Form FR 28 FR 28 Application for Employment with the Board of Governors o

JULY 7, 2014  - DRAFT

Application for Employment

Board of Governors
of the Federal Reserve System
Washington, DC 20551

OMB No. 7100-0181
Average hours per response: 1
Approval expires February 28, 2011

An equal opportunity employer

Please type or print

Background
Position for Which Application is Made

Date of Application

Date Available

Last

Previous, if any

Full Name
First

Middle

Address
Number & Street

City

State

ZIP Code

E-mail address
Telephone (Include Area Code)
Home

Office

Are you a United States citizen?

Cell

Yes

No

If “no,” state your country or countries of citizenship:

Some positions require that an employee be a U.S. citizen or intending citizen.
(12 CFR § 268.205)

Education and Training*

From

Mo.

Name and Complete Address of Schools Attended

How did you learn about this position?

To
Yr.

Graduate

Mo.

Yr.

Yes

Year
Graduated

No

Type of
Degree

Major Subjects

College—Attendance or degrees from accredited schools  

Graduate School—Attendance or degrees from
accredited schools

Technical/Other Training Schools

High School

Minor Subjects

*Note: If any education was not completed, give reason:
Titles of Publication(s), Thesis, etc.

Professional licenses, Organizations, Membership in the Bar

Typing Speed Computer Skills/Other Training or Skills
wpm

The Federal Reserve may not conduct or sponsor, and an organization (or a person) is not required
to respond to, a collection of information unless it displays a currently valid OMB control number.

FR 28 (03/08)

JULY 7, 2014  - DRAFT

Employment Record

Please list all employment, including periods of unemployment. If you were employed under a different name than shown on page one, please indicate.
Current Employment (month & year)

Title of Position

Salary or Earnings

Classification Grade
(If in Federal Service)

From

Start

To

Base

Name and Address of Employer

Immediate Supervisor

Supplemental (Itemize)

Name

Telephone
May We Contact?

Yes

No

Reason for Desiring to Change Employment
Date of Last Promotion

Number of Hours Worked Per Week

Date of Last Salary Increase

Amount of Increase

Brief Description of Duties and Responsibilities

Previous Employment (month & year)

Title of Position

From

Classification Grade
(If in Federal Service)

Salary or Earnings Start

End

Base
Supplemental

To
Name and Address of Employer

Immediate Supervisor
Name

May We Contact?

Telephone
Reason for Desiring to Change Employment

Current

Yes

No

Number of Hours Worked Per Week

Brief Description of Duties and Responsibilities

Previous Employment (month & year)

Title of Position

From

Classification Grade
(If in Federal Service)

To
Name and Address of Employer

Immediate Supervisor
Name
Telephone

Reason for Desiring to Change Employment
Brief Description of Duties and Responsibilities

Salary or Earnings Start

End

Base
Supplemental

May We Contact?
Yes
Number of Hours Worked Per Week

No

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Previous Employment (month & year)

Title of Position

From

Classification Grade
(If in Federal Service)

To
Name and Address of Employer

Salary or Earnings

Start

Immediate Supervisor
Name

May We Contact?
Yes

Telephone
Reason for Desiring to Change Employment

No

Number of Hours Worked Per Week

Brief Description of Duties and Responsibilities

Title of Position

Previous Employment (month & year)
From

Classification Grade
(If in Federal Service)

To
Name and Address of Employer

Salary or Earnings
Base
Supplemental

Start

End

Immediate Supervisor
Name

May We Contact?
Yes

Telephone

No

Number of Hours Worked Per Week

Reason for Desiring to Change Employment

End

Base
Supplemental

Brief Description of Duties and Responsibilities

Title of Position

Previous Employment (month & year)
From

Classification Grade
(If in Federal Service)

Salary or Earnings
Base

Name and Address of Employer

Immediate Supervisor
Name

May We Contact?

Telephone
Reason for Desiring to Change Employment

End

Supplemental

To

Start

Yes
Number of Hours Worked Per Week

Brief Description of Duties and Responsibilities

If there are any gaps in your employment record above, please list and explain the gaps. Military Service Record

None

Service Branch

Type of Discharge

Description of Duties

Current Military Status
From

Active Service
To

Rank Attained

No

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References
List three persons who are not related to you but who have definite knowledge of your capability to perform the duties of the position for which you are
applying. Do not repeat the names of supervisors listed under “Employment Record.”

Telephone
(Include Area Code)

Address
(Include ZIP Code)

Name

Title or Occupation

General (If you answer Yes to any of these questions, explain fully in the Remarks section. A Yes response to any one of these questions may have an effect on whether the Board hires you based upon federal law, regulations, and the Board’s policies. Please give the question number in your explanation.)
Yes

No

1.

2.
3.
4.
5.

6.

7.
8.
9.

10.

Remarks

During the last 7 years, hHave you ever been convicted of a crime, imprisoned, on probation, or on parole? (You must include
felonyies, firearms or explosives violations, military court-martials, or misdemeanors? , and any other matter that was resolved by a
plea of nolo contendere (no contest). However, (Yyou may omit: [a] minor traffic violations that resulted in a fine of $300 or less; [b]
th
any offense committed before your 16 birthday; [bc] any offense committed before your 18th birthday that was finally adjudicated in a
juvenile court or under a youth offender law; and [cd] any conviction in which the record has been expunged under federal or state law
or set aside under the Federal Youth Corrections Act or similar state law.) Note: A criminal conviction is not an absolute bar to employment but
will be considered in relation to specific job requirements. Include convictions resulting from a plea of nolo contendere (no contest).
Are you now under charges, on trial, or awaiting trial for any violation of lawon criminal charges for any violation of law (such as a
misdemeanor or a felony)??
Have you ever been convicted by a military court-martial? If no military service, answer “NO.”
Are you delinquent on any Federal debt (e.g., federal taxes, loans, overpayment of benefits, defaults on guaranteed or insured loans)?
Have you ever been discharged or asked to resign from any position, or have you resigned after having been informed that your
employer intended to discharge you?
Do you receive any annuity from the United States or District of Columbia governments under any retirement act or any pension
or compensation for military service?
Are you related to or acquainted with any employee of the Board of Governors of the Federal Reserve System?
Are you related to any officer or director of a financial and/or banking institution?
Do you, your spouse, or your minor children own debt (bonds) or equity (stock) of a bank, thrift, or other depository institution or its
affiliates, or of a primary government securities dealer or its affiliates?
Are you willing to travel in connection with your duties? (Yes response does not require an explanation.)

(Attach any other information you feel reflects your qualifications for the position for which you are applying.)

Notes

College graduates: a copy of your college transcript is requested prior to
employment. Male applicants born after December 31, 1959, must be registered with the Selective Service System or have a valid exemption in order
to be eligible for Board employment. You will be required to certify your
status at the time of employment.
A background security investigation will be required for all new hires. Appointment will be subject to the applicant's successful completion of a background
security investigation and favorable adjudication. Failure to successfully meet
these requirements will be grounds for termination.
Some persons employed by the Board must satisfactorily complete a physical
examination and may be subject to drug testing.
Persons employed by the Board are required to provide information
showing their legal entitlement to work in the United States.
Those employed by the Board who served in the U.S. Armed Forces must
provide written evidence of type of discharge.
All positions at the Board are appointed without regard to the provisions of
the classified civil service except politically appointed positions.
Applications are retained in our active file for one year. Applicants who wish
consideration beyond this time must reapply.
Those employed by the Board must abide by the Standards of Ethical Conduct
for Employees of the Executive Branch.
Disclosure of previous names used by an applicant after the applicant has
reached the legal age of employment is necessary to confirm an applicant’s
employment record.
For information on alternative formats or questions for persons with disabilities,
or if you need assistance completing the application because of a disability,
contact the Board's Human Resources Function, Recruiting Office at 202452-3880, TDD (Telecommunications Device for the Deaf) 202-872-4984.

The Board of Governors of the Federal Reserve System has:
1. Adopted regulations and procedures to assure equal opportunity in
employment for all persons; to prohibit discrimination in employment
because of race, religion, color, national origin, sex, physical or mental
disability, or age; and to promote the full realization of equal employment
through a positive continuing program in every aspect of Board personnel
policy and practice. An aggrieved applicant for employment who believes
that he or she has been discriminated against because of race, religion,
color, national origin, sex, disability, or age should consult with an EEO
Counselor within 45 days of the date of the event he or she believes was
discriminatory. A list of EEO Counselors can be obtained from the Division
of Human Resources Management.
2. Rules regarding financial interests of employees that restrict ownership
by employees, their spouses, and their minor children of debt (bonds) or
equity (stock) of banks, thrifts, and other depository institutions or their
affiliates and of primary government securities dealers or their affiliates.
Questions should be directed to the Ethics Officer in the Board's Legal
Division.
I certify that, to the best of my knowledge and belief, all of the information on
and attached to this application is true, correct, and complete and made in
good faith. I consent to the release of information about my ability and fitness
for Board employment by employers, schools, law enforcement agencies
and other individuals and organizations, to investigators, personnel staffing
specialists, and other authorized employees of the Federal Government. I
understand that false or fraudulent information on or attached to this application
may be grounds for not hiring me or for firing me after I begin work, and may
be punishable by fine or imprisonment. I understand that any information I
give may be investigated. I have read and understand the Privacy Act Statement issued by the Board pursuant to the Privacy Act of 1974 and provided
to me in connection with the application.

Applicant’s Signature

PAPERWORK REDUCTION ACT NOTICE

JULY 7, 2014 - DRAFT

This application for employment is authorized by law [12 U.S.C. §§ 244 and 248(1)].
Public reporting burden for this employment application is estimated to average one hour per response,
including the time to gather the information in the required form and to review instructions and complete

the application. Send comments regarding this burden estimate or any other aspect of this employment application, including suggestions for reducing this burden, to Secretary, Board of Governors of
the Federal Reserve System, 20th and C Streets, N.W., Washington, DC 20551; and to the Office of
Management and Budget, Paperwork Reduction Project (7100-0181), Washington, DC 20503.