Service Years Experience

Contract Personnel Questionnaire

Prepare in duplicate. Type or print all responses. If answer is No, state so. Attach sheets if more space is needed.

Privacy Act Statement: Your information will be used as a basis for an investigation to determine your fitness and suitability for contractual services to the U.S.

Postal Service® (USPS®). Collection is authorized by 39 U.S.C. 3061. Providing the information is voluntary, but if not provided you may be denied access to Postal

Service premises, denied access to the mail, or denied participation under a USPS contract. We may disclose your information as follows: in relevant legal pro-

ceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or

individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign government

agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel.

1. Print Your Full Name (Last, First, Middle Name) 2. Print Your Mailing Address (Include Apartment/Suite Number)

3. City, State and ZIP+4 Code™ 4a. Home Telephone Number 4b. Work Telephone Number

(Include Area Code) (Include Area Code)

5. List Other Names Used. (i.e., maiden name, names by former marriages, names changed legally or otherwise, aliases, nicknames. Specify which and dates used.)

6. Social Security Number (SSN) 7. Date of Birth (MM/DD/YYYY) 8. Place of Birth (City and State/Country) 9. Sex

Male Female

11. Are You Presently a Highway Contract Driver?

10. Type of Screening (Check one)

Yes No

(If Yes, include Contract Number and Termini.)

Contractor Contractor’s Employee Sub-Contractor ADP Other

13. Contractor’s Name and Mailing Address 12. Highway Contract Number and Termini (If applicable)

14. Have You Had a Security Screening by USPS or Other Federal Agencies

Within the Last Year? Yes No Agency:

15. Dates and Places of Residence. (If actual places of residence differ from the mailing addresses, furnish and identify both. Begin with

present residence and go back for the past five years.)

From To

City

Number and Street State ZIP+4 Code

(MM/YYYY) (MM/YYYY)

16. Employment. (List ALL periods of employment for the past five years starting with your present employment. Include dates when unemployed.

Give name under which employed if different from name now used.)

Employer’s Address

From To Reason for Your Name During

Employer’s and

Occupation

Leaving

(MM/YYYY) (MM/YYYY) Period of Employment

Supervisor’s Names (City, State, Zip+4Code)

17b. Are You a Citizen of American Samoa or Any Other

17a. Are You a United States Citizen?

Territory Owing Allegiance to the United States? Yes No

Yes No

17c. Provide Alien Registration Number if not a United States Citizen

18b. Commercial Driver’s

18a. Do You Have a Valid License? (Driver/Chauffeur) If “Yes”, include License

Number, State, and Expiration Date. Yes No Yes No

License

PS Form 2025, March 2012, (Page 1 of 2) PSN 753*-**-***-**** (Continued on Page 2)

19b. Have you registered with the Selective Service System? If “Yes”,

19a. Are you a male born after December

19. Your Selective

provide your registration number. If “No”,

31, 1959? If “No”, go to 20a. If Yes,

Service Record

Yes Yes

show the reason for your legal exemption.

go to 19b. No No

19c. Registration Number 19d. Legal Exemption Explanation

20a. Military Service (Past or Present). (If Yes, complete Items 20b, 20c, 20d, 20e, and 20f.) Yes No

20d. Serial Number (If none, provide Grade or Rating at

20c. Branch of Service (Army, Navy, Air Force,

20b. Dates of Service (MM/YYYY)

time of separation)

Marines, etc.)

To From

20e. Were You Discharged from the Military Service Under Honorable Conditions? (If your discharge was changed to “honorable” or

“general” by a Discharge Review Board, answer “Yes”. If you received a clemency discharge, answer “No”.) If No, enter the date

and type of discharge you received in the blocks below. Yes No

Discharge Date (MM/YYYY) Type of Discharge

20f. While in Military Service, Were You Ever Convicted by Court Martial?

Yes No

Place (City and State/Country)

Court Martial Date (MM/DD/YYYY) Charge Disposition

21a. Have You Ever Been Convicted of, or Forfeited Collateral, for Any Felony/Misdemeanor Violation (Except Traffic Violations)?

(Generally, a felony is defined as any violation of law punishable by imprisonment of one year or longer.) Yes No

21b. During the Last 10 Years Have You Forfeited Collateral, Been Convicted, Been Imprisoned, Been on Probation, or Been

on Parole for any Violation of Law? (Do not include violations reported in question 21a.) Yes No

21c. Have You Ever Been Convicted of, or Forfeited Collateral for Any Assaults, Firearms or Explosives Violations?

Yes No

21d. Are You Now Under Charges for Any Violation of Law?

Yes No

If any answers to 21a - 21d are “Yes”, provide date, place, court location, charge, and disposition on an attached sheet.

21e. Are You Delinquent on any Federal Debt? (Include delinquencies arising from Federal taxes, overpayment of benefits, or other

debts to theU.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgage loans.) Yes No

Charge

Date (MM/YYYY) Place (City and State) Court Action Taken

If necessary, attach additional sheets.

22. In the Past 5 years, Have You Been Convicted of any Traffic Violations (Other Than Parking) or Currently Have Charges

Pending? (If Yes, complete information below.) Yes No

Charge

Date (MM/YYYY) Place (City and State) Court Action Taken

If necessary, attach additional sheets.

Check Here if Your Driver’s Abstract from Department of Motor Vehicles is Attached.

Warning

Review this form carefully to ensure you have answered all questions fully and correctly. Failure to answer all questions may result in your being denied access

to mail and/or Postal Service premises. A fine not to exceed $250,000 or imprisonment of not more than five years or both is provided by law (18 U.S.C. 1001)

for making a false statement or concealing any material fact on this Questionnaire.

Certification

I certify that the statements made by me on this questionnaire are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

Applicant’s Signature Date Signed (MM/DD/YYYY)

I attest I have advised the Applicant to truthfully complete this Questionnaire, and the Applicant has passed the Drug Screening Test (If applicable, provide

documentation).

Contractor’s Signature (Sign and print name) Telephone Number (Include area code) Date Signed (MM/DD/YYYY)

For Use of Postal Service Official Responsible for Reviewing for Completeness and Legibility. (See Administrative Support Manual 272.23, Contractor

Clearance, for complete instructions.)

USPS Official Signature (Sign and print name) Telephone Number (Include Area Code) Date Signed (MM/DD/YYYY)

Organization, City, State, and ZIP+4 Code

PS Form 2025, March 2012 (Page 2 of 2)

Contact this candidate