Form DD Form x558 DD Form x558 NLSC Application

NATIONAL LANGUAGE SERVICE CORPS PILOT APPLICATION

FOR NLSC ONLY:
CONTROL NUMBER

OMB No.
OMB Approval expires

PLEASE DO NOT RETURN YOUR FORM TO THE ORGANIZATION LISTED BELOW. RETURN COMPLETED FORM TO:
NATIONAL LANGUAGE SERVICE CORPS, P.O. BOX 12221, ARLINGTON, VA 22209-2221
The public reporting burden for this collection of information is estimated to average 18 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 the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense
Pentagon, Washington, DC 20301-1155 (XXXX-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply
with a collection of information if it does not display a currently valid OMB control number.

PRIVACY ACT STATEMENT
AUTHORITY: 5 U.S.C. 301, Departmental Regulations; 10 U.S.C. 131, Office of the Secretary of Defense; DoD Directive 5124.2, Under Secretary of Defense for
Personnel and Readiness; 50 U.S.C. 403-1b, War and National Defense; Public Law 109-364, Sec. 944, Administration of Pilot Project on Civilian Linguist Reserve Corps;
and Public Law 108-487, Sec. 613, Pilot Project on Civilian Linguist Reserve Corps. The OSD System of Records Notice name and number for this collection is National
Language Service Corps (NLSC) Pilot, DHRA 05.
PRINCIPAL PURPOSE(S): To allow U.S. citizens aged 18 years and older with language and special skills to apply for NLSC Pilot Charter Membership. Those selected
for activation and deployment will be officially tested and certified to validate NLSC Self Assessment skills. The information collected will be used to identify and contact
NLSC Charter Members and prospective Charter Members in times of need. The collection will allow preliminary background checks prior to any final appointment in the
NLSC of only those individuals the NLSC expects to employ temporarily during the Pilot program. Background checks are not expected for the remaining Charter
Members.
ROUTINE USE(S): To Federal Government agencies requesting language support to facilitate U.S. efforts on the war on terrorism or in furtherance of national security
objectives. The DoD "Blanket Routine Uses" set forth at the beginning of OSD's compilation of systems of records notices apply to this system.
DISCLOSURE: Voluntary. However, failure to provide information may result in non-enrollment in the NLSC Pilot, and refusal to grant access to Charter Member areas of
the NLSC Pilot Internet portal.

Thank you for taking the first step in becoming a member of the National Language Service Corps (NLSC), and in using your language skills for the
good of all. The information you provide on this form will be used by the NLSC for membership consideration. Please read the following information
carefully, and fill out this form to the best of your knowledge, as missing information may cause delays or prevent the processing of your application.
Should you have any questions regarding this form or the NLSC in general, please feel free to contact us via e-mail at [email protected], and a
NLSC staff member will contact you by the end of the next business day.
SECTION I - APPLICANT INFORMATION
1. LANGUAGE(S) APPLYING FOR
2.a. LAST NAME
3.a. STREET ADDRESS

b. FIRST AND MIDDLE NAMES

NEEDS DD 67

b. APARTMENT/SUITE NUMBER

c. CITY

d. STATE

4. TELEPHONE NUMBERS (Include area code)
a. HOME/CELL
b. DAYTIME

e. ZIP CODE

f. COUNTRY

5. E-MAIL ADDRESS

SECTION II - LANGUAGE EXPERIENCE
6. ENGLISH LANGUAGE SKILLS. HOW WOULD YOU RATE YOUR SKILLS IN ENGLISH (X one)
VERY GOOD

GOOD

7.a. PRIMARY LANGUAGE

POOR

b. HOW WOULD YOU RATE YOUR SKILLS IN THIS LANGUAGE (X one)
VERY GOOD

GOOD

POOR

c. WHERE DID YOU LEARN YOUR PRIMARY LANGUAGE (X all that apply)
AT HOME (IN U.S.)

AT SCHOOL (IN U.S.)

ABROAD

OTHER

d. IF THIS IS NOT YOUR NATIVE LANGUAGE, HOW LONG HAVE YOU SPENT LEARNING THIS LANGUAGE?
e. BRIEFLY DESCRIBE A TIME WHEN YOU USED THIS LANGUAGE TO ASSIST SOMEONE IN NEED, OR A TIME WHEN YOU USED YOUR
LANGUAGE SKILLS PROFESSIONALLY.

8.a. SECONDARY LANGUAGE

b. HOW WOULD YOU RATE YOUR SKILLS IN THIS LANGUAGE (X one)
VERY GOOD

GOOD

POOR

c. WHERE DID YOU LEARN YOUR SECONDARY LANGUAGE (X all that apply)
AT HOME (IN U.S.)

AT SCHOOL (IN U.S.)

ABROAD

OTHER

d. IF THIS IS NOT YOUR NATIVE LANGUAGE, HOW LONG HAVE YOU SPENT LEARNING THIS LANGUAGE?
e. BRIEFLY DESCRIBE A TIME WHEN YOU USED THIS LANGUAGE TO ASSIST SOMEONE IN NEED, OR A TIME WHEN YOU USED YOUR
LANGUAGE SKILLS PROFESSIONALLY.

DD FORM X558, 20080616 DRAFT

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SECTION III - GENERAL INFORMATION
9. U.S. CITIZEN (X one)
YES

10. 18 YEARS OF AGE OR OLDER (X one)

NO

YES

NO

11. IF YOU ARE AT LEAST 18 YEARS OR OLDER AND MALE, HAVE YOU REGISTERED WITH THE SELECTIVE SERVICE SYSTEM?
YES

NO

12. ARE YOU WILLING TO UNDERGO A NATIONAL AGENCY CHECK BACKGROUND INVESTIGATION?
YES

NO

13. ARE YOU WILLING TO TAKE A DRUG TEST?
YES

NO

SECTION IV - EDUCATION
14.a. HIGH SCHOOL/GED TESTING CENTER

b. YEAR ACQUIRED

c. STREET ADDRESS
d. CITY

e. STATE

f. ZIP CODE

g. COUNTRY

15.a. PRIMARY COLLEGE/UNIVERSITY ATTENDED

b. STREET ADDRESS

NEEDS DD 67

c. CITY
g. TOTAL CREDITS EARNED

d. STATE

e. ZIP CODE

h. MAJOR(S)

f. COUNTRY
i. DEGREE (if any)/YEAR RECEIVED

16.a. SECONDARY COLLEGE/UNIVERSITY ATTENDED

b. STREET ADDRESS
c. CITY
g. TOTAL CREDITS EARNED

d. STATE

e. ZIP CODE

h. MAJOR(S)

f. COUNTRY
i. DEGREE (if any)/YEAR RECEIVED

17. OTHER QUALIFICATIONS (If you have other qualifications which you feel are beneficial or complimentary to this application, please describe briefly here or attach
additional page(s) with your full name and date at the top right of each additional page.)

SECTION V - APPLICANT CERTIFICATION
I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete, and made in
good faith. I understand that false or fraudulent information on or attached to this application may be grounds for not hiring me or for dismissal from
the organization after I begin work and may be punishable by fine or imprisonment. I understand that any information I give may be investigated.
18.a. SIGNATURE

DD FORM X558 (BACK), 20080616 DRAFT

b. DATE SIGNED (YYYYMMDD)

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