FCA Claim Form

SectionOffice of Congressional Workplace Rights (United States)
OCWR ADR Form 4 Page 1
Oce of Congressional Workplace Rights
John Adams Building, 110 Second Street SE, Room LA-200 | Washington, DC 20540-1999 | (202) 724-9250 (O) | ocwr.gov
Revised June 2024
Oce of Congressional Workplace Rights
The Fair Chance to Compete for Jobs Act (FCA) Claim Form
Instrucons on how to complete this claim form and how to obtain help are provided at the end of this form.
Secon A: Informaon about you
1. Your full legal name: Last: ___________________ First: ___________________ Middle: ___________________
2. Preferred mailing address: ____________________________________________________________________
City: ____________________ State: ______________ Zip code: _______________
3. Preferred phone number: ___________________________
4. Preferred email: ___________________________________
Secon B: Informaon about your claim
Please complete all the steps below:
Step 1: Legislave branch employing oce that this claim is led against:
________________________________________________________________________
Step 2: Were you an applicant for employment with an employing oce within the legislave bran ch?
Yes [ ] No [ ]
Step 3: Title of the p osion that you applied for: _______________________________ ________
Was this posion a law enforcement ocer posion? Yes [ ] No [ ]
Did this posion require that you hold or maintain a security clearance?
Yes [ ] No [ ] I don’t know [ ]
Step 4: Date you applied: _______________________________
Step 5: Did the employing oce request that you disclose criminal history record informaon?
Yes [ ] No [ ]
Step 6: Date of the employing oce’s request for criminal history record informaon:
_________________________________________

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