Form FORM-1420-17 Contractor Employee Biographical Data Sheet

OMB Control No. 0412-0520; Expiration Date: 9/30/2004

CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET

1. Name (Last, First, Middle)      

2. Contractor’s Name      

3. Employee’s Address (include ZIP code)      

4. Contract Number      

5. Position Under Contract      

6. Proposed Salary      

7. Duration of Assignment      

8. Telephone Number (include area code)      

9. Place of Birth      

10. Citizenship (If non-U.S. citizen, give visa status)      

11. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment      

12. EDUCATION (include all college or university degrees)

13. LANGUAGE PROFICIENCY (see Instruction on Page 2)

NAME AND LOCATION OF INSTITUTION

MAJOR

DEGREE

DATE

LANGUAGE

Proficiency Speaking

Proficiency Reading

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

14. EMPLOYMENT HISTORY

Give last three (3) years. List salaries separate for each year. Continue on separate sheet of paper if required to list all employment related to duties of proposed assignment. Salary definition – basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions, consultant fees, extra or overtime work payments, overseas differential or quarters, cost of living or dependent education allowances.

POSITION TITLE

EMPLOYER’S NAME AND ADDRESS POINT OF CONTACT &TELEPHONE #

Dates of Employment (M/D/Y)

Annual Salary

From

To

Dollars

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)

SERVICES PERFORMED

EMPLOYER’S NAME AND ADDRESS POINT OF CONTACT &TELEPHONE #

Dates of Employment (M/D/Y)

Days at Rate

Daily Rate In Dollars

From

To

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

16. CERTIFICATION: To the best of my knowledge, the above facts as stated are true and correct.

Signature of Employee

Date      

17. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)

Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. Contractor understands that USAID may rely on the accuracy of such information in negotiating and reimbursing personnel under this contract. The making of certifications that are false, fictitious, or fraudulent, or that are based on inadequately verified information, may result in appropriate remedial action by USAID, taking into consideration all of the pertinent facts and circumstances, ranging from refund claims to criminal prosecution.

Signature of Contractor’s Representative

Date      

INSTRUCTION

Indicate your language proficiency in block 13 using the following numeric Interagency Language Roundtable levels (Foreign Service Institute Levels). Also, the following provides brief descriptions of proficiency levels 2, 3, 4, and 5. “S” indicates speaking ability and “R” indicates reading ability. For more in-depth description of the levels refer to USAID Handbook 28 or superseding policy directive.

2. Limited working proficiency

S Able to satisfy routine special demands and limited work requirements.

R Sufficient comprehension to read simple, authentic written material in a form equivalent to usual printing or typescript on familiar subjects within familiar contexts.

2. General professional proficiency

S Able to speak the language with sufficient structural accuracy and vocabulary to participate effectively in most formal and informal conversations on practical, social, and professional topics.

R Able to read within a normal range of speed and with almost complete comprehension of a variety of authentic prose material on unfamiliar subjects.

2. Advanced professional proficiency

S Able to use the language fluently and accurately on all levels normally pertinent to professional needs.

R Able to read fluently and accurately all styles and forms of the language pertinent to professional needs.

2. Functional native proficiency

S Speaking proficiency is functionally equivalent to that of a highly articulate well-educated native speaker and reflects the cultural standards of a country where the language is natively spoken.

R Reading proficiency is functionally equivalent to that of the well-educated native reader.

PAPERWORK REDUCTION ACT INFORMATION

The information requested by this form is necessary for prudent management and administration of public funds under USAID contracts. The information helps USAID estimate overseas logistic support and allowances, the educational information provides an indication of qualifications, the salary information is used as a means of cost monitoring and to help determine reasonableness of proposed salary.

PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this collection of information is estimated to average thirty minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:

United States Agency for International Development

Office of Acquisition and Assistance

Policy Division (M/OAA/P)

Washington, DC 20523-7100;

and

Office of Management and Budget

Paperwork Reduction Project (0412-0520)

Washington, DC 20503

AID 1420-17 (04/2007) Page 1 of 2