FR 28 Application for Employment

Application for Employment
Board of Governors
of the Federal Reserve System
Washington, DC 20551

Are you a United States Citizen?

Yes

OMB No: 7100-0181
Approval expires October 31, 2017
Page 1 of 5

An equal opportunity employer

No

Full Name (First, Middle, Last)

Previous Names (if any)

Position Title

Application Date

Date Available

MM/DD/YYYY

MM/DD/YYYY

Announcement Number Willingness to Travel (Up to...)
Yes, 75% of the Time
Yes, 100% of the Time

No
Yes, 25% of the Time
Yes, 50% of the Time
How did you first learn about this job opportunity?
Address

Contact Information

Number and Street

Home Phone

City / Town
Zip / Postal Code

State / Province
Country

Work Phone

Primary Phone Number:

Home

Cell Phone

Cell

Work

E-mail Address

Rehabilitation Act

The Board complies with the Rehabilitation Act of 1973, as amended, and provides job applicants with disabilities reasonable accommodations to
assist them in applying for jobs at the Board. If you have a disability and would like to request an accommodation in order to apply for a job at the
Board, please call 202-452-3880 or e-mail [email protected].

Equal Opportunity Employer

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment on the basis of race, color,
religion, sex, sexual orientation, gender identity, national origin, age, disability, genetic information, or application, membership, or service in the
uniformed services

Privacy

You may review the Federal Reserve Board’s Privacy Act Notice at http://www.federalreserve.gov/careers/pdf/fr1273.pdf.

Paperwork Reduction Act

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. 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. This application for
employment is authorized by law (12 U.S.C. §§ 244 and 248(l)). 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, NW, Washington, DC 20551; and to the Office of Management and Budget, Paperwork Reduction Project (7100-0181), Washington, DC 20503.
FR 28

11/2016

Education and Training

List all educational experiences, including high school, college (attendance or degree from accredited schools), graduate school
(attendance or degree from accredited schools), and technical or other training schools. You must specifiy at least one education entry.
Institution

Program

Name

Major

Street Address

Minor

City / Town

Type of Degree

State / Province

Did you graduate?...................................

Zip / Postal Code

Country

Year Graduated

Institution

Program

Name

Major

Street Address

Minor

City / Town

Type of Degree

State / Province

Year Graduated

Institution

Program

Name

Major

Street Address

Minor

City / Town

Type of Degree

Year Graduated

Institution

Program

Name

Major

Street Address

Minor

City / Town

Type of Degree

Start Date (MM/YYYY)

Country

Year Graduated

Start Date (MM/YYYY)

No

Yes

No

End Date (MM/YYYY)

Did you graduate?...................................

Zip / Postal Code

Yes

End Date (MM/YYYY)

Did you graduate?...................................

Zip / Postal Code

Country

State / Province

Start Date (MM/YYYY)

No

End Date (MM/YYYY)

Did you graduate?...................................

Zip / Postal Code

Country

State / Province

Start Date (MM/YYYY)

Yes

Yes

No

End Date (MM/YYYY)

Certifications/Professional Licenses

Enter the most relevant certification/professional license first. Do not list expired certifications/professional licenses.
Certification/Professional License

FR 28

Issuing Organization

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11/2016

Employment Record

Please list all employment, including periods of unemployment. You must specify at least one work experience entry.
List current or most recent job first.
1. Name during employment:
Position Title

Federal Classification Grade

No. of Hours Worked Per Week

Start Date

End Date

MM/YYYY

MM/YYYY

Employer

Salary or Earnings

Name

Base....................................... $

$

Supplemental ........................ $

$

Street Address

Current/End

Supervisor

City / Town
Zip / Postal Code

Start

State / Province
Country

Name

Phone Number

May we contact this supervisor?

Brief description of duties and responsibilities

Yes

No

Reason for desiring to change employment

2. Name during employment:
Position Title

Federal Classification Grade

No. of Hours Worked Per Week

Start Date

End Date

MM/YYYY

MM/YYYY

Employer

Salary or Earnings

Name

Base....................................... $

$

Supplemental ........................ $

$

Street Address

Current/End

Supervisor

City / Town
Zip / Postal Code

Start

State / Province
Country

Name

Phone Number

May we contact this supervisor?

Brief description of duties and responsibilities

Yes

No

Reason for desiring to change employment

3. Name during employment:
Position Title

Federal Classification Grade

No. of Hours Worked Per Week

Start Date

End Date

MM/YYYY

MM/YYYY

Employer

Salary or Earnings

Name

Base....................................... $

$

Supplemental ........................ $

$

Street Address
State / Province
Country

Brief description of duties and responsibilities

FR 28

Current/End

Supervisor

City / Town
Zip / Postal Code

Start

Name

May we contact this supervisor?

Phone Number

Yes

No

Reason for desiring to change employment

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Employment Record (Continued)

4. Name during employment:
Position Title

Federal Classification Grade

No. of Hours Worked Per Week

Start Date

End Date

MM/YYYY

MM/YYYY

Employer

Salary or Earnings

Name

Base....................................... $

$

Supplemental ........................ $

$

Street Address

Current/End

Supervisor

City / Town
Zip / Postal Code

Start

State / Province
Country

Name

Phone Number

May we contact this supervisor?

Brief description of duties and responsibilities

Yes

No

Reason for desiring to change employment

5. Name during employment:
Position Title

Federal Classification Grade

No. of Hours Worked Per Week

Start Date

End Date

MM/YYYY

MM/YYYY

Employer

Salary or Earnings

Name

Base....................................... $

$

Supplemental ........................ $

$

Street Address

Current/End

Supervisor

City / Town
Zip / Postal Code

Start

State / Province
Country

Name

Phone Number

May we contact this supervisor?

Brief description of duties and responsibilities

Yes

No

Reason for desiring to change employment

6. Name during employment:
Position Title

Federal Classification Grade

No. of Hours Worked Per Week

Start Date

End Date

MM/YYYY

MM/YYYY

Employer

Salary or Earnings

Name

Base....................................... $

$

Supplemental ........................ $

$

Street Address
State / Province
Country

Brief description of duties and responsibilities

FR 28

Current/End

Supervisor

City / Town
Zip / Postal Code

Start

Name

May we contact this supervisor?

Phone Number

Yes

No

Reason for desiring to change employment

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11/2016

References

List three persons who are not related to you but who have definite knowledge of your capability to perforn the duties of the position for which
you are applying. Do not repeat the names of supervisors listed under “Employment Record.” You must specify three reference entries.
First Name

Last Name

Email

Phone Number

General Questions

Complete all the questions below. If you answer “Yes” to any of these questions, explain fully below each question. 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.
1. Are you delinquent on any federal debt (e.g., federal taxes, loans, overpayment of benefits, defaults on guaranteed
or insured loans)? ....................................................................................................................................................................

Yes

No

2. Are you now under charges, on trial, or awaiting trial on criminal charges for any violation of law (such as a misdemeanor or a felony)? ..........................................................................................................................................................................................

Yes

No

3. Are you related to any officer or director of a financial and/or banking institution? ........................................................

Yes

No

4. Are you related to or acquainted with any employee of the Board of Governors of the Federal Reserve System? ......

Yes

No

5. 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? .........................................................................................................

Yes

No

6. 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? ............................

Yes

No

7. Do you, your spouse, or your minor children own shares of a financial services sector mutual fund or ETF?.............

Yes

No

8. During the last seven years, have you ever been convicted of a crime, imprisoned, on probation, or on parole? .........

Yes

No

9. 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? ...................................................................................................

Yes

No

10. Have you experienced any periods of unemployment?........................................................................................................

Yes

No

(You must include felonies, firearms or explosives violations, military court-martials, misdemeanors, and any other matter that was
resolved by a plea of nolo contendere (no contest). However (you may omit: (a) minor traffic violations that resulted in a fine of
$300 or less; (b) any offense committed before your 16th birthday; (c) any offense committed before your 18th birthday that was
finally adjudicated in a juvenile court or under a youth offender law; and (d) 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.

By signing below, I understand that I am certifying that, to the best of my knowledge, the information I am providing is accurate and complete.
I understand that false or fraudulent information may be grounds for not hiring me or for firing me after I begin work, and may be punishable by
fine or imprisonment. Any intentionally false statement on this form or willful misrepresentation relative thereto is a violation of law punishable by
a fine of not more than $10,000 or imprisonment of not more than 5 years, or both (18 U.S.C. § 1001).
Signature:
FR 28

Date:

MM/DD/YYYY

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11/2016