Please complete the following by marking yes or no for each question and sign and date the form at the bottom. This checklist will assist with processing your application and must be submitted along with your application forms. If you answer "NO" to any question, you may not qualify for the position. Any false statement or willful misrepresentation will result in disqualification; if discovered after hiring you may be subject to inquiry as well as administrative or disciplinary action up to and including dismissal.
| YES | NO | |
|---|---|---|
| 1. I am a citizen of the United States. | _____ | _____ |
| 2. All members of my immediate family (spouse, parents, siblings, children, or cohabitants) are US citizens. (Note: This is not an ‘automatic’ disqualifier but is a factor that may affect whether a clearance can be granted.) | _____ | _____ |
| 3. I have a BA/BS degree from an accredited college or university (or I will have prior to July 22, 2009). | _____ | _____ |
| 4. I understand that I must be at least 21 years old and not have reached my 37th birthday by the time of appointment. (preference eligible veterans excepted) | _____ | _____ |
| 5. I am a preference eligible veteran as defined by current law. | _____ | _____ |
| 6. I am in compliance with the Selective Service Act and I have registered as required (male applicants only). | _____ | _____ |
| 7. I am willing to carry and, if necessary, use firearms in the performance of Special Agent duties. | _____ | _____ |
| 8. I am willing to travel frequently and to live and serve anywhere overseas or in the United States. | _____ | _____ |
| 9. I have a valid U.S. driver’s license. | _____ | _____ |
| 10. If I am offered a position, I understand that I must successfully undergo a background investigation and be granted access to Top Secret/Sensitive Compartmented Information (TS/SCI). I understand I must successfully complete a medical examination and a determination of my suitability for Foreign Service employment. | _____ | _____ |
| 11. In accordance with the Lautenberg Amendment to the Gun Control Act that states a person convicted of a misdemeanor crime of domestic violence may no longer possess a firearm, I can certify I have not been convicted of any such violation and I am not otherwise prohibited from possessing firearms. | _____ | _____ |
| 12. I understand that I must successfully undergo a rigorous training program, which includes firearms qualification, physical fitness standards and tests, specialized driving tests, as well as academic subjects and that failure to pass any aspect of the training program is grounds for separation. | _____ | _____ |
Applicant's Name (printed): __________________________________________________ |
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Signature:____________________________________ Date: _______________________ |
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