1 Employee Application

Tennessee Valley Authority

Application For Employment

General Instructions:

Be sure you’re in PAGE LAYOUT under VIEW

Print or type neatly using black type or black ballpoint pen.

Do not send any papers which you would want returned because they will be destroyed if your application becomes outdated. Be sure to sign your name and recheck your social security number for accuracy.

A false statement or dishonest answer to any questions may be grounds for cancellation of employment after appointment and may be punishable by fine and imprisonment.

Application And Eligibility Information:

Application Status:

Applications are continued in active status for six months. (Clerk-word processor, compensation clerk, contract clerk, editorial clerk, travel clerk, library assistant, secretary, descriptive indexer, librarian, and craft apprentice applicants remain active for two years.) Eligibility may be extended for an additional six months by completing a new application during the active period.

Eligibility:

TVA may consider for appointment only U.S. Citizens and noncitizens if they meet the criteria specified each year in conjunction with the appropriation process. No one under 16 years of age is employed and no one under 18 is employed in a hazardous job.

Security And Medical Investigation:

All appointments are subject to a security and medical investigation.

Test Information The following is a list of jobs with test requirements. If you are scheduled for tests, you will receive further instructions.
Job	Test Required	Quality	Tested By
Secretary	Typing	48 wpm	TVA/State Emp. Svs.
Clerk Word Processor	Typing	48 wpm	TVA/State Emp. Svs.
Editorial Clerk	Typing	48 wpm	TVA/State Emp. Svs.
Library Assistant	Typing	48 wpm	TVA/State Emp. Svs.
Descriptive Indexer	Typing	48 wpm	TVA/State Emp. Svs.
Travel Clerk	Typing	48 wpm	TVA/State Emp. Svs.
Compensation Clerk	Typing	48 wpm	TVA/State Emp. Svs.
Contract Clerk	Typing	48 wpm	TVA/State Emp. Svs.
Generating Plant Operator Training Program	EEI Test(s)		TVA
Generating Group Maint. Training Program	EEI Test(s)		TVA
Craft Apprenticeship Programs	EEI Test(s)/GATB/NJATC		TVA/State Emp. Svs.

Job Categories In TVA

(Trades And Labor Positions And Apprentice Training Programs)

Some of the job categories for trades and labor workers are listed below with a very brief and general description of duties and qualifications. This is furnished for general information only and is not a complete list. In filling out applications, you are urged to furnish details of your work experience related to the type of work you desire. Applicants for skilled crafts must list years of training, experience, or both equal to journeyman requirements.

*Boilermaker  5232

Assembles and repairs boiler-related equipment; welds. Three years’ related experience or apprentice training required.

*Crane Operator  6576

Operates various types of cranes to hoist and place materials. Three years’ related experience or apprentice training required.

*Electrician  5632

Installs wiring, cable, fixtures and control equipment; repairs and maintains electrical equipment; and welds. Four years’ related experience or apprentice training required.

*Equipment Mechanic  6632

Repairs and maintains crane, earth-moving, and related construction equipment; welds. Four years’ related experience or apprentice training required.

*Gas Diesel Mechanic  6332

Repairs and maintains internal combustion gasoline-powered equipment and certain types of diesel equipment. Four years’ related experience or apprentice training required.

*Grade and Pave Equipment  6580

Operates heavy construction, earth-moving equipment; reads grade stakes. Three years’ related experience or apprentice training required.

*Instrument Mechanic  5932

Performs calibration, maintenance, and repair on the instrumentation and control equipment associated with a generating or nuclear plant. Four years’ related experience or apprentice training required.

*Machinist  6232

Sets up and operates machine tools to specifications; reads blueprints; uses measuring devices; and welds. Four years’ related experience or apprentice training required.

*Steamfitter  7132

Installs pressure and other piping systems; reads blueprints; rigs; welds. Four years’ related experience or apprentice training required.

* Crafts with apprentice training programs

Laborer Class (various jobs)  6106

Includes manual labor, placing concrete, operating pneumatic or air-operated tools, stripping forms, etc. Placement on a specific job depends on candidate’s related experience.

Truck Driver  Vehicle Maintenance Helper  Warehouseman  Driver

Includes driving various size trucks, refueling, lubricating, and changing tires; issuing, storing, and loading materials in warehouse. Placement on a specific job depends on candidate’s related experience.

Generating Plant Operator Training Program

• Nuclear Operator 7611

• Fossil Operator 7711

• Hydro Operator 7811

A two-year training program combining classroom and on-the-job training to become an assistant unit operator (AUO). Rotating shifts.

Generating Group Maintenance Training Program

• Boilermaker 7435

• Electrician 7436

• Heavy Equipment Operator 7437

• Instrument Mechanic 7438

• Machinist 7439

• Steamfitter 7440

• Turbine Crew Mechanic 7441

A four-year training program that combines classroom training with independent study lessons and on-the-job training to become a journeyman maintenance employee.

Job Categories In TVA

(Salaried)

Chemical Engineering 0110 -- Manager (experience managing large groups) 0120 -- Research and Design 0130 -- Operations 0140 -- Metallurgical Engineer 0198 -- Chemical Engineering (General) Civil Engineering 0210 -- Manager (experience managing large groups) 0220 -- Construction (General) 0221 -- Construction (Nuclear) 0222 -- Construction (Fossil and Hydro) 0240 -- Structural Design (General) 0250 -- Highway and Railroad 0260 -- Hydraulic and Hydrologic 0270 -- Geological/Geotechnical Engineer 0298 -- Civil Engineering (General) Electrical Engineering 0310 -- Manager (experience managing large groups) 0320 -- Construction (General)

0321 -- Construction (Nuclear) 0322 -- Construction (Fossil and Hydro) 0330 -- Design (General) 0331 -- Design (Nuclear) 0332 -- Design (Fossil and Hydro) 0350 -- Power Operations and Maintenance (General) 0351 -- Power Operations and Maintenance (Nuclear) 0352 -- Power Operations and Maintenance (Fossil and Hydro) 0398 -- Electrical Engineering (General) Mechanical Engineering 0410 -- Manager (experience managing large groups) 0420 -- Construction (General) 0421 -- Construction (Nuclear) 0422 -- Construction (Fossil and Hydro) 0430 -- Design (General) 0431 -- Design (Nuclear) 0432 -- Design (Fossil and Hydro) 0450 -- Power Operations and Maintenance (General) Continued

Job Categories (Salaried)

0451 -- Power Operations and Maintenance (Nuclear) 0452 -- Power Operations and Maintenance (Fossil and Hydro) 0498 -- Mechanical Engineering (General) Nuclear Engineering and Nuclear Physics 0510 -- Manager (experience managing large groups) 0520 -- Nuclear Fuels 0530 -- Hazards Control 0540 -- Nuclear Plant Operations 0550 -- Reactor Physicist 0560 -- Nuclear Research and Design 0598 -- Nuclear Engineering and Nuclear Physics (General) Engineering Specialties 0610 -- Materials Engineer 0615 -- Specifications 0620 -- Project Control Engineer 0625 -- Systems Engineer 0630 -- Quality Assurance Engineer (General) 0634 -- Quality Assurance Engineer (Nuclear) 0635 -- Quality Assurance Engineer (Manufacturing) 0640 -- Welding Engineer 0645 -- Licensing 0650 -- Special Energy Systems 0655 -- Power Research and Planning 0660 -- Instrument Engineer 0665 -- Telecommunications 0670 -- Cost Estimate Engineer 0675 -- Rates, Sales, Demonstrations, and Conservation 0680 -- Photogrammetic Engineer Safety Engineering 0710 -- Safety Engineer 0720 -- Mine Safety Engineer 0730 -- Fire Protection Engineer Industrial Engineering 0810 -- Industrial Engineer (General) 0850 -- Statistics and Operations Research Administrative 0910 -- Administrative Officer 0920 -- Records Officer 0930 -- Transportation 0940 -- Office Procedures Analyst 0950 -- Public Administrator 0960 -- Industrial Management 0970 -- Security Administrator 0998 -- Administrative (General) Automated Data Processing 1010 -- Computer Specialist 1020 -- Systems Analyst 1030 -- Programmer Analyst 1040 -- Computer System Hardware Engineer 1050 -- Mathematician, Statistician 1060 -- Computer System Hardware Engineer 1070 -- Programming Technician 1080 -- Information Systems Specialist 1090 -- Automated Data Processing (General) Regional Planning and Development 1110 -- Architect 1120 -- Landscape Architect 1130 – Regional Planner and Developer 1140 – Recreation Specialist 1150 -- Forester 1160 -- Economist 1198 -- Regional Planning and Development (General)

Health and Environment 1210 -- Physician 1220 -- Health Promotion 1230 -- Environmental Engineer and Scientist 1240 -- Industrial Hygiene 1250 -- Health Physicist 1255 -- Employee Assistance/Rehabilitation Counselor 1260 -- Health and Environmental Technician 1261 -- Health Physics Technician 1270 -- Nurse 1280 -- Medical Aide 1290 -- Psychologist Law 1310 -- General Attorney 1320 -- Title Attorney 1330 -- Legal Assistant Human Resources 1410 -- Human Resource Officer 1420 -- Human Resource Staff Officer 1430 -- Equal Employment Opportunity Officer 1440 -- Training Officer Publicity and Information 1510 -- Communications Specialist (General) 1515 -- Audiovisual 1520 -- Graphics 1525 -- Media Relations 1530 -- Journalism 1535 -- Public Information 1540 -- Editor 1550 -- Librarian 1560 -- Home Economist Materials, Sales, and Real Estate 1610 -- Property and Supply Officer 1620 -- Purchasing Agent 1630 -- Salesman 1640 -- Realty Specialist 1650 -- Marketing and Advertising Analyst 1660 -- Contract and Claims Specialist Accounting 1710 -- Accountant/Accounting Officer 1720 -- Budget Officer 1730 -- Payroll Officer Agriculture 1810 -- Agricultural Economist 1820 -- Agricultural Engineer 1830 -- Agriculturist Science 1910 -- Biologist 1920 -- Chemist 1930 -- Geoscientist 1940 -- General Scientist 1950 -- Geologist 1960 -- Meteorologist Education and Welfare 2010 -- Education Administrator 2020 -- Education (Technical) 2030 -- Education (Nontechnical) 2040 -- Education Specialist and Education Specialist (Environmental) General Foreman and Superintendents 2110 -- Administrator 2120 -- Craft Superintendent 2190 -- Building Construction (General)

Job Categories (Salaried)

Drafting and Design 2210 -- Trainee 2220 -- Modeling Technician 2240 -- Drafter 2260 -- Computer Graphics Technician 2270 -- Layout Technician 2280 -- Cartographic Technician Inspector 2310 -- Electrical/Electronic 2320 -- Mechanical 2330 -- Nondestructive Examination (NDE) 2340 -- Civil and Soils/Concrete 2350 -- Materials Tester and Inspector 2370 -- Hanger 2380 -- Trainee 2398 -- Inspector and Tester (General) Engineering Aide 2420 -- Chemical 2430 -- Civil 2431 -- Survey 2432 -- Welding 2433 -- Cost/Project Control 2440 -- Electrical 2445 -- Instrumentation 2449 -- Computer Hardware Maintenance 2450 -- Energy Services Technician 2460 -- Hydraulic and Hydrologic 2465 -- Hanger 2470 -- Mechanical 2480 -- Nuclear 2490 -- Apprentice 2495 -- Industrial Technology Scientific Aide 2510 -- Agriculture 2520 -- Biology 2530 -- Chemistry 2531 -- Radiochemical Laboratory Analyst 2532 -- Radiochemical Laboratory Analyst Trainee 2540 -- Forestry

2550 -- Geoscience 2560 -- Mathematics and Research 2570 -- Trainee Clerical 2610 -- General 2611 -- Accounting Clerk 2612 -- File Clerk 2613 -- Courier 2614 -- Personnel Clerk 2615 -- Materials Clerk 2616 -- Statistical Clerk 2625 -- Compensation Clerk 2630 -- Data Entry Operator 2640 -- Computing Equipment Operator 2645 -- Editorial Clerk 2650 -- Library Assistant 2655 -- Legal Clerk 2660 -- Clerk-Word Processor 2670 -- Clerk-Stenographer 2675 -- Travel Clerk 2680 -- Data Processor Property Protection, Custodial and Miscellaneous Service 2710 -- Aircraft Pilot 2720 -- Public Safety Officer 2721 -- Patrol Officer 2722 -- Clerk Monitor 2723 -- Safety Technician 2730 -- Reservoir Property Worker 2740 -- Custodian (Janitor) 2741 -- Orderly 2742 -- Gardener 2750 -- Communications Assistant 2751 -- Bindery Equipment Operator 2752 -- Composing Machine Operator 2753 -- Lithographic Pressman 2754 -- Reprographics Equipment Operator 2756 -- Photographer 2760 -- Telephone Operator 2770 -- Unskilled Salary Policy

Burden Estimate Statement (Pursuant to 5 CFR 1320.21) Public reporting burden for this collection of information is estimated to average 1 hour 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this burden, to Agency Clearance Officer, Tennessee Valley Authority, 1101 Market Street, Chattanooga, TN 37402; and to the Office of Management and Budget, Paperwork Reduction Project (3316-0063), Washington, DC 20503.

Privacy Act Statement

Subsection (e) (3) of 5 U.S.C. §522a (Section 3 of the Privacy Act) requires that TVA inform you of its authority to request information and the uses which TVA may make of the information requested. That subsection further requires TVA to inform you of the effects of not providing any or all of the requested information.

TVA’s authority to request the information you will provide is derived from the TVA Act (16 U.S.C. §§831-831ee), Executive Order No. 10450, the Atomic Energy Act of 1954, as amended, and a number of other statutes and Presidential Executive orders. Information provided on the form may be furnished to people, agencies, organizations, or institutions in order to obtain information regarding you in connection with an investigation to determine (1) fitness for TVA employment; (2) clearance to perform services for TVA under personal services, consultant, or other contracts; or (3) security clearance or clearance for access to TVA installations.

Furnishing the requested information is voluntary; however, failure to provide all or part of the information may result in a lack of further consideration for employment, clearance or access, or in the termination of your employment.

Information provided on this form is normally used only to determine fitness for employment or security clearance or clearance for access to TVA installations. Information obtained on this form may be furnished to third parties as authorized by law. For example, should a dispute arise or a congressional inquiry be made regarding TVA employment practices, the information may be made available outside of TVA in the course of that dispute or inquiry. Further, information on this form may be made available to law enforcement agencies in the exercise of their duties, or to a prospective employer or TVA contractor upon proper request.

OMB No. 3316-0063

Exp. Date: 08/31/2003

Tennessee Valley Authority

Application For Employment

Please TAB to gray areas

Please follow attached instructions. Type, print, or write plainly. Use additional sheets if necessary.

Return to Employee Service Center, TVA, 400 W. Summit Hill Drive, Knoxville, TN 37902 unless otherwise advised.

1.	Social Security Number		Date
	     		     

2.	Last Name	First Name	Middle Name
	     	     	     

3.	Home Mailing Address		Permanent Mailing Address
	Street	     	     
	City	     	     
	County	     	     
	State	     	     
	Zip + 4	     	     
	Phone	     	Work Phone	     
	E-mail	     

4.

Other Names Ever Used (e.g., maiden name, nickname, etc.) and timeframe used

10. Type of work or position desired (see Job Categories)

Name

Mo./Yr. to Mo./Yr.

First Choice

 

 

 

 

     

     

     

     

     

     

     

     

     

     

Second Choice

 

 

 

 

     

     

     

     

     

     

     

11.

Would you accept:

5.

Have you ever worked for TVA?

Yes No

Temporary employment?

Yes No

If “yes,” provide:

Summer employment?

Yes No

Date Last Worked

Location

Part-time employment?

Yes No

     

     

Full-time employment?

Yes No

6.

Are you a citizen of the United States?

Yes No

12.

What is the lowest

Hourly

Annually

If “no,” list:

entrance salary you

     

     

Country or Citizenship

would accept?

     

13.

At what locations will you accept employment?

7.

Drivers License No.

State of Issue

8. Drivers License Type

     

     

     

     

14.

Are you related in any way to

Yes No

9.

Union Membership; Name of Union

Local No.

a TVA employee? If “yes,” state the name of each

     

     

employee and exact relationship. Provide position

Address

and location, if known.

     

     

     

     

Military Service And Veterans Preference

15. Military Active duty in Armed Forces (Complete only if you have served in the United States Military Service (active duty); you are a spouse of a service-connected disabled ex-service personnel; you are a widow, widower, or mother of ex-service personnel). Documentary Evidence; Proof of Discharge, campaign awards, and/or disability status are not required with this application (except as specified below); however, in the event of appointment to a TVA position, documentary evidence must be presented. Omit National Guard or reserve service unless your organization was activated.

Branch of Service	Serial Number	Date of Entry	Date of Discharge	Rank at Discharge	No. Days Lost Time (AW 107; A86 AWOL)
     	     	     	     	     	     

a. Training Purposes Only?		Yes	No		h. Are disability retirement benefits or a			Yes	No
b. Were all separations under honorable		Yes	No		pension being paid by the VA or by the
conditions? If “no,” specify:					Depts. of the Army, Navy, or Air Force for
	     				disability? If “yes,” state percent:      %
	     				V.A. Claim No.      
c. Is compensation being paid for a military		Yes	No		i. Are you a reservist?			Yes	No
service connected disability? If “yes,”					If “yes,”: ACTIVE INACTIVE
state percent:      %
d. Did you receive a Purple Heart Award?		Yes	No		DO NOT WRITE IN THIS SPACE
e. Did you receive an expedition or campaign		Yes	No
medal? If “yes,” name medal and					 Nonveteran  Veteran
campaign:					 Non-compensable Disabled Veteran
	     				 Compensable Disabled Veteran __________%
	     				Documentary evidence including dates of military service
f. Are you a member of the Armed Forces?		Yes	No		reviewed; the status check above determined.
					Certified
g. Is your military retirement a result of an		Yes	No			(Employment/Human Resource Consultant)
injury/disease received as a result of an
armed conflict?					Date

If disability is compensable at 10% or more, you must present documentary evidence at the time application is made.

If you are the spouse of a veteran who has a service-connected disability, or if you are a veteran’s widow or widower who has not remarried, or if you are a widowed, divorced, or separated mother of a deceased or totally disabled veteran who was honorably discharged, please complete form number TVA 3595 to establish preference eligibility and check this space.

Education

16. Highest grade completed 1 through 12?       Date of leaving?       GED? Yes No

		Graduated?				Degree	G.P.A.
School	Name and Location	Yes	No	Date	Field of Major Study	Awarded	Scale
High	     	 	 	     	     	     	     
Tech	     	 	 	     	     	     	     
Other	     	 	 	     	     	     	     
College	     	 	 	     	     	     	     
College	     	 	 	     	     	     	     

Licenses/Certificates

17. List job related licenses or certificates that you have, such as; registered professional engineer, lawyer, nurse, etc. If additional space is required, please provide additional information on a separate sheet of paper.

License/Certificate Type			Number
     			     
Issued By	Issue Date	Expiration Date	State/Country Of Issue
     	     	     	     

Special Skills, Accomplishments and Awards

18. Provide the title and year of any honors, awards, or fellowships you have received which are related to the job you are seeking. List your special qualifications, skills, or accomplishments that are associated with the job for which you are applying. Some examples are skills with computers or other machines; most important publications; public speaking and writing experience; membership in professional or scientific societies; patents or inventions; welding certificates; etc. If additional space is required, please provide additional information on a separate sheet of paper.

     

     

Prior Work Experience

19. Begin with your present or most recent employment and work backwards, listing and describing every employment you have had during the past five years, including all periods of military service, unemployment, self-employment, and school vacation work. If your work more than five years ago is related to the type of position for which you are applying, list and describe the related employment.

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description Of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description Of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title Of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Prior Work Experience (Cont’d)

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title Of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title Of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title Of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Prior Work Experience (Cont’d)

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title Of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title Of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Employer’s Name		Home Office Address (City, State, Zip Code)				Telephone Number
     		     				(   )      
Date Employed, Unemployed, Self		Job Site Location	Position Held			Reason For Leaving
Employed		(City, State)				     
From Mo/Yr	To Mo/Yr					     
     	     	     	     			     
Name & Title Of Superior						     
     						     
Residence While Employed (City, Apt. No., State, Zip Code)						     
     						     
Official Residence If Different From Above				Salary
     				Beginning	$     		Per      
     				Ending	$     		Per      
Description of Your Work				Number And Occupation of Employees
     				Supervised By You
     				     
     				     
     				     
     				     

Background Information

20. Dates and places of permanent residence (begin with present date and go back five years or to your 18^th birthday, whichever is later). Give complete addresses.

Date
From	To	Address	City	State	Zip
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     

21. Have you ever been convicted of an offense against the law, or are you now under charges for any offense against the law? This includes Felony, Misdemeanor, and Traffic Convictions. Also report any Court Martial and Non-Judicial punishment while in the military. You are not required to report (1) Speeding tickets of less than $150, (2) Juvenile court convictions, or (3) Convictions for which a court expungement order has been issued.

Yes No

If “yes,” submit form TVA 9871 listing all convictions

(You may request this form from TVA Employee Service Center at 1-888-275-8094.)

22. Have you ever been discharged, fired, or terminated for cause? Have you ever resigned after being given notice from any job for any reason within the past five years?

Yes No

If “yes,” provide details on separate sheet.

References

23. List references not related to you by blood or marriage, who are or have been mainly responsible for close direction of your work, or who are in a position to judge your work critically in those occupations in which you regard yourself as best qualified. Also, include persons who have knowledge of education and experience reported under items 16 and 19 of this application. Also, list personal character references.

Name And How Associated Employer, Teacher, Commanding Officer, etc.		Business or Home Address Business, Number, Street, City, State, Zip Code	Telephone Number			Years Known
A.	     	     
	     	     	(   )      			     
B.	     	     
	     	     	(   )      			     
C.	     	     
	     	     	(   )      			     
D.	     	     
	     	     	(   )      			     
E.	     	     
	     	     	(   )      			     
F.	     	     
	     	     	(   )      			     

United States of America

Tennessee Valley Authority

Authority For Release of Information

For the purpose of establishing my eligibility for employment and/or for a security clearance at Tennessee Valley Authority (TVA), I voluntarily consent to a thorough investigation and any required updates of my past employment activities, personal characteristics, credit history, education, medical and criminal records, and Fitness for Duty history. This investigation may be carried out by TVA, its agents, or contractors.

Accordingly, I authorize and request any employers, courts, or law enforcement agencies, educational institutions, medical personnel or institutions, credit bureaus or financial institutions, or individuals—neighbors, friends, associates with whom I am acquainted or others, who possess information, recorded or not, pertinent to the above matters, to provide such information, facts, or opinions to the personnel who contact them.

I hereby release TVA and any individual, including record custodians, from any and all liability for damages of whatever kind or nature which may, at any time, result to me on account of compliance, or any attempts to comply, with this authorization.

Certification of Accuracy by Applicant

I certify that the information furnished in answer to the questions on this form are correct and complete to the best of my knowledge and belief. I understand that the accuracy of this information is of great importance in the consideration of my eligibility for employment, security clearance, or access authorization. I understand that a false statement or omission of material fact may be sufficient cause of rejection or revocation of my security clearance and/or employment and may be punishable by law.

By my signature, I hereby authorize the release of information as specified above and certify the accuracy of the information I have provided.

Name

     

SSN

     

Signature

     

Date

     

Invitation to Self-Identify

Applicable Federal laws provide equal employment opportunity and prohibit discrimination in employment because of race, color, religion, sex, national origin, age (if 40 or over), or condition of handicap (mental or physical) and reprisal. TVA applies equal employment opportunity/affirmative action principles and complies with applicable Federal laws prohibiting discrimination. These principles apply to all aspects of working for TVA, including hiring, training, and advancement opportunities. Applicants who believe they have been discriminated against, for any one of the previously listed reasons, in the selection for employment, should bring the claim of discrimination to the attention of a TVA Equal Opportunity Counselor within 30 calendar days of the date the alleged discrimination occurred.

TVA provides an administrative procedure to help applicants and employees informally resolve alleged discriminatory practices or, if not resolved, to determine whether unlawful discrimination has occurred. As an applicant you have a right to use this procedure if you believe you are being discriminated against. Your exercise of this right will not be held against you.

Trained EO Counselors are available to all applicants through each organization’s Human Resource Office. Contact the Human Resource Consultant that serves the organization that you feel discriminated against you in employment and request to be assigned an EO Counselor. Consult the TVA telephone directory for the address and telephone number of the Human Resource Consultant in your area, or call Employee Service Center 1‑888‑275‑8094, and they will refer you to the responsible HR Consultant.

Race and National Origin Definitions

This information is requested solely for the purpose of determining compliance with Federal Civil Rights Law, and your response will not affect consideration of your application. By providing this data, you will assist us in assuring that employment actions are administered in a nondiscriminatory manner. Pages 12 and 13 should be submitted with your application. They will be destroyed after data has been collected.

American Indian or Alaskan Native: Having origins in any of the original peoples of North America, and maintaining cultural identification through tribal affiliation or community recognition.

Asian or Pacific Islander: Having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. For example, India, China, Japan, or Korea, the Phillipine Islands, and Samoa.

Black, not Hispanic origin: Having origins in any of the black racial groups of Africa. Does not include persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins (see Hispanic).

Hispanic: A person of Mexican, Puerto Rican, Cuban, or South American, or other Spanish cultures or origins. Does not include persons of Portuguese culture or origin.

White, not of Hispanic origin: Having origins in any of the original peoples of Europe, North Africa, or the Middle East. Does not include persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins (see Hispanic). Also includes persons not included in other categories.

Not applicable: Non-U.S.

Social Security No.	     		Date of Birth	     		Sex: Female Male
Race and National Origin:		White	Black		Hispanic		Asian/Pacific Islander
(see definitions above)		American Indian/Alaska Native			Not Applicable (Non-U.S.)

Invitation to Self-Identify

(Cont’d)

Handicap Codes

01 Handicap recorded on medical records only 05 No handicap 06 No handicap of types listed 13 Speech impairments (stuttering, aphasia, laryngectomy) Hearing Impairments 15 Hard of hearing or deaf in one ear 16 Total deafness in both ears with some speech 17 Total deafness in both ears, unable to speak clearly Vision Impairments 22 Tunnel vision or legal blindness 23 Inability to read ordinary size print, not correctable by glasses 24 Blind in one eye 25 Blind in both eyes Missing Extremities 27 One hand 28 One arm 29 One foot 32 One leg 33 Both hands or arms 34 Both legs or feet 35 One hand or arm and one foot or leg 36 One hand or arm and both feet or legs 37 Both hands or arms and one foot or leg 38 Both hands or arms and both feet or legs Nonparalytic Orthopedic Impairments (Because of chronic pain, stiffness, or weakness in bones or joints, there is some loss of ability in movement or use.) 44 One or both hands 45 One or both feet 46 One or both arms 47 One or both legs 48 Hip or pelvis 49 Back 57 Movement loss of two or more parts of the body

Partial Paralysis (due to brain, nerve, or muscle problem) 61 One hand 62 One arm, any part 63 One leg, any part 64 Both hands 65 Both legs, any part 66 Both arms, any part 67 One side of body, including one arm and one leg 68 Three or more major parts of the body (arms and legs) Complete Paralysis 70 One hand 71 Both hands 72 One arm 73 Both arms 74 One leg 75 Both legs 76 Lower half of body, including legs 77 One side of body, including one arm and one leg 78 Three or more major parts of the body (arms and legs) Other Impairments 80 Heart disease with no restriction or limitation of activity 81 Heart disease with restriction or limitation of activity 82 Convulsive disorder (epilepsy) 83 Blood disease (sickle cell disease, leukemia, hemophilia) 84 Diabetes 86 Pulmonary or respiratory disorders (tuberculosis, emphysema, asthma) 87 Kidney dysfunctioning (dialysis required) 88 Cancer (a history with complete recovery) 89 Cancer (undergoing surgical and/or medical treatment) 90 Mental retardation 91 Mental or emotional illness (with history of treatment) 92 Severe distortion of limbs and/or spine (dwarfism, severe distortion of back) 93 Disfigurement of face, hands, or feet (birth defects, burns, injury) 94 Learning disability (a disorder in one or more of the processes involved in understanding, perceiving, or using language or concepts, spoken or written, i.e., dyslexia)

  

  

Enter the numerical code in the boxes from list above, in the case of multiple disabilities, enter the code

for the most severe handicapping condition.

TVA 1 (2-2001) [2-2001] Page 4