District of Columbia Government Employment Application (DC2000)

DISTRICT OF COLUMBIA GOVERNMENT
EMPLOYMENT APPLICATION (DC2000)
Please answer the questions and complete all required fields on this application. In addition, please respond to all of the
ranking factors listed in the vacancy announcement. Finally, if you are claiming residency preference for a career
service or management supervisory service position, please complete the residency preference form.
1. POSITION VACANCY INFORMATION
Position Title
Vacancy Announcement Number
2. PERSONAL DATA
Last Name
First Name
Middle Name
Street Address
City
Apt #
State
Zip Code
Ward
Telephone (including area code):
Home
Business
Social Security Number
Other names ever used
Date of Birth
A copy of this form will be emailed to you. It must be printed, signed and mailed
to the name and address found at the end of the vacancy announcement.
Email
3. D.C. EMPLOYMENT HISTORY AND AVAILABILITY
a. Are you now or were you ever employed by the District of Columbia Government?
b. Mark below each type of current or previous D.C. government appointment. Check all applicable boxes.
Temporary
Term
Permanent
Career
Excepted Service
Executive Service
Management Supervisory Service
Legal Service
Other
c. List highest grade, classification series and step attained: Grade
When can you start work?
Series
Step
Lowest pay or grade you will accept
4. RESIDENCY
a. Are you claiming a residency preference for the position indicated above?
Yes
No
b. I understand the residency preference requirements (found at the end of this document).
Yes
No
c. If the position you are applying for above is in the Career Service, Management Supervisory Service, or
Legal Service, excluding the Senior Executive Attorney Services, are you claiming a residence
preference? (If you claim residency preference, you must complete the Residency Preference for
Employment form, DC-2000RP).
Yes
No
d. If the position you are applying for above is in the Excepted Service, Executive Service, or Senior
Executive Attorney Service, do you acknowledge and understand that, if selected, you must be a
domiciliary of the District of Columbia at the time of the appointment or within 180 days of the
appointment date, and maintain District domicile for the duration of the appointment?
Yes
No
5. MILITARY SERVICE AND VETERANS PREFERENCE
Veterans preference is granted by law to disabled veterans, to veterans who served on active duty in certain time periods
or military operations, and, under certain conditions, to the spouses, widows, widowers, or mothers of deceased or
disabled veterans.
Have you ever served on active duty in the United States Armed Forces?
Yes
No
Yes
No
(Answer "NO" if your only active duty was for training, including basic training, in the Reserves and
National Guard.)
Did you or will you retire at or above the rank of Major or Lieutenant Commander?
(If "YES," you are not eligible for veterans preference unless your retirement is based upon a serviceconnected disability.)
From
To
Dates of Active Duty Service (Month/Day/Year)
Character of Separation
Campaign or Expeditionary Medals Received
Preference claimed:
5-point preference
(Please check one. You must show proof when hired.)
Separation Date
10-point preference
None
6. EDUCATION
a. High School
Indicate highest grade completed:
Name and Address of School
Did you graduate?
Yes
Zip Code
No
Attended From
If no, have you received a GED high school equivalency?
Yes
To
(month/year)
(month/year)
b. Colleges and Universities
School 1
Indicate highest degree(s) obtained (e.g., A.A., B.S):
Name and Address of College or University
Zip Code
Major
Minor
Major Semester Credit Hours
Attended From
OR Major Quarter Credit Hours
To
(month/year)
(month/year)
School 2
Indicate highest degree(s) obtained (e.g., A.A., B.S):
Name and Address of College or University
Zip Code
Major
Minor
Major Semester Credit Hours
Attended From
OR Major Quarter Credit Hours
To
(month/year)
(month/year)
No
7. TRAINING
List relevant training, licenses or skills (e.g., sign language). Include schools attended, addresses, certificates or
degrees awarded, dates attended, number of credit hours, and major/minor field or subjects studied.
8. LANGUAGE CAPABILITIES
List the languages you speak, read and write
Language
Read
Speak
Write
9. WORK EXPERIENCE
List paid or unpaid work experience relevant to the position for which you are applying.
No Work Experience
PRESENT OR MOST RELEVANT POSITION:
Employer's Name
Dates of Employment
(Month/Year)
Annual Salary
Address
Starting $
From
To
Final
Telephone
$
Name and Title of Supervisor
Reason for leaving
No. of Employees Supervised
If District or Federal Employment, List Series, Grade or Rank and Date of Last Promotion
Job Title and Duties, Responsibilities and Accomplishments
Average
Hours
Per Week
POSITION:
Employer's Name
Dates of Employment
(Month/Year)
Annual Salary
Address
Average
Hours
Per Week
Starting $
From
To
Final
Telephone
$
Name and Title of Supervisor
No. of Employees Supervised
Reason for leaving
If District or Federal Employment, List Series, Grade or Rank and Date of Last Promotion
Job Title and Duties, Responsibilities and Accomplishments
POSITION:
Employer's Name
Dates of Employment
(Month/Year)
Annual Salary
Address
Starting $
From
To
Final
Telephone
$
Name and Title of Supervisor
Reason for leaving
No. of Employees Supervised
If District or Federal Employment, List Series, Grade or Rank and Date of Last Promotion
Job Title and Duties, Responsibilities and Accomplishments
Average
Hours
Per Week
POSITION:
Employer's Name
Dates of Employment
(Month/Year)
Annual Salary
Address
Average
Hours
Per Week
Starting $
From
To
Final
Telephone
$
Name and Title of Supervisor
No. of Employees Supervised
Reason for leaving
If District or Federal Employment, List Series, Grade or Rank and Date of Last Promotion
Job Title and Duties, Responsibilities and Accomplishments
POSITION:
Employer's Name
Dates of Employment
(Month/Year)
Annual Salary
Address
Starting $
From
To
Final
Telephone
$
Name and Title of Supervisor
Reason for leaving
No. of Employees Supervised
If District or Federal Employment, List Series, Grade or Rank and Date of Last Promotion
Job Title and Duties, Responsibilities and Accomplishments
Average
Hours
Per Week
10. BACKGROUND INFORMATION - You must answer each question in this section before we can
process your application.
When answering item "a," you may omit: 1) traffic fines; 2) any violation of law committed before your 18th birthday, if
finally decided in juvenile court or under a youth offender law; 3) any conviction set aside under the Federal Youth
Corrections Act or similar state law; and 4) any conviction whose record was expunged under federal, state, or local
law. We will consider the date, facts, and circumstances of each event you list. In most cases, you can still be
considered for District jobs.
a. During the past 10 years have you been: 1) convicted of or forfeited collateral for any felony; or
2) convicted by a court-martial?
Yes
No
A felony is defined as any violation of law punishable by imprisonment of longer than one year, except for a violation
called a misdemeanor under State, county, or local law, which is punishable by imprisonment of two years or less.
IF YOU ANSWERED "YES" TO "a," GIVE DETAILS IN THE SPACE BELOW. For each violation, write the 1) date;
2) charge; 3) place of violation; 4) court; and 5) action taken by the court.
b. Do any of your relatives work for the District of Columbia government? Include: father, mother, husband,
wife, son, daughter, brother, sister, uncle, aunt, first cousin, niece, nephew, father-in-law, mother-in-law,
son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter,
stepsister, half brother, and half sister.
Yes
No
If "YES," in the space below, write for each of these relatives their: 1) name; 2) relationship to you; and 3) agency of
the District of Columbia government in which the person works.
c. Do you receive or have you ever applied for retirement pay, pension, or other pay based on District of
Columbia government, federal civilian, or federal military service?
Yes
No
SALARY REDUCTION OF REEMPLOYED ANNUITANTS: An individual selected for employment in the District
government on or after January 1, 1980, who is receiving an annuity under any District government civilian retirement
system, shall have his or her pay reduced by the amount of annuity allocable to the period of employment as a
reemployed annuitant.
d. Are you a citizen of the United States?
Yes
No
e. Are you legally authorized to work in the United States?
Yes
No
To work for the District of Columbia government in certain public safety positions, you must be a citizen of the United
States. If selected, you will be required to submit evidence of identity and employment eligibility.
11. SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION
YOU MUST SIGN THIS APPLICATION. Read the following carefully before you sign. I understand that a false
statement on any part of my application may be grounds for not hiring me, or for firing me after I begin work (D.C.
Official Code § 1-616.51 et seq.) (2001). I understand that the making of a false statement on this form or materials
submitted with this form is punishable by criminal penalties pursuant to D.C. Official Code § 22-2405 et seq. (2001).
I understand that any information I give may be investigated as allowed by law or Mayoral order. I consent to the
release of information regarding my suitability for District of Columbia Government employment by employers,
schools, law enforcement agencies, and other individuals and organizations, to investigators, personnel staffing
specialists, and other authorized employees of the District of Columbia government. I certify that, to the best of my
knowledge and belief, all of my statements are true, correct, and complete.
Sign
Date
RANKING FACTORS
Name
Vacancy Announcement Number
The ranking factors found in the vacancy announcement will be used in the evaluation process for all positions other
than wage grade. All applicants MUST respond to the ranking factors. Please describe specific incidents of sustained
achievements from your experience that show evidence of the level at which you meet the ranking factors that have
been determined to be of importance for the position for which you are applying. You may refer to any experience,
education, training, awards, outside activities, etc. that include the degree to which you possess the job related
knowledge, skills, and abilities described in the ranking factors. The information given in response to the ranking factors
should be complete and accurate to the best of your knowledge. FAILURE TO RESPOND TO ALL RANKING
FACTORS MAY ELIMINATE YOU FROM CONSIDERATION.
Use the spaces below to respond to the ranking factors on the job vacancy announcement.
Ranking Factor 1
Ranking Factor 2
Ranking Factor 3
Ranking Factor 4
Ranking Factor 5
Ranking Factor 6
Please continue to the next page and press "Go" if you are not claiming residency preference. If you are claiming
residency preference, please complete the next page and then press "Go."
DISTRICT OF COLUMBIA GOVERNMENT
RESIDENCY PREFERENCE FOR EMPLOYMENT
NOTICE: This form is to be filled out and submitted with each application for a posi-tion in the Career
Service, Legal Service other than the Senior Executive Attorney Service, Excepted Service
(attorney positions only), or the Management Supervisory Service. Preference, if applicable, will
not be granted unless this form is completed and received at the time of application.
Name
Social Security Number
Position Applied For
Vacancy Announcement Number
CHECK ONLY ONE OF THE FOLLOWING STATEMENTS
I.
I, the undersigned, am currently a District government employee whose service began on or before December 31,
1979 and has been continuous since that date. I understand that I will not be required to submit proof of,
establish or maintain residency as a result of receiving preference.
II.
I, the undersigned, am a former employee of the U.S. Department of Health and Human Services at St.
Elizabeths Hospital who accepted employment with the District government, without a break in service, effective
October 1, 1987. My service with the District government has been continuous since that date. I understand
that I will not be required to submit proof of, establish or maintain residency as a result of receiving preference.
III.
I, the undersigned, am not a bona fide District resident, and I understand that I am not entitled to claim
a residency preference.
IV.
I, the undersigned, am a bona fide District resident and I do NOT claim a residency preference.
V.
I, the undersigned, am a bona fide resident of the District of Columbia and claim a residency preference
in applying for the position indicated above. My current address is
I understand that, if selected for this position, I will be required to submit proof of bona fide District residency and
to maintain bona fide District residency for a period of five (5) consecutive years from the date of appointment or
promotion.
FOR OFFICIAL USE ONLY
Preference Applied
Preference Not Applied-State Reason
Applicant's Signature
Date (Month, Day, Year)
Personnel Office Representative
When you are ready to print out the entire DC2000 Employment Application form, please press "Go." At that time, you
will receive a copy of this form at the email address you entered on the first page. Please print a copy of the form, sign
it, and mail it to the name and address found at the end of the vacancy announcement.
Go
FACTS ON RESIDENCY PREFERENCE
An applicant for initial appointment with the District government in the Career Service, Legal Service other than the
Senior Executive Attorney Service (SEAS), Excepted Service (attorney positions only), or the Management
Supervisory Service who is a bona fide District resident AT THE TIME OF APPLICATION may claim a residency
preference over a non-resident applicant.
An employee who applies for a competitive promotion in the Career Service, Legal Service other than the SEAS,
Excepted Service (attorney positions only), or the Management Supervisory Service and who is a bona fide
District resident AT THE TIME OF APPLICATION may claim a residency preference.
Residency preference is to be claimed by completing the front of this form and submitting it with the employment
application.
A bona fide District resident who does NOT claim a residency preference AT THE TIME OF APPLICATION for
initial appointment or competitive promotion, if found to be qualified, will be rated and ranked but WILL NOT
receive any preference. If selected, the individual is not required to maintain bona fide District residency.
Residency preference will be afforded as follows:
Five (5) points will be added to the rating and ranking score of each qualified applicant who claims a
hiring preference upon application for initial appointment.
Except for promotional examinations (e.g., police officers, firefighters, and correctional officers), five
(5) points will be added to the rating and ranking score of each qualified employee who claims or is
entitled to preference upon application for a competitive promotion, only when there is at least one (1)
qualified outside applicant for the position who claims a preference.
Preference candidates, including those who do not receive preference points, will be selected ahead of
equally qualified non-preference candidates.
A person who claims a residency preference and is selected for the position must agree in writing no later than
the date of appointment to maintain residency for a period of five (5) consecutive years from the effective date
of his or her appointment. Failure to maintain bona fide District residency will result in forfeiture of employment.
The requirement to maintain bona fide District residency is applicable ONLY to applicants and employees who claim
a residency preference at the time of application for initial appointment or competitive promotion and are selected.
Entitlement to preference: Any person who was employed by the District government on December 31, 1979, and
who is still employed by the District government without having had a break in service of one (1) workday or more
since that date; or, pursuant to the provisions of Public Law 98-621, any former employee of the U.S. Department of
Health and Human Services at St. Elizabeths Hospital who accepted employment with the District government
without a break in service effective October 1, 1987 and who has not had a break in service since that date, will be
granted a residency preference upon application for a COMPETITIVE PROMOTION in the Career Service, Legal
Service other than the SEAS, Excepted Service (attorney positions only), or the Management Supervisory Service, if
at least one (1) qualified applicant for the position has claimed a residency preference. If selected, the employee is
not required to establish or maintain bona fide District residency.
An employee who is under a five-year (5-year) residency requirement and who claims a residency
preference in applying for a competitive promotion, and is selected, will be required to begin a new five-year
(5-year) residency requirement effective with the date of the new appointment.