CG-1227B U.S. Coast Guard Non-Appropriated Fund Employment Applic

DEPARTMENT OF HOMELAND SECURITY

U.S. Coast Guard
NONAPPROPRIATED FUND EMPLOYMENT APPLICATION

OMB No. 1625-New
Expires: mm/dd/yyyy

PRIVACY ACT NOTICE
Authority:

The U.S. Coast Guard rates applicants under the authority of Title 5 of U.S. Code, Sections 301, 1104, 1302, 2103, 3301, 3304,
Executive Order 9397, and Departmental Regulations.
Principal Purpose:
To collect information needed to determine how well an applicant’s education and work experience qualify them for the job they
are applying for.
Routine Use:
This information provided will be shared with the hiring manager and interview panel members. It may also be shared in response
to a request for discovery or for appearance of a witness, information that is relevant to the subject matter involved in a pending
judicial or administrative proceeding.
Disclosure:
Voluntary, however failure to disclose requested information may result in an applicant not receiving consideration for a position in
which the information is needed.
Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is OMB 1625-new,
expiration xx-xx-xxxx. The estimated average time to complete this application is 40 minutes. If you have any comments regarding the burden estimate
you can write to U.S. Coast Guard, Community Services Command, 510 Independence Parkway, Suite 500, Chesapeake, VA 23320.

APPLICANT INFORMATION
Name

Position Applied for

Announcement Number

Date

Address

City

State

Zip Code

Personal email Address (if available)

Daytime Phone

Evening Phone

EDUCATION
Mark highest level education completed
School

Name and City/State

Credit Hours
Completed

Course of Study

Degree or Diploma
Received (if any)

High School

College

Graduate
Other Education or
Training
List any certifications or licenses you hold that may qualify you for employment.
List any job-related professional or technical organizations to which you belong.

MILITARY SERVICE
Branch of Service

Date Entered Service

Date of Discharge or Retirement

Final Rank

Honorable Discharge

Describe briefly major duties and responsibilities.

If previous military service (discharge or retirement), please attach a copy of the DD-214.

PREVIOUS FEDERAL GOVERNMENT EMPLOYMENT
Have you ever been employed by this or any other NAF (Coast Guard
MWR, Exchange or Department of Defense, AAFES, NEXCOM, DECA,
Marine Corp Exchange)?
Y
N
Location
Job Title

Name of NAF

Salary per

Employment Dates

/
Have you ever been employed as a Federal Civil Service Employee?
Location

Job Title

Y

N
Salary per

Employment Dates

/
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WORK EXPERIENCE List most recent employment first. Account for all gaps in employment. Complete all fields.
Job Title
From (mm/yyyy)

Employer
To (mm/yyyy)

Address
Supervisor’s Name

Final Salary

Supervisor’s Phone

Description of Duties

Reason for Leaving

May we contact your current supervisor?

Y

N

If we need to contact your current supervisor before making an offer, we will contact you first.
Job Title
From (mm/yyyy)

Employer
To (mm/yyyy)

Address
Supervisor’s Name

Final Salary

Supervisor’s Phone

Description of Duties

Reason for Leaving

May we contact your former supervisor?

Y

N

Job Title
From (mm/yyyy)

Employer
To (mm/yyyy)

Address
Supervisor’s Name

Final Salary

Supervisor’s Phone

Description of Duties

Reason for Leaving

May we contact your former supervisor?
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Y

N
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WORK EXPERIENCE CONTINUED
Job Title
From (mm/yyyy)

Employer
To (mm/yyyy)

Address
Supervisor’s Name

Final Salary

Supervisor’s Phone

Description of Duties

Reason for Leaving

May we contact your former supervisor?

Y

N

Job Title
From (mm/yyyy)

Employer
To (mm/yyyy)

Address
Supervisor’s Name

Final Salary

Supervisor’s Phone

Description of Duties

Reason for Leaving

May we contact your former supervisor?

Y

N

Please attach additional pages as needed for job history.
GENERAL
Are you a U.S. citizen?
Y
N

If no, give the country of your citizenship:

Are you eligible for military spouse employment
preference?
Y
N
Spouse’s report station

Are you eligible for military spouse, widow/widower, or mother's derived
preference?
Y
N
If so, attach Standard Form 15 and applicable documentation.
Reporting Date (mm/dd/yyyy)

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 terminating me after I begin work. I understand that any information I give may be investigated.
Signature

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Date (mm/dd/yyyy)

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