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Application For Senior Administrative Law Judge OPM 1655 - Official Federal Forms
| Application For Senior Administrative Law Judge Form. This is a national form and can be used in OPM US Office Of Personnel Management . |
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United States Office of Personnel Management Form Approved: OMB No. 3206-0248 Application for Senior Administrative Law Judge Description of the Senior Administrative Law Judge (SALJ) Program: The SALJ Program allows retired Administrative Law Judges (ALJs) to be reemployed on a temporary and intermittent basis to complete hearings of one or more specified case(s) in accordance with the Administrative Procedure Act of 1946. Upon appointment, and while reemployed, the retired ALJ is referred to as a SALJ. (See 5 U.S.C. § 3323(b), and 5 CFR 930.201, et seq) Who Can Apply: Retired Federal ALJs formerly employed by the Federal Government, and currently receiving an annuity under the Civil Service Retirement System (CSRS) or the Federal Employee Retirement System (FERS). Retired ALJs are required to demonstrate through proper documentation that they possess a current license to practice law under the laws of a State, the District of Columbia, the Commonwealth of Puerto Rico, or any other territorial court established under the Constitution. If eligible, the U.S. Office of Personnel Management (OPM) will place the retired ALJs name on its SALJ Master List for referral to a hiring agency for possible reemployment. Placement on the SALJ Master List is not a guarantee of reemployment. Instructions: Type or print clearly in black or blue ink. Complete the application and Geographic Preference Statement for Senior Administrative Law Judge Applicant (OPM Form 1655-A). Submit your application and requested documentation to: Human Capital Leadership & Merit System Accountability Division, Administrative Law Judge Program, U.S. Office of Personnel Management, 1900 E Street, NW, Washington, DC 20415. 1. Name (Last, First, MI) 2. Social Security Number 3. Telephone Numbers Daytime ( ) Other ( ) 4. Address (Street, City, State, ZIP Code) 5. Email Address (if available) 6. Are you a U.S. Citizen? R No R Yes 8. Retirement Date (mm/dd/yyyy) 7. Highest Grade and Step/Level and Rate as ALJ R CSRS 9. Are you a Civil Service annuitant? CSA Claim Number: R No 10. Do you meet the licensure requirements under 5 CFR 930.201 et seq? R FERS | R Yes If yes, list the state(s) and /or jurisdiction(s) where you are currently licensed to practice law (attach proof of licensure): R Yes R No 11. Since the date of your original appointment as an If yes, in which jurisdiction: Please describe the nature and ALJ, have you ever been disciplined or cited for outcome of the proceeding (if needed, please attach a separate breach of ethics or unprofessional conduct by, or sheet to this form): been the subject of a complaint to, any court, administrative agency, bar association, disciplinary committee, or other professional group? R Yes R No 12. List your ALJ experience. If desired, attach a resume or OF-612, Optional Application for Federal Employment to this form. From (mm/yyyy) To (mm/yyyy) Title Grade/Level Employer (Agency) Location (City/State) 13. For which agencies are you interested in conducting hearings? 14. Availability to work: R Part Time 5 U.S.C. § 3323(b) 5 CFR 930.201 et seq 15. Are you willing to travel? R Yes Page 1 R Full Time R No OPM Form 1655 January 2008 American LegalNet, Inc. www.FormsWorkFlow.com United States Office of Personnel Management Form Approved: OMB No. 3206-0248 Privacy Act Statement The information on this form is collected pursuant to 5 U.S.C. § 3323(b) and 5 CFR 930.201 et seq. The primary use of the information is to determine eligibility for reemployment as a SALJ. The information may be disclosed to appropriate Federal, State, or local agencies when relevant to civil, criminal, or regulatory investigations or prosecutions; in judicial or administrative proceedings; to congressional offices; and to Federal agencies for employment or security reasons. Your Social Security Number (SSN) is requested under the authority of Executive Order 9397, which requires the SSN for the purpose of uniform, orderly administration of personnel records. Providing this information is voluntary, however, failure to provide the requested information will prevent processing of the application. We may confirm information from your records with prospective nonfederal employers concerning tenure of employment, civil service status, length of service, and date and nature of action for separation as shown on personnel action forms of specifically identified individuals. Public Burden Statement We estimate the public reporting burden for this collection will vary from 30 to 45 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering data, and completing and reviewing the information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, OPM Forms Officer, Washington, DC 20415-7900. The OMB number, 3206-0248, is currently valid. OPM may not collect this information and you are not required to respond, unless this number is displayed. Do not send completed application forms to this address. Reasonable Accommodation Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate. Applicants requiring reasonable accommodation for any part of the hiring process should contact the appointing agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis. THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER 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 reemployment as a SALJ is subject to investigation of suitability in accordance with 5 CFR 731.201 through 731.303. In addition, I understand that reemployment is subject to conflict of interest and security investigation requirements by the appointing agency. Signature Date Print Form 5 U.S.C. § 3323(b) 5 CFR 930.201 et seq Save Form Page 2 Clear Form OPM Form 1655 January 2008 American LegalNet, Inc. www.FormsWorkFlow.com
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