Form 2100/14 Applicant Background Questionnaire

Refresh

POC

OMB NUMBER: 3064-0138
EXPIRATION DATE: 12/31/2015

Federal Deposit Insurance Corporation

APPLICANT BACKGROUND QUESTIONNAIRE
The Federal Deposit Insurance Corporation (FDIC) is requesting your completion of this form to assist the Corporation in evaluating and improving its efforts
to publicize job openings. Based on this information, the FDIC can access the effectiveness of specific outreach efforts and our means of communicating
information on job vacancies.
EFFECTS OF NONDISCLOSURE: Providing this information is strictly voluntary. This information will have no effect on hiring decisions and will
not be released to the individuals who review the applications, to the selecting official, to anyone else who can affect your application, or to the
public.
Your Social Security Number (SSN) is requested under the authority of Executive Order 9397 (November 22, 1943) for the orderly administration of
personnel records. Submission of your SSN is voluntary and failure to furnish your SSN on this form will have no effect on your application.
Persons are not required to consider a response to this collection of information unless it displays a currently valid OMB control number.
Information provided on this form will be used for program evaluation. Personal identifying information will not be included in the tabulation of data in the
FDIC database.
The public reporting burden for this collection of information is estimated to average 8 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. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Paper Reduction Act
th
Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17 Street, N.W., Washington, D.C. 20429; and to the Office of Management
and Budget, Paperwork Reduction Project (3064-0138), Washington, D.C. 20503. 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.
Solicitation of this information is in accordance with 5 CFR Section 720, “Federal Equal Opportunity Recruitment Program” (FEORP).

Name (Last, First, MI)

Social Security Number (Last 4 digits)

Date of Birth

Sex
Male

***-**Title, Grade, Announcement Number of Position for which you are applying.

Do you have a disability?
Yes
No
If you checked “Yes” above, is your disability one of the *targeted disabilities listed below?

Yes

Female

No

*The Equal Employment Opportunity Commission targets the following disabilities for extra recruitment efforts: Deaf, Blind, Missing
Extremities, Partial/Complete Paralysis, Convulsive Disorders, Mentally Retarded, Mental Illness, or Distortion Limb/Spine.
ETHNIC SELF-DETERMINATION
Are you Hispanic, Latino, or of Spanish Origin? (Determination: A person of Cuban, Mexican, Puerto Rican, South or Central American,
or other Spanish culture or origin, regardless of race.)
Yes
No
RACE SELF-IDENTIFICATION
Please read the descriptions, then mark one or more races to indicate what you consider yourself to be.
A. American Indian or Alaska Native

A person having origins in any of the original peoples of North and South
America (including Central America), and who maintains tribal affiliation
or community attachment.

B. Asian

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.

C. Black or African American

A person having origins in any of the black racial groups of Africa.

D. Native Hawaiian or Other or
Pacific Islands.

A person having origins in any of the original peoples of Hawaii, Guam, Samoa,
or other Pacific Islander.

E. White

A person having origins in any of the original peoples of Europe, the Middle East,
or North Africa.
PRIVACY ACT STATEMENT

Collection of this information is authorized by 5 U.S.C. § 7201 and Executive Order #9397. The information requested on this form will be used for program evaluation and to prepare
statistical reports regarding race, gender or national origin of applicants. Personal information identifying you will not be used in the tabulation of data in any FDIC database. Your
Social Security Number (SSN) is requested to further ensure record accuracy. Disclosure of this information may be made to: The Equal Employment Opportunity Commission, the
Merit Systems Protection Board, or the Office or Special Counsel in the discharge of their duties; the United States Office of Personnel Management to locate individuals for personnel
research or survey response; a Federal agency in response to its requests for use in its Federal Equal Opportunity Recruitment Program to the extent that the information is relevant
and necessary to the agency's efforts in identifying sources for minority recruitment; a congressional office in response to an inquiry made at the request of the individual supply the
information; another Federal agency, court or a party in litigation before a court or administrative body; contractors, grantees or volunteers performing or working on a contract, service,
grant, cooperative agreement or job for the Federal government; and in accordance with any other routine uses of records specified in the government-wide system of records notice,
Applicant Race, Sex, National Origin and Disability Status Records, 61 Federal Register 36,934. Completion of this form is voluntary and even if the information is not supplied, there
will be no adverse affect on hiring decisions.

FDIC 2100/14 (10-05)