Form TVA 1 TVA 1 Application for Emplopyment

TVA SENSITIVE INFORMATION

Tennessee Valley Authority

Application for Employment

OMB No. 3316-0063

Exp. Date: MM/DD/YYYY

General Instructions:Be sure you’re in PAGE LAYOUT under VIEW

This is a fillable form. It is preferred that you complete the form on your computer and print it out to sign. If you cannot, please use black ink and print legibly.

Do not send any papers which you would want returned because they will be destroyed if your application becomes outdated.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 6 months.

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.

Tennessee Valley Authority

Application for Employment

Please TAB to gray areas

Please follow attached instructions. Use additional sheets if necessary.

Return to Talent Management, Employment Office, 1101 Market Street, Chattanooga, TN 37402-2801.

1.	Social Security Number							Date
	     							     
2.	Last Name			First Name			Middle Name
	     			     			     
3.	Other Names: (i.e., Include maiden name, former married names, aliases, nicknames, etc., and the dates used)
	Name					From (mm/dd/yyyy)			To (mm/dd/yyyy)
	     					     			     
	     					     			     
	     					     			     
4.	Home Mailing Address				5. Are you a citizen of the United States? Yes No
	Street	     			If “no”, list: Country of Citizenship:      
	City	     			6. Have you ever worked for TVA? Yes No
	County	     			If “yes”, provide:
	State	     			Date Last Worked       Location ____________________
	Zip + 4	     			7. Are you related in any way to a TVA employee? Yes No
	Phone	     			If “yes”, state the name of each employee and exact relationship and provide position and location if known:
	Cell Phone	     			     
	E-mail	     			     

Military History Data

8.	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

9.		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
	     		     	     	     

Education

10.

List month and year of starting and ending dates using (mm/yy) format for each school. Please do not indicate you have received a degree unless you have actually received one. Listing a degree that you have not received will be considered falsification of application. If additional information is needed, please use a photocopy of this page.

High School-(must be completed)

Full Name of School (No Initials or Abbreviations)

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

City/State/Zip Code

     

     

     

Attendance Only

Highest Grade Completed (1-12)

Start Date mm/yy

End Date mm/yy

G.P.A.

     

GED Received

Date Received

Location of Records (address, city and state)

     

     

     

     

     

Graduated w/Diploma

College or University

Full Name of School (No Initials or Abbreviations)

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

City/State/Zip Code

     

     

     

Attendance Only Certificate Field of Study:      

Start Date mm/yy

End Date mm/yy

G.P.A.

     

     

     

I have received a Degree Yes or NO: if yes, please complete the section below

Start Date mm/yy

End Date mm/yy

G.P.A.

Associate in

     

     

     

     

     

Bachelor in

     

     

     

     

     

Masters

     

     

     

PHD

     

     

     

     

     

College or University

Full Name of School (No Initials or Abbreviations)

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

City/State/Zip Code

     

     

     

Attendance Only Certificate Field of Study:      

Start Date mm/yy

End Date mm/yy

G.P.A.

     

     

     

I have received a Degree Yes or NO: if yes, please complete the section below

Start Date mm/yy

End Date mm/yy

G.P.A.

Associate in

     

     

     

     

     

Bachelor in

     

     

     

     

     

Masters

     

     

     

PHD

     

     

     

     

     

Technical School Other

     

Full Name of School (No Initials or Abbreviations)

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

City/State/Zip Code

     

     

     

Attendance Only Certificate Diploma

Start Date mm/yy

End Date mm/yy

G.P.A.

Field of Study:

     

     

     

     

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

11.	Begin with present date and go back five years. Account for all periods of unemployment and self-employment with job site locations. Give home office address as well as all job site locations (city/state) where you worked over 30 days. If more space is needed, please use a photocopy of this page.
Employer’s Name (No initials or abbreviations)					Home Office Address (City, State, Zip Code)
     					     
Date Employed, Unemployed, Self Employed				Area Code/Telephone No.		Position Held	Beginning/Ending Salary
From (mm/yy)		     	To Present	     		     	     
Supervisor					Job Site (Location, City, State)
     					     
Reason for Leaving					Home while employed with this employer ( City, State, Zip Code)
     					     
If you marked Self Employed or Unemployed—Provide a reference below-(Non-Family Member)
Name of Reference					Address and Daytime Telephone Number of Reference
     					     

Employer’s Name (No initials or abbreviations)					Home Office Address (City, State, Zip Code)
     					     
Date Employed, Unemployed, Self Employed				Area Code/Telephone No.		Position Held	Beginning/Ending Salary
From (mm/yy)	     	To	     	     		     	     
Supervisor					Job Site (Location, City, State)
     					     
Reason for Leaving					Home while employed with this employer ( City, State, Zip Code)
     					     
If you marked Self Employed or Unemployed—Provide a reference below-(Non-Family Member)
Name of Reference					Address and Daytime Telephone Number of Reference
     					     

Employer’s Name (No initials or abbreviations)					Home Office Address (City, State, Zip Code)
     					     
Date Employed, Unemployed, Self Employed				Area Code/Telephone No.		Position Held	Beginning/Ending Salary
From (mm/yy)	     	To	     	     		     	     
Supervisor					Job Site (Location, City, State)
     					     
Reason for Leaving					Home while employed with this employer ( City, State, Zip Code)
     					     
If you marked Self Employed or Unemployed—Provide a reference below-(Non-Family Member)
Name of Reference					Address and Daytime Telephone Number of Reference
     					     

Employer’s Name (No initials or abbreviations)					Home Office Address (City, State, Zip Code)
     					     
Date Employed, Unemployed, Self Employed				Area Code/Telephone No.		Position Held	Beginning/Ending Salary
From (mm/yy)	     	To	     	     		     	     
Supervisor					Job Site (Location, City, State)
     					     
Reason for Leaving					Home while employed with this employer ( City, State, Zip Code)
     					     
If you marked Self Employed or Unemployed—Provide a reference below-(Non-Family Member)
Name of Reference					Address and Daytime Telephone Number of Reference
     					     

Background Information—Dates and places of permanent residence

12.	Begin with present date and go back five years. Give complete addresses. If more space is needed, please use a photocopy of this page or another sheet of paper.
Date
From (mm/yyyy)		To (mm/yyyy)	Address	City	State	Zip
     		     	     	     	     	     
     		     	     	     	     	     
     		     	     	     	     	     
     		     	     	     	     	     
     		     	     	     	     	     

13.	In the past 5 years, have you ever been discharged, fired, or terminated for cause? Yes No
	In the past 5 years, have you ever resigned (quit) after written or verbal notice that you were being discharged (fired) from any job for any reason? 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.

     

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 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.

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.

Two or more races

Social Security No.	     		Date of Birth	     	Sex: Female Male
Race and National Origin:		White Black/African American Hispanic/Latino Asian (Non Hispanic) Native Hawiian or Pacific Islander American Indian/Alaskan Native Not Applicable (Non-US) Two or more races Please list: ________________________
(see definitions above)

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 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.

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