Please type or print in Dark Ink and provide as detailed and complete information as possible.
Give us your complete name including appropriate prefix and suffix. For prefix use Mr., Mrs., Ms., Miss, Dr., Senator, Judge, Mayor, etc. Suffix includes Sr., Jr., III, MD, etc.
SOCIAL SECURITY NUMBER:
VETERAN: Check appropriate box.
U.S. CITIZEN: Check appropriate box.
PARTY: Check appropriate box.
Starting with the area code, provide all possible Phone Numbers including extensions.
Enter complete addresses for all applicable. If you have a non-U. S. address, use the City, State, Zip line to provide correct foreign province/state/country. Enter a Voter Registration address if different from Home address. Check the box to select where you want all correspondence sent; i.e., Home, Work or Voter Registration.
Tell us how you would describe your professional expertise/experience by using the terms provided below. You may select two categories if appropriate. Select the most descriptive terms.
Provide specifics on your educational background. Starting with the most recent, list the educational Institutions you have attended (show complete name). Select the most appropriate Degree Earned (if you did not earn a degree select "NONE"). Indicate the Year Degree was Earned (ex:'72). You can enter up to three institutions. Do not include high school.
List your employment activities beginning with the most recent. Provide the name of the Employer. Show the last position held with each employer in the Last Title/Position space. For Years of Employment give the total time you were with that employer; i.e., '75-'85.
Have you volunteered or been employed by any governmental entity? Provide here the Level of government by inputting either Federal, State or Local. From the list below, select the Area or Department that most appropriately describes the area of your involvement.
|Accounting||Health & Human Services|
|Environment/Natural Resources||Veterans Affairs|
Indicate either Paid or Volunteer. Input the Title or Position that you last held with the entity. Provide the Years you served at the entity; i.e., '77-'90.
List three references; these should be people who know you well and live in the United States. They could include a good friend, a professional associate who knows you well and someone who has worked with you in a volunteer or governance capacity. Please provide a variety of reference relationships for us. Do not list relatives.
This section is very important. Be as specific as possible.
From the list attached, select the Department, Agency or Commission in which you have an interest. You may select up to five. If you have an interest in the Executive Office of the President, select White House. If the entity in which you are interested is not listed, type in the agency or commission you wish to join.
From the list below, select the general Positions or Areas that most appropriately describes your interest. You may select up to three to indicate multiple areas of interest.
If your interests are more specific than you have been allowed to indicate above, you have an opportunity in the Specific Position field to provide the exact position for which you desire to be considered. Be as clear as possible on the position description including the applicable department, agency or commission.
Sign on the line provided.
Presidential Personnel Office
The White House
Washington, DC 20502
If you wish to, contact us at:
Fax: (202) 456-1121
Phone: (202) 456-9713
PROVIDING THIS INFORMATION AT THIS TIME IS OPTIONAL; HOWEVER YOU MAY BE ASKED LATER TO COMPLETE A PERSONAL DATA STATEMENT WHERE THIS INFORMATION IS REQUIRED. If you choose to provide the information now, mark the box indicating the appropriate response for Gender and Race. Provide Spouse Name in the space provided.