TVA 17878 Applicant Information Sheet

Sensitive Information
Tennessee Valley Authority

Applicant Information Sheet

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

The following information is required:
Name

SSN

Address
Are you authorized to work in the United States?

Yes

No

Under which of the following are you authorized to work in the United States?
U.S. citizen
Lawfully admitted for permanent residence (permanent residence card [green card] -

A#

)

Granted asylum and granted an employment authorization document
Refugee and granted an employment authorization document
Temporary work visa or employment authorization document
None of the above. Explain:
Veteran Status
Are you a U.S. veteran?
Yes
No
Veterans and Derivative Preference Eligible candidates must provide the latest copy of their DD-214 or a letter from the U.S.
Department of Veteran’s Affairs that includes your name, rank, years of service, and “Character of Service.” Disabled Veterans
must in addition provide a letter from the U.S. Department of Veteran’s Affairs dated within one year of the closing date of the
position on which they are applying stating the percentage of the disability. TVA does not use the point system, and all veterans
are not eligible for Veteran’s Preference.
Data on Convictions
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 of $200 or greater. Also report any court martial and non-judicial
punishment while in the military.)
Yes
No If yes, please explain below.
Date

Location

Charge/Offense

Penalty Imposed

Explanation (if applicable):

1. Have you ever been discharged, fired or terminated from employment?
2. Have you ever resigned from employment?

Yes

Yes

No

No

3. If you answered yes to either of the above, please provide details below and include dates.
Details/Dates (if applicable):

Permanent County of Residence:
I certify that the above information is correct to the best of my knowledge and belief.
Signature

TVA 17878 [11-2007] Page 1 of 4

Date

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Voluntary Invitation to Self-Identify
The policy of TVA is to provide Equal Employment Opportunity (EEO) and to prohibit discrimination in employment. In an
effort to ensure TVA is successful in meeting our commitment to EEO, we invite you to provide the following information.
This information will be used for statistical purposes only. The completion of this portion of the form is strictly voluntary.

Gender

M

F

Race and National Origin Definitions (Please select one)
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 (Non-Hispanic). A person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine
Islands, Thailand, and Vietnam.
Black or African-American. A person having origins in any of the black racial groups of Africa. Terms such as
“Haitian” or “Negro” can be used in addition to “Black or African American.”
Hispanic or Latino(a). A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture
or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino(a).”
Native Hawaiian or Pacific Islander (Non-Hispanic). A person having origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands.
White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Two or more races from those listed

Disability

Yes

No (If yes, indicate the appropriate numerical code from the listing on page 2.)

I have voluntarily provided the above self-identification information to TVA.
Signature

TVA 17878 [11-2007] Page 2 of 4

Date

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Voluntary Invitation to Self-Identify (Continued)
Disability Codes
01 Handicap recorded on medical records only
05 No handicap
06 No handicap of types listed
Speech Impairments
13 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
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

TVA 17878 [11-2007] Page 3 of 4

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 restrictive 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)

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Burden Estimate Statement
(Pursuant to 5 CFR 1320.21)
Public reporting burden for this collection of information is estimated to average 5 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. 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 17878 [11-2007] Page 4 of 4

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