ࡱ> Y[X !Lbjbj .NeeaPP84*t&ld4%%%%%%%$'*`&9"&?:&q!q!q!F%q!%q!q!$[%\~v/%%P&0&E%+q+,[%+[%l+dq!Y\+++&& |+++&++++++++++P p: Federal Deposit Insurance Corporation APPLICANT BACKGROUND QUESTIONNAIRE ౦Ϸ (౦Ϸ) 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 ౦Ϸ 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 ౦Ϸ 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 Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th 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 Date of BirthSex FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Male  FORMCHECKBOX  FemaleTitle, Grade, Announcement Number of Position for which you are applying.  FORMTEXT      Do you have a disability?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If you checked Yes above, is your disability one of the *targeted disabilities listed below?  FORMCHECKBOX  Yes  FORMCHECKBOX  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.)  FORMCHECKBOX  Yes  FORMCHECKBOX  No RACE SELF-IDENTIFICATION Please read the descriptions, then mark one or more races to indicate what you consider yourself to be.  FORMCHECKBOX  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.  FORMCHECKBOX  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.  FORMCHECKBOX  C. Black or African American A person having origins in any of the black racial groups of Africa.  FORMCHECKBOX  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.  FORMCHECKBOX  E. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.PRIVACY ACT STATEMENTCollection 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 ౦Ϸ 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. ౦Ϸ 2100/14 (10-05)     OMB NUMBER: 3064-0138 &IJ x y ' ( MO()TUV`a  $&(˶m\!jhpVCJOJQJU&jhpVCJOJQJUmHnHu!jhpVCJOJQJUjhpVCJOJQJUhpV5CJOJQJhpV6CJOJQJhpVCJOJQJhpVCJH*OJQJhpV5CJOJQJhpVCJOJQJhpVCJOJQJhpVCJOJQJhpV5CJOJQJ$&IJ x y ' (  $$Ifa$ $$Ifa$$dN`'()@ABPT$If^kd$$Ifl4 s>+L,0 4 la^f4 TU6^gaaaa$Ifkd$$Ifl4\9!>+  3  04 la^f4(2468LNPZ\^`|~jlnԳԨ|ԨԨkԨ!jhpVCJOJQJU*jh hpV5CJOJQJU*jh hpV5CJOJQJUhpV5CJOJQJjhpV5CJOJQJU!jhpVCJOJQJUhpVCJOJQJjhpVCJOJQJU&jhpVCJOJQJUmHnHu%fhjgaaa$Ifkd$$Ifl4\9!>+ 3  04 la^f4jl;^kd$$Ifl4p>+L,04 la^f4$If^kd$$Ifl4$>+L,04 la^f4xyӿӫӗӍ|qf|V|JjhpVOJQJUht:hpV5CJOJQJaJhpV5CJOJQJhpV5CJOJQJhpV5OJQJhpVOJQJhpVCJ OJQJ'jh hpVCJOJQJU'jh hpVCJOJQJU'jh hpVCJOJQJUhpVCJOJQJjhpVCJOJQJU'jh hpVCJOJQJU$If $$Ifa$^kd]$$Ifl4>+L,04 la^f4  $If:;<=KLMOrst!#$%345?@siiWi#j+ h hpVOJQJUhpVCJ OJQJ'j h hpVCJOJQJUhpVCJOJQJjhpVCJOJQJUhpVCJOJQJhpV5CJOJQJhpV5CJOJQJhpV5OJQJ#jv h hpVOJQJUjhpVOJQJU#j h hpVOJQJUhpVOJQJ":$If $$Ifa$^kd $$Ifl4>+L,04 la^f4:;<st "z____$  @@$If]^`a$ $  @$Ifa$$  @$If]^`a$^kd $$Ifl4X>+L,04 la^f4"#$@A6hRRR  @$If]^`  @@$If]^` $  @$Ifa$qkd $$Ifl4*0>+.04 la^f4@A456789GHIKghi`abcqrsu~!څ{qhpVCJOJQJhpVCJOJQJhpV5CJOJQJ'j@h hpVCJOJQJU'j9h hpVCJOJQJU'j2 h hpVCJOJQJUjhpVCJOJQJUhpVCJ OJQJhpVCJOJQJhpVOJQJhpVCJOJQJ,678hiee$  @@$If]^`a$ $  @$Ifa$qkd $$Ifl4*0>+.04 la^f4E`~~qVVV$  @@$If]^`a$ $ d@$Ifa$$ @@$Ifa$qkd $$Ifl4V0>+.04 la^f4`abeee$  @@$If]^`a$ $  @$Ifa$qkd$$Ifl470>+.04 la^f4([kdG$$Ifl >+L, 0 4 la^ $$Ifa$qkd$$Ifl470>+.04 la^f4!!!!!!!!!!!!LL L!L  !T<@] !TX @@  @^`$^a$!!!!!!!!!!!!!!!!!LLLLLL L!LµhxxhV|CJOJQJUh%CJOJQJhChxxCJOJQJhxxCJOJQJh,jh,UhpVCJOJQJ&jhpVCJOJQJUmHnHuhpVCJOJQJEXPIRATION DATE: 02/28/2019 ,&P/ =!"#$% $$If^!vh#vL,:V l4s0 5L,/ 4a^f4 $$If^!vh#v#v #v3 #v :V l4055 53 5 / /  / /  / /  / 4a^f4vDText11D Text12 ###-##-####vDText13tDeCheck3tDeCheck4$$If^!vh#v#v #v3 #v :V l40,55 53 5 / /  / /  / / 4a^f4$$If^!vh#vL,:V l4$05L,/ 4a^f4vDText14$$If^!vh#vL,:V l4p0,5L,/  4a^f4tDeCheck1tDeCheck2hDehDe$$If^!vh#vL,:V l40,5L,/  / 4a^f4tDeCheck6tDeCheck7$$If^!vh#vL,:V l40,5L,/ 4a^f4$$If^!vh#vL,:V l4X0,5L,/ 4a^f4tDeCheck5$$If^!vh#v#v.:V l4*055./ 4a^f4hDe$$If^!vh#v#v.:V l4*055./ 4a^f4hDe$$If^!vh#v#v.:V l4V055./ 4a^f4hDe$$If^!vh#v#v.:V l47055./ 4a^f4hDe$$If^!vh#v#v.:V l47055./ 4a^f4$$If^!vh#vL,:V l0 ,5L,/  4a^^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8 Normal_HmH sH tH B@B  Heading 1$$@&a$5CJD@D  Heading 2$$@&a$ 5>*CJ@@@  Heading 3$$@&a$5>*DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4>@4 Title$a$5CJ2B@2 Body TextCJ:J@: Subtitle$a$5CJ4@"4 Header  !4 24 Footer  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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(!xx 0FDIC 2100/14, Applicant Background Questionnaire-2100 - Recruitment, Assignment and Separation$Application Background Questionnaire Linda KirtonWest, Linda D.,        Oh+'0 ,\|     4౦Ϸ 2100/14, Applicant Background Questionnaire02100 - Recruitment, Assignment and SeparationLinda Kirton(Application Background Questionnaire౦Ϸ.gov and ౦Ϸ.netNormalWest, Linda D.6Microsoft Office Word@ @p@"yK@n ~|՜.+,D՜.+,L px  -RIMU Federal Deposit Insurance Cor+  1౦Ϸ 2100/14, Applicant Background Questionnaire TitleL@(@_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnce4=,Forms for Placement outside the FirewallLWest@౦Ϸ.govWest, Linda D.  !"#$%&')*+,-./023456789:;<=>?@ABCDEFGIJKLMNOQRSTUVWZRoot Entry Fd~\Data (1Table1*,WordDocument.NSummaryInformation(HDocumentSummaryInformation8PCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q