AO 78 (12/21)FEDERAL JUDICIAL BRANCH

APPLICATION FOR EMPLOYMENT

If you need additional space, continue under “Remarks” listing item number

1. Name (Last, First, Middle Initial) 2. Phone Number

3. Present Address (Street, City, State, Zip)

4. Email Address

5. Other Names Previously Used for Employment Purposes 6. Date of Birth (complete only for law enforcement positions) GENERAL

7. Are you a U.S. Citizen? YES NO If no, give the Country of your citizenship

8. a. Were you ever a federal civilian employee? YES NO If yes, give highest civilian grade: / / Pay Plan Grade Step

b. Are you receiving a federal civilian annuity payment? YES NO

c. Are you receiving federal severance pay? YES NO If yes, give former agency contact/telephone:

d. Have you received a federal separation incentive payment YES NO If yes, state mo/yr received and former agency contact/telephone: in the past 5 years?  

9. Do you have any relatives who are Judges, Officers or YES NO If yes, give their names, positions, and relationships to you. employees of the United States Courts?

10. Have you ever served on active duty with the military? YES NO (If selected, you will need to provide your DD-214 (copy 4), Certificate of Release or Discharge from Active Duty, so that your service may be  

verified and credited)  

BACKGROUND INFORMATION 

11. During the last 5 years, have you been fired from any job for

YES NO If yes, provide in Section 17 the date, explanation of problem, reason for  

any reason, did you quit after being told that you would be fired,

leaving, and employer’s name/address.

did you leave any job by mutual agreement because of specific  

problems, or were you debarred from Federal employment by the

Office of Personnel Management or any other Federal agency?

12. Are you delinquent on any Federal debt? (Include  

YES NO If yes, provide in Section 17 the type, length, and amount of  

delinquencies arising from Federal taxes, loans, overpayment of

delinquency/default, and steps being taken to correct the error/repay the debt.

benefits, and other debts to the U.S. Government, plus defaults of

Federally guaranteed or insured loans (e.g., student loan, home  

mortgage loan)).

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EDUCATION 

13. a. Do you have a high school diploma or G.E.D. equivalent? YES NO

b. Name and location of colleges or universities

attended (including law schools)

Dates Attended

Credit Hours

Q uarter Semester

Degree

Date Received

Grade Point

Average and/or

scholastic standing

14. c. Other schools or training attended (list name/location of school, dates attended, subject studied, certificates received, and other pertinent data):

JOB RELATED SKILLS, AWARDS, SPECIAL ACCOMPLISHMENTS 

15. List any skills (e.g., language, computer, keyboarding speed), honors, awards, or special accomplishments (e.g., memberships in professional/honor societies, leadership activities, performance awards) that you believe are relevant to your ability to perform the job:  

APPLICANTS FOR LEGAL POSITIONS 

16. a. Are you admitted to the Bar? YES NO If yes, list the Bar(s) to which admitted and date(s) of admission. If no, skip to  18b.

 Is your Bar membership ACTIVE INACTIVE

b. What was your scholastic standing in law school? UPPER ½ UPPER ⅓ UPPER ¼

YES No

c. Were you a member of an editorial board of law review or a

moot court participant?

17. REMARKS (Use this space for continuation of answers. List the item number being explained.)

Page 3 of 5  

WORK EXPERIENCE

(Start with your present position and work back 10 years. Include any military service. Use additional page if necessary.)

A

Dates of Employment (mm/dd/yyyy)

From: To:

Number of hours  

worked per week:

Exact Title of Your Position

Salary or Earnings

Starting $ Per

Final $ Per

Pay Plan/Grade

(If in federal Service)

Place of Employment

City  

State

Name and Title of Immediate Supervisor

Business Telephone: (Area Code and Phone Number)

Name and Address of Employer (firm, organization, etc.)

Reason for Leaving

 

Description of Work

B

Dates of Employment (mm/dd/yyyy)

From: To:

Number of hours  

worked per week:

Exact Title of Your Position

Salary or Earnings

Starting $ Per

Final $ Per

Pay Plan/Grade

(If in federal Service)

Place of Employment

City  

State

Name and Title of Immediate Supervisor

Business Telephone: (Area Code and Phone Number)

Name and Address of Employer (firm, organization, etc.)

Reason for Leaving

 

Description of Work

Page 4 of 5  

C

Dates of Employment (mm/dd/yyyy)

From: To:

Number of hours  

worked per week:

Exact Title of Your Position

Salary or Earnings

Starting $ Per

Final $ Per

Pay Plan/Grade

(If in federal Service)

Place of Employment

City  

State

Name and Title of Immediate Supervisor

Business Telephone: (Area Code and Phone Number)

Name and Address of Employer (firm, organization, etc.)

Reason for Leaving

 

Description of Work

D

Dates of Employment (mm/dd/yyyy)

From: To:

Number of hours  

worked per week:

Exact Title of Your Position

 

Salary or Earnings

Starting $ Per

Final $ Per

Pay Plan/Grade

(If in federal Service)  

Place of Employment

City

State

Name and Title of Immediate Supervisor

Business Telephone: (Area Code and Phone Number)

Name and Address of Employer (firm, organization, etc.)

Reason for Leaving

 

Description of Work

Page 5 of 5  

OPTIONAL BACKGROUND INFORMATION – RESPOND ONLY IF REQUIRED BY THE VACANCY ANNOUNCEMENT 

Answer questions 18, 19, and 20, only if required by the vacancy announcement. Your answers should include convictions resulting from a plea of nolo contendere (no  contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if  finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction  for which the record was expunged under Federal or state law.

18. During the last 7 years, have you been convicted, imprisoned, on  probation, or on parole? (Include felonies, firearms or explosives  violations, misdemeanors, and all other offenses)

19. Have you been convicted by a military court-martial in the  past 7 years?  

YES NO If yes, provide in Section 21 the date, explanation of violation, place of  occurrence, and name/address of police dept or court.

YES NO If yes, provide in Section 21 the date, explanation of violation, place of  occurrence, and name/address of military authority or court.  

20. Are you now under charges for any violation of law? YES NO If yes, provide in Section 21 the date, explanation of violation, place of  occurrence, and name/address of police dept or court.

21. REMARKS (Use this space for continuation of answers. List the item number being explained.) 

APPLICANT CERTIFICATION

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 false or fraudulent information on or attached to this application may be grounds for not hiring me, or firing me after I begin work,  and may be punishable by fine or imprisonment. I understand that any information I give may be investigated.

SIGNATURE DATE SIGNED