TVA 17878 Applicant Information Sheet

TVA SENSITIVE INFORMATION

Tennessee Valley Authority

Applicant Information Sheet

OMB No. 3316-0063

Exp. Date: MM/DD/YYYY

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? Yes No

2. Have you ever resigned from employment? Yes 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

     

Date

     

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

     

Date

     

Voluntary Invitation to Self-Identify (Continued)

Disability Codes

	01 Handicap recorded on medical records only			Partial Paralysis (due to brain, nerve, or muscle
	05 No handicap			problem)
	06 No handicap of types listed			61 One hand
				62 One arm, any part
	Speech Impairments			63 One leg, any part
	13 Stuttering, Aphasia, Laryngectomy			64 Both hands
				65 Both legs, any part
	Hearing Impairments			66 Both arms, any part
	15 Hard of hearing or deaf in one ear			67 One side of body, including one arm and one leg
	16 Total deafness in both ears with some speech			68 Three or more major parts of the body (arms and legs)
	17 Total deafness in both ears, unable to speak clearly
				Complete Paralysis
	Vision Impairments			70 One hand
	22 Tunnel vision or legal blindness			71 Both hands
	23 Inability to read ordinary size print, not correctable by glasses			72 One arm
	24 Blind in one eye			73 Both arms
	25 Blind in both eyes			74 One leg
				75 Both legs
	Missing Extremities			76 Lower half of body, including legs
	27 One hand			77 One side of body, including one arm and one leg
	28 One arm			78 Three or more major parts of the body (arms and legs)
	29 One foot
	32 One leg			Other Impairments
	33 Both hands or arms			80 Heart disease with no restriction or limitation of activity
	34 Both legs or feet			81 Heart disease with restrictive or limitation of activity
	35 One hand or arm and one foot or leg			82 Convulsive disorder (epilepsy)
	36 One hand			83 Blood disease (sickle cell disease, leukemia,
	37 Both hands or arms and one foot or leg			hemophilia
	38 Both hands or arms and both feet or legs			84 Diabetes
				86 Pulmonary or respiratory disorders
	Nonparalytic Orthopedic Impairments			(tuberculosis, emphysema, asthma)
	(Because of chronic pain, stiffness, or weakness in			87 Kidney dysfunctioning (dialysis required)
	bones or joints, there is some loss of ability in			88 Cancer (a history with complete recovery)
	movement or use.)			89 Cancer (undergoing surgical and/or medical
	44 One or both hands			treatment)
	45 One or both feet			90 Mental retardation
	46 One or both arms			91 Mental or emotional illness (with history of treatment)
	47 One or both legs			92 Severe distortion of limbs and/or spine
	48 Hip or pelvis			(dwarfism, severe distortion of back)
	49 Back			93 Disfigurement of face, hands, or feet (birth defects,
	57 Movement loss of two or more parts of the body			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)

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 [10-??-2013] Page 25 of 25

TVA SENSITIVE INFORMATION