OPM Form 1655 Application for Senior Administrative Law Judge

United States Office of Personnel Management

OMB No. 3206-0248
Expiration: 09/30/2027

Application for Senior Administrative Law Judge

Description of the Senior Administrative Law Judge (SALJ) Program: The SALJ Program allows retired Administrative Law
Judges (ALJs) to be reemployed on a temporary and intermittent basis to complete hearings of one or more specified case(s) in
accordance with the Administrative Procedure Act of 1946. Upon appointment, and while reemployed, the retired ALJ is
referred to as a SALJ. (See 5 U.S.C. § 3323(b), and 5 CFR 930.201, et seq)
Who Can Apply: Federal ALJs who retired from the Federal Government, and who are currently receiving a federal annuity
under the Civil Service Retirement System (CSRS) or the Federal Employee Retirement System (FERS). Retired ALJs are required
to demonstrate through proper documentation that they are licensed and authorized to practice law under the laws of a State,
the District of Columbia, the Commonwealth of Puerto Rico, or other territorial court established under the Constitution. Judicial
status is acceptable in lieu of "active" status in States that prohibit sitting judges from maintaining "active" status to practice
law. Being in "good standing" is also acceptable in lieu of "active" status in States where the licensing authority considers "good
standing" as having a current license to practice law. If eligible, the U.S. Office of Personnel Management (OPM) will place the
retired ALJs name on its SALJ Master List for referral to a hiring agency for possible reemployment. Placement on the SALJ
Master List is not a guarantee of reemployment.
Instructions: Type or print clearly in black or blue ink. Complete the application and Geographic Preference Statement for
Senior Administrative Law Judge Applicant (OPM Form 1655-A). Submit your application and requested documentation to:
Administrative Law Judge Program Office, U.S. Office of Personnel Management, 1900 E Street, NW, Washington, DC
20415, or Email to [email protected].
1. Name (Last, First, MI)

2. Last 5 Digits of SSN

3. Telephone Numbers
Daytime
Other

4. Address (Street, City, State, ZIP Code)

6. Are you a U.S. Citizen?
Yes

5. Email Address (if available)

7. Highest Grade and Step/Level and Rate as ALJ

No

8. Retirement Date (mm/dd/yyyy)

9. Are you a Civil Service annuitant?
No

Yes

CSA Claim Number:

FERS

10. Do you meet the licensure requirements described above in "Who Can Apply?"
Yes

CSRS

No

11. Since the date of your original appointment as an ALJ, have you ever been
disciplined or cited for breach of ethics or unprofessional conduct by, or been
the subject of a complaint to, any court, administrative agency, bar association,
disciplinary committee, or other professional group?
Yes
No
5 U.S.C. § 3323(b)
5 CFR 930.201 et seq

If yes, list the state(s) and /or jurisdiction(s)
where you currently meet the licensure
requirements (attach proof of licensure):

If yes, in which jurisdiction: Please describe
the nature and outcome of the proceeding (if
needed, please attach a separate sheet to this
form):

OPM Form 1655
September 2024
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United States Office of Personnel Management

OMB No. 3206-0248
Expiration: 09/30/2027

12. List your ALJ experience. If desired, attach a resume to this form.
From (mm/yyyy)

To (mm/yyyy)

Title

Grade/Level

Employer
(Agency)

Location
(City/State)

13. For which agencies are you interested in conducting hearings?
14. Availability to work: Part Time
15. Are you willing to travel? Yes

Full Time
No

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. 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

The public reporting burden to complete this information collection is estimated at 45 minutes per response, including time for
reviewing instructions, searching data sources, gathering, and maintaining the data needed, and the completing and reviewing
the collected information. 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 and expiration date. Send comments regarding this burden
estimate or any other aspect of this collection information, including suggestions for reducing this burden to the U.S. Office of
Personnel Management, ATTN: ALJ Program at [email protected]. Current information regarding this collection of
information including all background materials can be found at https:/www.reginfo.gov/public/do/PRAMain by using the search
function to enter either the title of the collection ALJ Program or the OMB Control Number 3206-0248.

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.
I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct,
complete and made in good faith. I understand that reemployment as a SALJ is subject to investigation of suitability in
accordance with 5 CFR Part 731. In addition, I understand that reemployment is subject to conflict of interest and security
investigation requirements by the appointing agency.
Signature

Date (mm/dd/yyyy)

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

OPM Form 1655
September 2024

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