Applicant Background Questionnaire

• Legal Form Number: FDIC 2100/14
• Section: Federal Deposit Insurance Corporation

OMB NUMBER: 3064-0138

EXPIRATION DATE: 02/28/2019

Federal Deposit Insurance Corporation

APPLICANT BACKGROUND QUESTIONNAIRE

The Federal Deposit Insurance Corporation (FDIC) is requesting your completion of this form to assist the Corporation in evaluating and improving its efforts to publicize job openings. Based on this information, the FDIC can access the effectiveness of specific outreach efforts and our means of communicating information on job vacancies. ; EFFECTS OF NONDISCLOSURE: Providing this information is strictly voluntary. This information will have no effect on hiring decisions and will not be released to the individuals who review the applications, to the selecting official, to anyone else who can affect your application, or to the public. ; Your Social Security Number (SSN) is requested under the authority of Executive Order 9397 (November 22, 1943) for the orderly administration of personnel records. Submission of your SSN is voluntary and failure to furnish your SSN on this form will have no effect on your application. ; Persons are not required to consider a response to this collection of information unless it displays a currently valid OMB control number. ; Information provided on this form will be used for program evaluation. Personal identifying information will not be included in the tabulation of data in the FDIC database. ; The public reporting burden for this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429; and to the Office of Management and Budget, Paperwork Reduction Project (3064-0138), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. ; Solicitation of this information is in accordance with 5 CFR Section 720, “Federal Equal Opportunity Recruitment Program” (FEORP).
Name (Last, First, MI)	Social Security Number	Date of Birth	Sex
			Male Female
Title, Grade, Announcement Number of Position for which you are applying.
Do you have a disability? Yes No If you checked “Yes” above, is your disability one of the *targeted disabilities listed below? Yes No ; *The Equal Employment Opportunity Commission targets the following disabilities for extra recruitment efforts: Deaf, Blind, Missing Extremities, Partial/Complete Paralysis, Convulsive Disorders, Mentally Retarded, Mental Illness, or Distortion Limb/Spine.
ETHNIC SELF-DETERMINATION ; Are you Hispanic, Latino, or of Spanish Origin? (Determination: A person of...