TVA 1 Application for Employment

Sensitive Information
OMB No. 3316-0063
Exp. Date: 11/30/2010

Tennessee Valley Authority

Application for Employment
General Instructions:

Application and Eligibility Information:

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

Application Status:
Applications are continued in active status for one
year.

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application becomes outdated.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.

Eligibility:
United States citizens and individuals who are not
U.S. citizens but who meet hiring criteria for TVA as
outlined in the Citizenship Policy are eligible for TVA
employment. 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
investigation, medical evaluation, and drug test.
(Alcohol & Drug test Nuclear only).

Test Information
Some positions may require demonstrated proficiencies. If so, you will receive further instructions.
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.

TVA 1 (11-2007) Page 1 of 8

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Tennessee Valley Authority

Application For Employment
Please follow attached instructions. Type, print, or write plainly. Use additional sheets if necessary.
Return to Shared Resources, Employment Office, 1101 Market Street, Chattanooga, TN 37402-2801.
1.

Social Security Number

2.

Last Name

3.

Other Names: (i.e., Maiden, Nickname) and when used

4.

Date

First Name

Middle Name

Home Mailing Address

Permanent Mailing Address

Street
City
County
State
Zip + 4

5.

Phone

Work Phone

E-mail

Cell Phone

Are you a citizen of the United States?
If “no”, list:

Yes

No

6.

Country of Citizenship

7.

Have you ever worked for TVA?
If “yes”, provide:
Date Last Worked

Are you related in any way to a TVA employee?
Yes
No
If “yes”, state the name of each

8.

Yes

No

Location

At what locations will you accept employment?

employee and exact relationship. Provide position and
location if known:

Military History Data
9.

List all active military service. Omit National Guard or Reserve service unless your organization was activated.
To exercise Veteran’s Preference please enclose a copy of your DD214 and complete the enclosed TVA 3595. If you have
a service connected compensation disability, also send documentation of your compensable disability from the veterans
administration dated within the past year. If you are the spouse of a veteran who has a service connected disability or if
you are a veterans’ widow or widower who has not remarried, or if you are a widowed, divorced or separated mother of a
deceased or totally disabled vet who has honorably discharged, please complete the enclosed TVA 3595 to establish
preference eligibility.
Branch of Military Service

From (mm/yy)

To (mm/yy)

Service Number

Type of Discharge

Licenses/Certificates
10.

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
Issued By

TVA 1 (11-2007) Page 2 of 8

Number
Issue Date

Expiration Date

State/Country of Issue

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Education
11.

List starting and ending dates using (mm/yy) format. High School section must be completed. If additional space is
required, please provide additional information on a separate sheet of paper.

High School

Field of Study:

Full Name of School (No Initials or Abbreviations)

Complete Address (Street, P. O. Box, etc.)

Attendance Only
GED Received

Highest Grade Completed (1-12)

Start Date

End Date

G.P.A

Location of Records

Start Date

End Date

G.P.A

Start Date

End Date

G.P.A

Date Received

Graduated w/Diploma

College

Tech

Other

Full Name of School (No Initials or Abbreviations)

Attendance Only
Field of Study:

Certificate

Complete Address (Street, P. O. Box, etc.)

Diploma

Degree Received, list type:
A.S.
in
A.A.

in

B.S.

in

B.A.

in

Other Degrees, list type:
in

in

in

in

College

Tech

Certificate

Complete Address (Street, P. O. Box, etc.)

Diploma

Degree Received, list type:
A.S.
in
A.A.

in

B.S.

in

B.A.

in

Other Degrees, list type:
in

in

in

in

College

Tech

Certificate

Degree Received, list type:
A.S.
in
A.A.

in

Complete Address (Street, P. O. Box, etc.)

Diploma

B.S.

in

B.A.

in

Other Degrees, list type:
in

in

in

in

TVA 1 (11-2007) Page 3 of 8

Start Date

End Date

G.P.A.

Start Date

End Date

G.P.A.

Start Date

End Date

G.P.A.

City/State/Zip Code

Start Date

End Date

G.P.A.

Start Date

End Date

G.P.A.

Start Date

End Date

G.P.A.

Other

Full Name of School (No Initials or Abbreviations)

Attendance Only
Field of Study:

City/State/Zip Code

Other

Full Name of School (No Initials or Abbreviations)

Attendance Only
Field of Study:

City/State/Zip Code

City/State/Zip Code

Start Date

End Date

G.P.A.

Start Date

End Date

G.P.A.

Start Date

End Date

G.P.A.

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Prior Work Experience—Dates, Names, and Addresses of Employers
12.

Begin with present date and go back five years or to your 18th birthday, whichever is later. Account for all periods of
unemployment and self-employment. Give home office address as well as all job locations (city/state) where you
worked over 30 days. If more space is needed, please use a photocopy of this page or another sheet of paper.

Employer’s Name (No initials or abbreviations)
Date

Employed,

Unemployed,

From (mm/yy)
Supervisor

Self Employed

Position Held

Beginning/Ending Salary

Job Site (Location, City, State)
Residence While Employed (Address, City, State, Zip Code)

If you marked Self Employed or Unemployed—Provide a reference below.
Address and Daytime Telephone Number of Reference

Name of Reference

Employer’s Name (No initials or abbreviations)
Employed,

Area Code/Telephone No.

To Present

Reason for Leaving

Date

Home Office Address (City, State, Zip Code)

Unemployed,

From (mm/yy)

Self Employed

Home Office Address (City, State, Zip Code)
Area Code/Telephone No.

Position Held

Beginning/Ending Salary

To

Supervisor

Job Site (Location, City, State)

Reason for Leaving

Residence While Employed (Address, City, State, Zip Code)

If you marked Self Employed or Unemployed—Provide a reference below.
Address and Daytime Telephone Number of Reference

Name of Reference

Employer’s Name (No initials or abbreviations)
Date

Employed,

Unemployed,

From (mm/yy)

Self Employed

Home Office Address (City, State, Zip Code)
Area Code/Telephone No.

Position Held

Beginning/Ending Salary

To

Supervisor

Job Site (Location, City, State)

Reason for Leaving

Residence While Employed (Address, City, State, Zip Code)

If you marked Self Employed or Unemployed—Provide a reference below.
Address and Daytime Telephone Number of Reference

Name of Reference

Employer’s Name (No initials or abbreviations)
Date

Employed,

Unemployed,

From (mm/yy)

Self Employed

Home Office Address (City, State, Zip Code)
Area Code/Telephone No.

Position Held

Beginning/Ending Salary

To

Supervisor

Job Site (Location, City, State)

Reason for Leaving

Residence While Employed (Address, City, State, Zip Code)

Name of Reference

TVA 1 (11-2007) Page 4 of 8

If you marked Self Employed or Unemployed—Provide a reference below.
Address and Daytime Telephone Number of Reference

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12.

Prior Work Experience (Continued)

Employer’s Name (No initials or abbreviations)
Date

Employed,

Unemployed,

From (mm/yy)
Supervisor

Self Employed

Position Held

Beginning/Ending Salary

Job Site (Location, City, State)
Residence While Employed (Address, City, State, Zip Code)

If you marked Self Employed or Unemployed—Provide a reference below.
Address and Daytime Telephone Number of Reference

Name of Reference

Employer’s Name (No initials or abbreviations)
Employed,

Area Code/Telephone No.

To

Reason for Leaving

Date

Home Office Address (City, State, Zip Code)

Unemployed,

From (mm/yy)

Self Employed

Home Office Address (City, State, Zip Code)
Area Code/Telephone No.

Position Held

Beginning/Ending Salary

To

Supervisor

Job Site (Location, City, State)

Reason for Leaving

Residence While Employed (Address, City, State, Zip Code)

If you marked Self Employed or Unemployed—Provide a reference below.
Address and Daytime Telephone Number of Reference

Name of Reference

Employer’s Name (No initials or abbreviations)
Date

Employed,

Unemployed,

From (mm/yy)

Self Employed

Home Office Address (City, State, Zip Code)
Area Code/Telephone No.

Position Held

Beginning/Ending Salary

To

Supervisor

Job Site (Location, City, State)

Reason for Leaving

Residence While Employed (Address, City, State, Zip Code)

If you marked Self Employed or Unemployed—Provide a reference below.
Address and Daytime Telephone Number of Reference

Name of Reference

Employer’s Name (No initials or abbreviations)
Date

Employed,

Unemployed,

From (mm/yy)

Self Employed

Home Office Address (City, State, Zip Code)
Area Code/Telephone No.

Position Held

Beginning/Ending Salary

To

Supervisor

Job Site (Location, City, State)

Reason for Leaving

Residence While Employed (Address, City, State, Zip Code)

Name of Reference

TVA 1 (11-2007) Page 5 of 8

If you marked Self Employed or Unemployed—Provide a reference below.
Address and Daytime Telephone Number of Reference

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Background Information—Dates and places of permanent residence
13.

Begin with present date and go back five years or to your 18th birthday. Give complete addresses. If more space is
needed, please use a photocopy of this page or another sheet of paper.

Date
From
To
(mm/yyyy)
(mm/yyyy)

14.

Address

Have you ever been discharged, fired, or terminated for cause?

City

Yes

State

Zip

No

Have you ever resigned after being given notice from any job for any reason within the past five years?

Yes

No

If your answer to either of the above questions is “yes,” provide details below. If additional space is required, please
attach another sheet of paper.

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

TVA 1 (11-2007) Page 6 of 8

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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.

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.

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.

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.

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).

Social Security No.
Race and National Origin:
(see definitions above)

TVA 1 (11-2007) Page 7 of 8

Not applicable: Non-U.S.

Date of Birth
White
Black
American Indian/Alaska Native

Sex:

Female

Male

Hispanic
Asian/Pacific Islander
Not Applicable (Non-U.S.)

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Invitation to Self-Identify
(Continued)
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
27
28
29
32
33
34
35
36
37
38

Missing Extremities
One hand
One arm
One foot
One leg
Both hands or arms
Both legs or feet
One hand or arm and one foot or leg
One hand or arm and both feet or legs
Both hands or arms and one foot or leg
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
45
46
47
48
49
57

One or both hands
One or both feet
One or both arms
One or both legs
Hip or pelvis
Back
Movement loss of two or more parts of the body

61
62
63
64
65
66
67
68

70
71
72
73
74
75
76
77
78

Partial Paralysis (due to brain, nerve, or muscle
problem)
One hand
One arm, any part
One leg, any part
Both hands
Both legs, any part
Both arms, any part
One side of body, including one arm and one leg
Three or more major parts of the body (arms and
legs)
Complete Paralysis
One hand
Both hands
One arm
Both arms
One leg
Both legs
Lower half of body, including legs
One side of body, including one arm and one leg
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 (11-2007) Page 8 of 8

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VENDOR FOR THIS FORM:
INTERNAL TVA PRINT SHOP
CONTACT:
DOUG PRICE - CHATTANOOGA
423-751-3590
[email protected]
OR
GREG HALL - KNOXVILLE
865-632-8852
[email protected]