Form OPM 1655A OPM 1655A Geographic Peference Statement for Senior Adminstrative

United States Office of Personnel Management

Form Approved:
OMB No. 3206-0248

Geographic Preference Statement for
Senior Administrative Law Judge Applicant
Instructions: Type or print clearly in black or blue ink. In the boxes below, indicate with an "X" each location
where you would be available to serve as a Senior Administrative Law Judge (SALJ). You may show availability
for any locations listed. You will be considered only for positions where you have indicated your availability.
Submit form to: Administrative Law Judge Program Office, U.S. Office of Personnel Management, 1900 E
Street, NW, Washington, DC 20415.
Name (Last, First, MI)
Address (Street, City, State, Zip Code)

All Locations
Check this box only if
you are interested in
all locations.

Idaho

New York

Illinois

North Carolina

Indiana

North Dakota

Iowa

Ohio

Kansas

Oklahoma

Kentucky

Oregon

Louisiana

Pennsylvania

Maine

Puerto Rico

Maryland

Rhode Island

Alabama

Massachusetts

South Carolina

Alaska

Michigan

South Dakota

Arizona

Minnesota

Tennessee

Arkansas

Mississippi

Texas

California

Missouri

Utah

Colorado

Montana

Vermont

Connecticut

Nebraska

Virginia

Delaware

Nevada

Washington

Florida

New Hampshire

West Virginia

Georgia

New Jersey

Wisconsin

Hawaii

New Mexico

Wyoming

All Locations
Washington, DC,
Metro Area
(Rockville, MD;

Alexandria, VA;
Arlington, VA;
Falls Church, VA;
Washington, DC)

5 U.S.C. § 3323(b)
5 CFR 930.201 et seq

OPM Form 1655-A
September 2024

United States Office of Personnel Management

Form Approved:
OMB No. 3206-0248

Privacy Act Statement
The information on this form is collected pursuant to 5 U.S.C. § 3323(b) and 5 CFR 930.201 et seq.
The primary use of the information is to determine eligibility for reemployment as a SALJ. The
information may be disclosed to appropriate Federal, State, or local agencies when relevant to civil,
criminal, or regulatory investigations or prosecutions; in judicial or administrative proceedings; to
congressional offices; and to Federal agencies for employment or security reasons. The routine
uses that may be made of this information are in the system notice for the OPM/Central-6
system of records under the Privacy Act, published at
https://www.govinfo.gov/content/pkg/
PAI-2021-OPM-interim/xml/PAI-2021-OPM-interim.xml#routine.
Your Social Security Number
(SSN) is requested under the authority of Executive Order 9397, which requires the SSN for the
purpose of uniform, orderly administration of personnel records. Providing this information is
voluntary, however, failure to provide the requested information will prevent processing of the
application. The effect of not providing all other requested information will result in us not being able
to process your application.

Public Burden Statement
We estimate the public reporting burden for this collection will vary from 15 to 25 minutes, including time for
reviewing instructions, searching existing data sources, gathering data, and completing and reviewing the
information. Send comments regarding the burden estimate or any other aspect of the collection of information,
including suggestions for reducing this burden, to the U.S. Office of Personnel Management (OPM), Administrative
Law Judge Program Office, ALJ Program Manager, Washington, DC 20415-7900. The OMB number, 3206-0248,
is currently valid. OPM may not collect this information and you are not required to respond, unless this number is
displayed. Do not send completed application forms to this address.

Reasonable Accommodation
Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate.
Applicants requiring reasonable accommodation for any part of the hiring process should contact the appointing
agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis.

THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER
Signature

5 U.S.C. § 3323(b)
5 CFR 930.201 et seq

Date

OPM Form 1655-A
September 2024