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INSTRUCTIONS: This form is to be completed in triplicate and is to be submitted by the servicing personnel office along with
three copies of the employee's OF-612, Optional Application for Federal Employment, or resume to: Director, Personnel Staff,
U.S. Department of Justice, 1331 Pennsylvania Avenue, N.W., Suite 1110, Washington, DC 20530, Attention: RPL Office.
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Section 1 - Identification
| Name:
Home Address:
Home Phone:
Type of appointment currently or last held (Please check):
Career Excepted
Career Cond. Temporary
Tour of Duty in current or last position held (Please check):
Full-time: Part-time:
Veteran: Non veteran: |
Current or last position:
Title:
Series and grade:
Current or last employer:
Org. name:
Org address:
Org. phone no.:
Separation date:
Tenure Group: |
For employee: Please describe in twenty-five (25) words or less what you consider to be your employment strength and special
skills:
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Section II - Job Availability
Please indicate below the types of positions, series, and grades for which you are qualified and will accept referrals. Your personnel office
must certify that you are qualified for the positions, series, and grade level you select in addition to positions at the same
representative rate and work schedule as the position from which you were separated.
Please indicate if you are available for the following types of employment: (Please check)
Full-time: Part-time: Temporary (3 to 12 months):
You are entitled to be considered for positions in the commuting area in which you were separated.
FOR EMPLOYEE: I certify that I am available for the positions, series, and grades of employment I have selected above. I
understand that if I am offered a position for which I am registered and subsequently decline, or I decline an interview, I will be removed from further RPL
consideration for all positions, regardless of location, at or below the grade level of the position I decline. I further understand that any
or all of the information contained herein can be made available to prospective employers both within and outside the Department.
This information is requested pursuant to 5 CFR 330. I understand that if I fail to permit release of this information, I will not be given
consideration for the program.
(Employee Signature) (Date) |
FOR EMPLOYEE'S SERVICING PERSONNEL OFFICER: I certify that the employee is qualified for the types of
positions, series, and grades for which registered. I further certify that the information supplied as to employee's current or last
appointment and tour of duty is correct. The employee's current status is:
Separated by RIF
Under Specific Notice of Separation by RIF
In a position targeted for abolishment within 90 days.
Recovered from Compensable Injury
(Personnel Officer Signature) (Date) |
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