mm/dd/yyyy) _________________________________________.
9. I retired or will retire from (branch of service) ___________________________________.
10. My military rank and ID are/were _____________________________________________.
11. My last duty station is/was (city, state and country) __________________________________.
12. My current or last work phone number is/was ___________________________________.
13. My current or former supervisor's name is/was __________________________________.
14. My current or former supervisor's phone number is/was ___________________________.
SSN: _______-______-__________

FAA Form 52569 (11/00)

2

Section 3: GEOGRAPHIC PREFERENCES

Darken ONE circle in the first column to indicate your primary geographic choice. You may then select
up to two secondary geographic choices by darkening ONE or TWO circles in the second column. As
long as there are adequate numbers of qualified applicants available for a particular region, applicants
who have designated that region as a primary choice will be referred. If there are insufficient primary
geographic choice applicants in a region, additional applicants who selected that region as a
secondary geographic choice may be referred.

PRIMARY GEOGRAPHIC CHOICE - Select one
SECONDARY GEOGRAPHIC CHOICES - Select up to two
regions
0

0

Alaskan Region

Alaska

0

0

Central Region

Iowa, Kansas, Missouri, Nebraska

0

0

Eastern Region

Delaware, District of Columbia, Maryland, New Jersey,
New York, Pennsylvania, Virginia, West Virginia

0

0

Great Lakes Region

Illinois, Indiana, Michigan, Minnesota, North Dakota,
Ohio, South Dakota , Wisconsin

0

0

New England Region

Connecticut, Maine, Massachusetts, New Hampshire,
Rhode Island, Vermont

0

0

Northwest Mountain
Region

Colorado, Idaho, Montana, Oregon, Utah, Washington,
Wyoming

0

0

Southern Region

Alabama, Florida, Georgia, Kentucky, Mississippi,
North Carolina, South Carolina, Tennessee, Puerto
Rico, Virgin Islands

0

0

Southwest Region

Arkansas, Louisiana, New Mexico, Oklahoma, Texas

0

0

Western-Pacific
Region

Arizona, California, Hawaii, Nevada, American Samoa,
Guam, Marshall Islands

SSN: _______-______-__________

FAA Form 52569 (11/00)

3

Section 4: DIRECTLY RELATED EXPERIENCE
INSTRUCTIONS:
Position - start with most recent position and location
Supervisor - enter Y if you performed only supervisory
duties; enter N if you concurrently supervised and controlled
air traffic
Position and Location

Supervisor
(Y or N)

Facility Type - if Radar enter R, if VFR enter V
Dates - dates employed in this position
Fully Certified or Facility Rated - enter Y for Yes or N for No or NA for Not Applicable

Military
Rank

Facility
ID

Facility Type
(V or R)

Dates
Fr: _____/_____/_______

1.

Fully Certified
or Facility Rated

Date Fully Certified
or Facility Rated

____/____/_____

To: _____/_____/_______
Fr: _____/_____/_______

2.

____/____/_____

To: _____/_____/_______
Fr: _____/_____/_______

3.

____/____/_____

To: _____/_____/_______
Fr: _____/_____/_______

4.

____/____/_____

To: _____/_____/_______
Fr: _____/_____/_______

5.

____/____/_____

To: _____/_____/_______
Fr: _____/_____/_______

6.

____/____/_____

To: _____/_____/_______
Fr: _____/_____/_______

7.

____/____/_____

To: _____/_____/_______
Fr: _____/_____/_______

8.

____/____/_____

To: _____/_____/_______
Fr: _____/_____/_______

9.

____/____/_____

To: _____/_____/_______

NOTE: If your duty station was at a command that had co-located Radar and VFR facilities, please specify which option you worked. If you need
additional space, use a separate sheet of paper.
SSN: _______-______-__________

FAA Form 52569 (11/00)

4

Section 5: OTHER RELATED EXPERIENCE
A.
0
0
0
0
0
0

Darken the circle of any of the following in which you have experience.
Foreign Civilian Air Traffic Controller
Contract Tower Air Traffic Controller
Department of Defense Civilian Air Traffic Controller
Military Air Traffic Controller at FAA Facility
Former FAA Air Traffic Controller
Non-Radar Approach Control

0
0
0

Air Traffic Supervisor
Air Traffic Facility Manager
Certified Tower Operator

0
0
0

Ground Control Intercept
Ground Control Approach
Military Radar Unit

0
0
0
0
0

Weather Observer
Base Operations
Flight Dispatcher (Commercial)
Ramp Controller
Dispatcher

0
0
0
0
0

Private Pilot License
Date: ______/______/______
Commercial Pilot License
Date: ______/______/______
Instrument Rating
Date: ______/______/______
Certified Flight Instructor
Date: ______/______/______
Staff Work (aviation-related) - Must be full performance level
• Quality Assurance
Duty Station: ___________________________ From: ____/____/______ To: ____/____/______
Duty Station: ___________________________ From: ____/____/______ To: ____/____/______
Duty Station: ___________________________ From: ____/____/______ To: ____/____/______
• ICAO
Duty Station: ___________________________ From: ____/____/______ To: ____/____/______
Duty Station: ___________________________ From: ____/____/______ To: ____/____/______
Duty Station: ___________________________ From: ____/____/______ To: ____/____/______

B.
0
0
0
0
0

Darken the circle of any of the following for the type of airspace you have handled.
Class B Airspace
Class C Airspace
Class D Airspace
Airport Radar Surveillance Area (ARSA)
Terminal Radar Surveillance Area (TRSA)

C.
0
0
0
0
0

Darken the circle of any of the following for the types of aircraft you have controlled.
Rotorcraft
Prop
Turbo Prop
Jet
Turbo Jet

SSN: _______-______-__________

FAA Form 52569 (11/00)

5

Section 6: EDUCATION AND TRAINING

A.

Darken the appropriate circle of any aviation-related degrees you have received.
Degree

0
0
0
0

College or University
___________________________
___________________________
___________________________
___________________________

Associate
Bachelors
Masters
Ph.D.

Date Completed
Degree
____/____/______
____/____/______
____/____/______
____/____/______

Major
______________________
______________________
______________________
______________________

B. If you have you completed any aviation-related courses (other than those already indicated in A
above) complete the following. This includes FAA aviation-related courses.
Course Title
1.
2.
3.
4.
5.
6.

Date Completed

_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________

________/_______/________
________/_______/________
________/_______/________
________/_______/________
________/_______/________
________/_______/________

Section 7: AWARDS
If you have received a Letter of Commendation and/or a Commendation Ribbon related to your work as an air
traffic controller, darken the appropriate circle, enter the date (mo/day/yr), and give reason for the award or
ribbon.
Letter of
Commendation

Commendation
Ribbon

Date

Reason

0

0

___/___/____

__________________________________________

0

0

___/___/____

__________________________________________

0

0

___/___/____

__________________________________________

0

0

___/___/____

__________________________________________

0

0

___/___/____

__________________________________________

SSN: _______-______-__________

FAA Form 52569 (11/00)

6

RACE AND NATIONAL ORIGIN IDENTIFICATION
(Please read the instructions and Privacy Act Statement before completing form).

NAME: _________________________________________________________________________________
Last

First

MI

The categories below provide descriptions of race and national origins. Read the Definition of Category
descriptions and then blacken the circle next to the category with which you identify yourself. If you are of
mixed race and/or national origin, select the category with which you most closely identify yourself. Please
mark only one circle.
Name of
Male Female
Category
Definition of Category
0

0

American Indian
or Alaskan Native

A person having origins in any of the original peoples of North America,
and who maintains cultural identification through community recognition
or tribal affiliation.

0

0

Asian or Pacific
Islander

A person having origins in any of the original peoples of the Far East,
Southeast Asia, the Indian subcontinent, or the Pacific Islands. For
example, this area includes China, India, Japan, Korea, the Philippine
Islands, and Samoa.

0

0

Black, not of
Hispanic origin

A person having origins in any black racial groups of Africa. This does
not include persons of Mexican, Puerto Rican, Cuban, Central or South
American, or other Spanish cultures or origins.

0

0

Hispanic

A person of Mexican, Puerto Rican, Cuban, Central or South American,
or other Spanish cultures or origins. This does not include persons of
Portuguese culture or origin.

0

0

White, not of
Hispanic origin

A person having origins in any of the original peoples of Europe, North
America, or the Middle East. This does not include persons of Mexican,
Puerto Rican, Cuban, Central or South American, or other Spanish
cultures or origins.
Privacy Act and Public Burden Statements

Solicitation of this information is authorized by section 2000e-16 of title 42, which requires that agency employment practices be free
from discrimination and provide equal employment opportunities for all, and by the Uniform Guidelines on Employee Selection
Procedures (1978), 43 FR 38297 et seq. (August 25, 1978), which requires agencies to examine their employee selection procedures
to identify any adverse impact those procedures have on women and minorities. Solicitation of this information is in accordance with
Department of Commerce Directive 15, "Race and Ethnic Standards for Federal Statistics and Administrative Reporting." This
information will be used to make statistical determinations under the Federal Equal Opportunity Recruitment Program (5 USC 7201)
and affirmative action programs under section 717 of the title VII of the Civil Rights Act of 1964 as amended. The furnishing of this data
is voluntary; however, collection of the information is essential to the design and maintenance of effective recruitment and
preemployment processing programs which will provide the best possible employment opportunities to all candidates. You are
requested to furnish your social security number (SSN) under the authority of Executive Order 9397 (November 22, 1943), which
requires agencies to use the SSN for the sake of economy and orderly administration in the maintenance of personnel records.
Furnishing of the SSN is voluntary; however, failure to provide the SSN may result in inaccurate statistical records.
The public reporting burden for completing this form is estimated to vary from 1 to 3 minutes with an average of 2 minutes. The
estimate includes time for reviewing instructions, gathering data needed, and completing and reviewing entries. Send comments
regarding the burden estimate or any other aspect of this form, including suggestions for reducing the burden to: Federal Aviation
Administration, Office of Human Resource Management, 800 Independence Avenue, SW, Washington D.C. 20591.

SSN: _______-______-__________

FAA Form CAPS RNO (3/99)

7