Form 10-2201 Personal Qualifications Statement

This form must be printed by the applicant after each question is answered completely and accurately. If a question does not apply to you, write “N/A” (Not Applicable) as your response to that question. Incomplete and/or inaccurate answers will substantially extend the time required to complete the pre-employment qualification determination phase of the application process. If the information you provide on USPP Form 1 is incomplete and/or not notarized, the form will be returned to you and you will not move forward in the process until the application is completed according with the instructions provided herein.

NOTE: The date of the notary seal must match the date of your signature on the last page and must be completed prior to the date you submit the form to the United States Park Police.

The information you provide in this form will be used during the pre-employment qualification determination phase of the application process for the position for which you have applied. Please fill out the form completely and accurately. Keep in mind that:

The completion of this form is optional. However, failure to provide the information may prevent or delay the processing of your pre-employment qualifications determination, adversely affecting your consideration for appointment;

All statements are subject to verification;

Deliberate inaccuracies or incomplete statements may bar or remove you from further consideration in the pre-employment qualifications determination phase of the application process;

all time periods in your background must be accounted for; and,

no changes to the document are permitted after it is notarized.

It is to your advantage to respond openly. Any negative factor contained in the information provided by you will be evaluated in terms of the circumstances and facts surrounding it and its degree of relevance to the job. On the other hand, you may be removed from further consideration if you intentionally make a false statement of material fact or intentionally omit a material fact or if you practice or attempt to practice any form of deception or fraud in this Personal Qualification Statement.

If additional space is required for an answer to any question, use the “Continuation Sheet” found on the back of each answer sheet for that question, or provide your remarks on bond paper at the end of the section. Be sure to identify each entry on the continuation sheet(s) with the appropriate section and question number.

* PART XIII, “APPLICANT CERTIFICATION AND SIGNATURE” MUST BE SIGNED AND NOTARIZED *

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PART I - REQUIRED PAPERS/DOCUMENTS

(Must be presented during the Forms Review Session, or when directed.)

Unless otherwise indicated, the original document (or a certified true copy) and one copy of each document listed below must be presented when directed during the pre-employment qualifications determination phase of the application process. Original documents (birth certificate, diplomas, naturalization certificates, etc.) will be returned to the applicant after they are reviewed.

Birth certificate - Bring the original and a copy to leave with your paperwork
High school diploma or GED (GED must be accompanied by test scores) - Bring the original and a copy to leave with your paperwork
College transcripts (transcripts must be official copies provided by the institution in a sealed envelope) and diploma, upon request
Forms DD-214(s) for each period of military service, as well as all paperwork that supports any judicial or non-judicial punishment, and all paperwork related to any military discharge considered other than honorable
Selective Service card (even if you served in the military)
Naturalization certificate - Bring the original and a copy to leave with your paperwork
Marriage license(s) - Bring the original and a copy to leave with your paperwork
Court orders:

a. Divorce/annulment papers and all other legal documents which pertain to your present and/or previous marriage(s)

b. Legal separation(s) (copy only)

c. Child support

d. Name change(s)

e. Adoption(s)

f. Bankruptcies (copy only)

g. Copy of disposition(s) of any court action(s) civil and criminal, and copies of police reports of incidents you have been involved in

9. Driver’s license (actual current license and 1 copy (front and back)), certified copy of current license record, and records from all states that have issued you a driver’s license for the last 10 years

10. One copy each all Federal tax transcripts and state tax forms for the previous two tax years you were required to file returns (including Forms W-2’s) (Contact www.irs..gov and each state tax authority you filed in to obtain transcripts and copies of filed returns.)

11. A copy of your credit report (obtained from www.equifax.com) , obtained after the opening date of this current vacancy announcement

Birth certificate, marriage license, divorce/annulment papers, and change of name documents must be notarized if they are not the originals, or they must be annotated as being true copies by the agency providing the copies. These documents will be reviewed and the originals will be returned to you at the time they are presented. Failure to present required documents could delay your processing and/or remove you from further consideration.

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PART II - PERSONAL DATA

1. Applicant’s Full

Name

Last

First

Middle

Suffix

2. Aliases, Maiden Names, and Nicknames Used (list all)

Check One

Alias Maiden Name Nickname

Check One

Alias Maiden Name Nickname

Check One

Alias Maiden Name Nickname

2A. Have you ever legally changed your name? If “Yes”, provide details below:

Yes No

From (full name):

To (full name):

Court jurisdiction:

3. Date of Birth (mm/dd/yyyy)

4. Place of Birth (city, county, state, country)

5. Social Security Number

6. Sex

Male Female

7. Citizenship

U.S. Citizen

By Birth

Naturalization

Alien

Alien Registration Number

Date

Place/Court

Certificate Number

Petition Number

8. U.S. Passport

Passport Number

Date Issued (mm/dd/yyyy)

9. Dual Citizenship If you are (or were) a dual citizen of the United States and another country, specify country.

Country

10. Present Address

House Number, Street, Apt #

City

State

Zip Code

11. Legal Residence

House Number, Street, Apt #

City

State

Zip Code

12. Home Phone Number

13. Work Phone Number

14. Email Address

CONTINUATION PAGE

PART III - SELECTIVE SERVICE & MILITARY SERVICE DATA

Selective Service Number (Male Applicant’s Only)			2. Date of Registration
3. Have you ever applied to any branch of the military?				Yes No
4. What is the status of your application?
5. Have you ever been denied entrance to any of the armed forces?				Yes No
5A. If “Yes”, which branch?	Army Air Force Navy Marine Corps National Guard Coast Guard Merchant Marines
5B. If “Yes”, explain the basis for your denial and provide copies of all relevant paperwork.
6. Highest Rank Attained		7. Rank at Time of Discharge
8. Type of Discharge (i.e., Character of Service)
9. Were you recommended for re-enlistment after each period of military duty?		Yes No (If “No”, explain below)

10. Have you ever received a discharge from the Armed Forces that was “Other than Honorable”?		Yes No (If “Yes”, enter type of discharge)

10A. If question 10 is “Yes“, explain circumstances and *provide copies of all relevant paperwork*.

11. Were you ever subjected to any disciplinary actions (judicial or non-judicial) while in the Armed Forces?		Yes No (If “Yes”, explain below)
11A. If question 11 is “Yes“, explain circumstances and *provide copies of all relevant paperwork*.

12. Were you ever the subject of any criminal investigation conducted by military authorities concerning any alleged misconduct on your part?		Yes No (If “Yes”, explain below)
12A. If question 12 is “Yes“, explain circumstances and *provide copies of all relevant paperwork*.

CONTINUATION PAGE

PART IV - FINANCIAL DATA

1. Do you now, or have you ever had, any wage garnishments on your salary?			Yes (Explain) No
1A. If “Yes”, please explain.
2. Have you ever been found delinquent on income or other tax payments?			Yes (Explain) No
2A. If “Yes”, please explain.
2B. Have the delinquent taxes been paid?			Yes (Explain) No
3. Have you ever had a lien placed against your property for failing to pay taxes or other debts?			Yes No
3A. If “Yes”, please explain.
4. Have you ever had any real or personal property repossessed?			Yes (Explain) No
4A. If “Yes”, please explain.
5. Have you ever had a court-ordered financial judgment against you?			Yes (Explain) No
5A. If “Yes”, please explain.
6. Do you presently have a financial judgment pending in court?			Yes (Explain) No
6A. If “Yes”, please explain.
7. Have you ever filed or declared bankruptcy or utilized a wage earner’s plan?			Yes (Explain) No
7A. If “Yes”, please explain.
8. Do you or your spouse have any other source(s) income?			Yes (Explain) No
8A. If “Yes”, please provide the following: (Continue on next page, if necessary.)
Source of income	Self Spouse	Monthly Income	$
Source of income	Self Spouse	Monthly Income	$
Source of income	Self Spouse	Monthly Income	$
Source of income	Self Spouse	Monthly Income	$
Source of income	Self Spouse	Monthly Income	$
Source of income	Self Spouse	Monthly Income	$
Source of income	Self Spouse	Monthly Income	$

CONTINUATION PAGE

PART IV - FINANCIAL DATA

(Continued)

9. List all current loans, credit cards, mortgage/rent, and contractual agreements for which you have payments. (Continue on next page, if necessary.)
9A.	Type of debt
	Monthly payment		$
	Present balance		$
	To whom owed
9B.	Type of debt
	Monthly payment		$
	Present balance		$
	To whom owed
9C.	Type of debt
	Monthly payment		$
	Present balance		$
	To whom owed
9D.	Type of debt
	Monthly payment		$
	Present balance		$
	To whom owed
9E.	Type of debt
	Monthly payment		$
	Present balance		$
	To whom owed
9F.	Type of debt
	Monthly payment		$
	Present balance		$
	To whom owed
10. Financial delinquency: If the answer to either question 10A or 10B is “Yes”, provide the information requested below: (Continue on next page, if necessary.)
10A. Have you ever been over 180 days delinquent on any debt(s)?						Yes No
10B. Are you currently over 90 days delinquent on any debt(s)?						Yes No
Type of Debt		When Incurred		Amount	Present Balance	To Whom Owed
				$	$
				$	$
11. Have you ever been a part to any public record civil court actions? If “Yes”, provide the information requested below.						Yes No
Month/Year		Action		Result	Name of Parties	Court

CONTINUATION PAGE

PART V - REFERENCES

Give the data requested below on three (3) references who:

Are not related to you by blood or marriage,
Are not former employers and not mentioned elsewhere in this form,
Are responsible adults of reputable standing in their community, and are located in the United States,
Are aware of your qualifications and fitness for this position, and
Have known you well for at least five (5) years.

Reference #1
Check One		Name (Last, First, Middle)				Years Known	Citizenship
Mr.	Mrs.
Ms.	Miss
Residence Address (street address, city, state, zip code)

Home Phone #			Business Phone #		Email Address

Occupation				Place of Employment

Address of Employment (street address, city, state, zip code)

Reference #2
Check One		Name (Last, First, Middle)				Years Known	Citizenship
Mr.	Mrs.
Ms.	Miss
Residence Address (street address, city, state, zip code)

Home Phone #			Business Phone #		Email Address

Occupation				Place of Employment

Address of Employment (street address, city, state, zip code)

Reference #3
Check One		Name (Last, First, Middle)				Years Known	Citizenship
Mr.	Mrs.
Ms.	Miss
Residence Address (street address, city, state, zip code)

Home Phone #			Business Phone #		Email Address

Occupation				Place of Employment

Address of Employment (street address, city, state, zip code)

PART VI - PERSONAL ASSOCIATES

Give the data requested below on three (3) persons with whom you have associated (i.e., persons whom you have seen frequently) during the past three (3) years. Do not include relatives, former employers, or any persons mentioned elsewhere in this form.

Personal Associate #1
Check One		Name (Last, First, Middle)				Years Known	Citizenship
Mr.	Mrs.
Ms.	Miss
Residence Address (street address, city, state, zip code)

Home Phone #			Business Phone #		Email Address

Occupation				Place of Employment

Address of Employment (street address, city, state, zip code)

Personal Associate #2
Check One		Name (Last, First, Middle)				Years Known	Citizenship
Mr.	Mrs.
Ms.	Miss
Residence Address (street address, city, state, zip code)

Home Phone #			Business Phone #		Email Address

Occupation				Place of Employment

Address of Employment (street address, city, state, zip code)

Personal Associate #3
Check One		Name (Last, First, Middle)				Years Known	Citizenship
Mr.	Mrs.
Ms.	Miss
Residence Address (street address, city, state, zip code)

Home Phone #			Business Phone #		Email Address

Occupation				Place of Employment

Address of Employment (street address, city, state, zip code)

PART VII - EDUCATION DATA

1. Name of senior high school:
School address: (street address, city, state, zip code)
Dates attended:	From:					To:
Highest grade completed:			Did you graduate?			Yes No		Did you receive a diploma?		Yes No
2. List all Colleges and Universities attended
Name of College/University		Location			Dates Attended				Degree Attained






2A. Number of credit hours completed.					2B. Major field of study.
3. Characterize your grades (check one):				Poor Passable Average Good Excellent
4. Were you ever disciplined, dismissed, suspended, or expelled in college/university? If “Yes”, explain on Continuation sheet on next page.							Yes (If “Yes”, explain below) No
4B. How was your conduct and department in college? (Give details.)
5. Have you ever been interviewed, cited, detained, arrested, or had any other contact with any college/university police agency or security force?							Yes (If “Yes”, explain below) No
5A. If “Yes”, explain :

CONTINUATION PAGE

PART VIII - EMPLOYMENT DATA

1. Have you ever been discharged from employment (fired) for any reason?		Yes (If “Yes”, explain below) No
1A. If “Yes”, explain:
2. Have you ever resigned (quit) after being informed that your employer intended to discharge (fire) you for any reason?		Yes (If “Yes”, explain below) No
2A. If “Yes”, explain:
3. Have you ever resigned (quit) after being informed that your employer intended to take any form of disciplinary action against you?		Yes (If “Yes”, explain below) No
3A. If “Yes”, explain:
4. Have you ever walked off (left) a job without giving proper notice?		Yes (If “Yes”, explain below) No
4A. If “Yes”, explain:
5. Have you ever stolen anything from any of your employers?		Yes (If “Yes”, explain below) No
5A. If “Yes”, explain:
6. Have you ever used illegal drugs on any job you ever held?		Yes (If “Yes”, explain below) No
6A. If “Yes”, explain:
7. Have you ever committed any other crimes (even those which went undetected) while on any job you ever held?		Yes (If “Yes”, explain below) No
7A. If “Yes”, explain:

CONTINUATION PAGE

PART IX - DRIVING RECORD

1. Insert data below for ALL (even dismissed) traffic violations or citations (excluding parking tickets) that you have received since first receiving a driver’s license. Include in your response, but do not limit it to, such violations as speeding, reckless driving, changing lanes without caution, stop sign violations, red light violations, and driving while intoxicated/driving under the influence (DWI/DUI).
Date	Violation/Charge		Location (city/state)		Police Agency	Final Disposition			Fine Amount	Points
									$
									$
									$
									$
									$
									$
2. Do you currently have a valid driver’s license for the state in which you reside?							Yes No
3. Provide the information requested below on all driver’s licenses that are now or have been issued to you from any state (even though these licenses may now be expired or have been replaced by another issuing agency or state).
Issuing State		License Number		Expiration Date		Type of License



4. Is your driver’s license now or has it ever been:
Denied or refused								Yes No
Suspended								Yes No
Revoked								Yes No
Subjected to any other similar penalty or action								Yes No
4A. If you answered “Yes” to any of the above, explain in detail

5. Are there any restrictions or special conditions attached with your Driver’s License? If “Yes”, explain:								Yes No

CONTINUATION PAGE

PART IX - DRIVING RECORD

(Continued)

6. Have you ever obtained or possessed a falsified or fictitious driver’s license? If “Yes”, explain:	Yes No

7. Are your Vehicle License Plates now or have they ever been:
Denied	Yes No
Suspended	Yes No
Revoked	Yes No
Subjected to any other similar penalty or action	Yes No
If you answered “Yes” to any of the above, explain in detail below:

8. List all motor vehicle accidents (include date, time, place, charges, accident circumstances and results, name of police agency that made the report and final disposition of the case).

CONTINUATION PAGE

PART X - ARREST/CONVICTION AND CRIMINAL HISTORY

1. Have you ever been:
Arrested?	Yes No
Charged by any law enforcement authority?	Yes No
Convicted of any offense against the law?	Yes No
Subjected to forfeiture of collateral in connection with an arrest?	Yes No
Placed on parole?	Yes No
Released on parole?	Yes No
Required to appear before a juvenile court for an act that would have been a crime if committed by an adult?	Yes No
Fingerprinted for any reason?	Yes No
If you answered “Yes” to any of the above, explain in detail all charges, even those dismissed, expunged, or nolleprossed. If more than one instance, fully explain each instance.

2. Are you now:
Charged with an offense by any law enforcement authority?	Yes No
Presently on bail or out on personal recognizance or other conditional release?	Yes No
On probation of any type (include restricted driver’s license)?	Yes No
3. Are you now, or have you ever been, involved as a defendant in any criminal court action?	Yes No
4. Are you now, or have you ever been, involved as a plaintiff or defendant in any civil court action?	Yes No
5. Do you currently have any judgments against you?	Yes No
6. If you answered “Yes” to any of the questions 2-6 on this page, give full and complete details below. Include, as a minimum, the date of the offense, original charge(s), final charge(s), city and state, name of law enforcement agency involved, circumstances of case, and final disposition. For judgments, give case number, court location, reason for case, and final disposition.

CONTINUATION PAGE

PART X - ARREST/CONVICTION AND CRIMINAL HISTORY

(Continued)

1. Do you now, or have you in the past used, tried, or experimented with:
Marijuana (in any form)[ Regardless of its legal status in the location is was used?]	Yes No
Illegal Narcotics (heroin, cocaine, crack, or illegal drugs of any kind)?	Yes No
Dangerous drugs of any kind (LSD, PCP, MDMA, Ecstasy, etc.)?	Yes No
Other drugs used contrary to their intended purpose, legally prescribed or not?	Yes No
Inhalants (glue, solvents, aerosols, whip-its, etc.)?	Yes No
2. Do you now, or have you in the past illegally bought, sold, or possessed marijuana, narcotics, other dangerous drugs, or illegal drugs with the intent to use personally or to provide to others to use, contrary to their intended purpose?	Yes No
3. Have you been present when controlled substances were used, sold, possessed, or delivered in a manner contrary to the intended or prescribed use of the substance?	Yes No
4. Do you now take, or have you ever taken, any medication other than under your doctor’s prescription (with the exception of over-the-counter medications?	Yes No
5. Have you been found responsible for violating any confidentiality agreement between yourself and your employer?	Yes No
6. Have you obtained copy-written material by electronic means (songs, movies, software)?	Yes No
If you answered “Yes” to questions 1-4 & 6, explain in detail below:

CONTINUATION PAGE

PART XI - MISCELLANEOUS

1. Are there any circumstances that would in any way:
Limit or prohibit your use of weapons or firearms?	Yes No
Restrict or prohibit you from working on particular days or during certain hours?	Yes No
Restrict you from confirming to Department of the Interior standards of appearance and/or grooming?	Yes No
If you answered “Yes” to any of the above, explain in detail below:
NOTE: We will consider requests for reasonable accommodation for disability or religious reasons under the applicable legal standards. This includes determining whether providing the accommodation would pose an undue hardship.
2. Have you ever been issued a permit or license to carry a handgun or other weapon on your person? If “Yes”, explain:	Yes No

3. If you have ever been issued a permit or license to carry a handgun, have you ever discharged your weapon (other than at an approved range) or been the subject of an investigation regarding the discharge of your weapon? If “Yes”, explain:	Yes No

4. List any special skills you possess that you believe may be applicable to the position for which you are applying (skills with equipment, public speaking experience, membership in a professional scientific community or other such organization, etc.).

Part XI - MISCELLANEOUS

(Continued)

5. Are you able to communicate in any language other than English (including sign language)?

Yes No

Enter language and indicate your knowledge of each by checking the box in the proper column.

Reading

Speaking

Understanding

Writing

Language

Exc.

Good

Fair

Exc.

Good

Fair

Exc.

Good

Fair

Exc.

Good

Fair

6. List hobbies and spare-time interests:

7. List all police/law enforcement/fire agencies below with whom you have applied. List the steps you have completed with the agency (written test, oral interview, polygraph, background completed, physical agility, medical, psychological, etc.). Also, list current application status with each agency. If you have applied to the same agency more than once, list each time separately.

Agency

Address/Email

Phone

Date Applied

Last Step Taken

Investigator

Status

8. Have you ever applied for a police officer position with the U.S. Park Police? If “Yes”, provide dates application(s) was submitted:

Yes No

9. Have you ever been denied employment by any organization noted in items 7 and 8 above? If “Yes”, provide agency name and reason for denial.

Yes No

10. Have you ever applied for any Federal position for which a background investigation was initiated? If “Yes”, provide agency name:

Yes No

Part XI - MISCELLANEOUS

(Continued)

11. Do you have experience as a sworn police/law enforcement officer? If “Yes”, provide details below:	Yes No

12. Do you have any objections to being reassigned to any area within the United States? If “Yes”, state objection:	Yes No

13. If you are selected for appointment, how many days’ notice do you require?
14. List any family member or friend who is currently employed by this Department or who has been employed by this Department in the past.

15. Are there incidents in your life, not mentioned elsewhere herein, that may reflect upon your qualifications to perform the duties that you may be called upon to take or that might require further explanation? If “Yes”, provide full details below.	Yes No

CONTINUATION PAGE

PART XII - APPLICANT ESSAY

YOU MUST WRITE, an essay of at least 200 words on why you want to be a United States Park Police Officer. You may include any information you feel is important, but you must address the topics listed below

Your essay will be evaluated on your ability to write and your ability to express ideas clearly by using correct grammar and spelling. Please be sure to write legibly.

Use only pages 29 – 30 for your essay. Please print your name, applicant number and date on each page.

Describe in your own words why you want to be a United States Park Police Officer?
How did you hear about the United States Park Police?
What do you think your role as a park police officer shall be?
What are your career aspirations/expectations as a United States Park Police Officer?

PART XII – APPLICANT ESSAY

(Continued)

PART XIII – APPLICANT’S CERTIFICATION AND SIGNATURE

I understand that sworn appointments to the United States Park Police are probationary for a period of one year from the hire date. During this probationary period officers must demonstrate their fitness for continued employment with the United States Park Police.

I am aware that withholding/omitting information or making false Statements on USPP Form 1 (and supplemental USPP Form 1A) may be the basis for disapproval before appointment or dismissal after appointment, and constitute a felony violation of the United States Code, Title 18, Section 1001. Any changes to this document after the document is notarized will invalidate the applicant from further processing.

I hereby acknowledge these conditions and certify that all statements made by me on USPP Form 1 and supplemental USPP Form 1A are true and complete, to the best of my knowledge.

Signature of Applicant _______________________________________________

Date ________________________________________________20___________

SUBSCRIBED AND SWORN TO BEFORE ME

This ___________________________ day of ________________ 20 __________

_______________________________________________

Notary Public

[SEAL]

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PART XIV – CONDITIONS OF EMPLOYMENT

Due to the nature of the work required of the United States Park Police Officer, the following conditions of employment must be acknowledged by your initials in the boxes to the left of each statement and signature below.

(Initial in Box)

You must attend and successfully complete a 17-week police academy at the Federal Law Enforcement Training Center in Glynco, GA.

You must be willing to relocate if necessary to locations around the United States, including but not limited to California, New York, and Washington, D.C.

You must be willing to work shift work, weekends, holidays, and unscheduled overtime.

You must be willing to maintain required physical fitness standards throughout your career as a sworn officer.

NOTE: We will consider requests for reasonable accommodation for disability or religious reasons under the applicable legal standards. This includes determining whether providing the accommodation would pose an undue hardship.

I hereby understand and accept the conditions of employment listed above.

Applicant’s Name (Print)

Applicant’s Name (Signature)	Date


Forms Reviewer (Signature)	Date

NOTICES

PRIVACY ACT STATEMENT

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing Federal Investigative forms.

Authority: The authority to collect information on the attached form is derived from one or more of the following:

Title 5, Code of Federal Regulations, section 5.2; Title 5, United States Code, sections 1303, 1304, and 3301; sections 8(b), 8(c), and 9(c) of Executive Order 10450; Title 42, United States Code, section 2455; and Title 22, United States Code, sections 1434 and 2585.

Purposes and Uses: The information you supply will be used principally as a basis for an investigation to determine your qualification for employment purposes. As part of such an investigation, the Standard Form 87 (Fingerprint Chart) will be sent to the Federal Bureau of Investigation and may be retained there. This information and information developed through investigation may be furnished to designated officers and employees of agencies and departments of the Federal Government for employment purposes, including security clearance determination, an access determination, an evaluation of qualifications, and loyalty to the U.S. Government, and a determination regarding qualifications to perform a contractual service to the Federal Government. The information may also be disclosed to any agency of the Federal Government having a working relationship with regard to Office of Personnel Management activities, to the intelligence agencies of the Federal Government, or to others having reasons as published in the Federal Register.

Effects of Nondisclosure: The Personal Qualification Statement requests specific information. It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Under 5 U.S.C. 8315, a false answer to questions relating to membership in the Communist Party, U.S.A., or other communist or fascist organizations could deprive you of your right to an annuity when you reach retirement age. Deliberately and materially making false or fraudulent statements on this form will be grounds for not hiring you or for firing you after you begin work. In addition, these violations will become part of your permanent record for future employment.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the determination of your pre-employment qualifications. The authority for soliciting and verifying your SSN is Executive Order 9397. The SSN is used as an identifier throughout your Federal career from the time of application through retirement. It will be used primarily to identify your records with the Office of Personnel Management and other Federal agencies in connection with lawful requests for information about you from former employers, educational institutions, and financial or other organizations. The information gathered through the use of the SSN will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of system of records. The SSN also will be used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.

PAPERWORK REDUCTION ACT STATEMENT

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) as part of the pre-employment qualification’s phase of the application process to help us determine your qualifications for the position of a United States Park Police Officer. Your response is required to obtain or retain a benefit; however, failure to provide the requested information may prevent or delay the determination of your pre-employment qualifications, adversely affecting your consideration for appointment as a United States Park Police Officer. The OMB Control Number, 1024-0245, is currently valid. We may not collect this information and you are not required to respond unless this number is displayed.

ESTIMATED BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 3 hours 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 the burden estimate or any other aspect of this collection of information to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Dr. (MS-242), Reston, VA 20192. Do not send your completed form to this address.

RECORDS RETENTION - TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule, Information and Public Image Management (Item 9D) (N1-79-08-4))

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title	United States Park Police
File Modified	0000-00-00
File Created	2021-01-23

Form 10-2201 Personal Qualifications Statement

United States Park Police Pre-Employment Suitability Determination Process

Form 10-2201 Personal Qualifications Statement 09252017

Form 10-2201, "Personal Qualifications Statement"

OMB: 1024-0245

Table of Contents

PART XII - APPLICANT ESSAY

PART XIV – CONDITIONS OF EMPLOYMENT