Standard Form 171 Personal Qualifications Statement, Customs Security Officer applicant
Document date 17 December 1970
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Id: Cooper-Part-26:023-026
Subject: Cooper Files: Cooper-Part-26:023-026 Document: Standard Form 171 Personal Qualifications Statement, Customs Security Officer applicant Id: Cooper-Part-26:023-026 Page: https://cooper.theunsolved.net/documents/Cooper-Part-26%3A023-026 What is wrong (title, date, type, which pages belong together, copies)? What does the scan show?
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FBI 164-81, Vault Part 26 pp. 23–26 (DB Cooper-6644–6647), Form, dated 17 Dec 1970 — cooper.theunsolved.net/documents/Cooper-Part-26%3A023-026
PERSONAL QUALIFICATIONS STATEMENT
Kind of position (or) if you are filing for (or a title of examination): Customs Security Officer
b. Announcement number: [redacted] 7. Birth date: [redacted] Month | Day | Year 8. Social Security Number: [redacted]
Options by which you wish to be considered (if listed on examination announcement): S
9. If you are currently on a register of eligibles for appointment or a reappointment to a federal position, give the name of the examination, the name of the other [illegible] maintaining the register, the date on your notice of rating, and your rating.
Patent's places you wish to be employed: Open
Home telephone: [redacted] 3. Business telephone: [redacted] A. Code | Number | Area Code | Number [redacted]
Name [redacted] (age) ☒ Mr. ☐ Miss ☐ Mrs.
D. Lowest pay or grade you will accept: PAY $ [redacted] | Pr [redacted] | GRADE: OK GS-4
Current address [redacted] City | State | ZIP Code
12. Are you willing to travel? (If not...) ☒ NO | ☐ SOME | ☐ OFTEN X
13. When will you be available? [redacted]
Will you accept: A) Reemployment/appointment of: —1 month or less? X YES —1 to 4 months? X YES —4 to 12 months? X YES Is less than full time work? (Less than 40 hours per week) X YES
(C) Will you accept a job in: —Washington, DC? X YES —any place in the United States? X YES —outside of the United States? X YES —only in (specify)
EDUCATION (A) Did you graduate from high school or did you graduate within the next nine months? YES ☒
(B) Name and location (city and State) of last high school attended [redacted]
3. Name and location (city, State, and ZIP Code of college or other or university. (If you expect to graduate within 9 months, give MONTH and year you expect degree.) [rows blank or redacted]
Dates attended | Years completed | Credits completed From | To | Day | Night | Semester hours | Quarter hours | Type of degree | Year of degree [all redacted or blank]
(D) Chief undergraduate college subjects: Semester hours | Quarter hours [blank]
(E) Chief graduate college subjects: Semester hours | Quarter hours [blank]
(F) Major field of study at highest level of college work [blank]
7. Other schools or training (city, county/a, trade, vocational, armed forces, or business). Give for each the name and location (city, State, and ZIP Code of school) [blank]
HONORS, AWARDS, AND FELLOWSHIPS RECEIVED
16. FOREIGN LANGUAGES Enter foreign languages and indicate your knowledge of each by placing "X" in proper columns
Reading | Speaking | Understanding | Writing Fair | Good | Fair | Fair | Good | Fair | Fair | Good | Fair | Fair | Good | Fair [blank]
Special qualifications and skills (licenses, skills with machines, patents or inventions, publications—do not submit copies unless requested, public speaking, memberships in professional or scientific societies; typing or shorthand speed, etc.) [blank]
Rodger Borres Approved SD-R0187
DB Cooper-6644
FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER Standard Form 171 (Formerly SF 57) July 1964 U.S. Civil Service Commission
ATTACH SUPPLEMENTAL SHEETS OR FORMS HERE Answer all questions correctly and fully
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19. If you have ever been employed by the federal government as a civilian, give your last: Grade Job Title 20. Birth place City: State for Foreign Country: 21. Legal or voting residence (State)
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2. REFERENCES. List three persons who are NOT related to you and who have definite knowledge of your qualifications and fitness for the position for which you are applying. Do not repeat names of supervisors listed under Item 18. EXPERIENCE.
Full Name | Present Business or Home Address (Number, street, city, State and ZIP Code) | Business or Occupation [redacted] | [redacted] | Lt. Col | | USMC(Ret) [redacted] | [redacted] | Lt. USMC [redacted] | Same as above | MSGT USMC
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3. MILITARY EXPERIENCE. A. Have you ever served on active duty in the United States military service? (Exclude tours of active duty for training as a reservist or Guardsman.) If "Yes," complete Items B through F below.
Dates (From-To) | Branch | Serial or Service Number [redacted] | USMC | [redacted]
C. Have you ever been discharged from the armed services under other than honorable conditions? (You may omit any such discharge changed to honorable by a Discharge Review Board or similar authority.)... If "Yes," give details in Item 32
D. Do you claim 5-point preference based on active duty in the armed forces?...
If "Yes," you will be required to furnish records to support your claim at the time you are appointed
E. Do you claim 10-point preference?... If "Yes," complete and attach Standard Form 15, "Claim for 10 point Veteran Preference," together with the proof called for in that form.
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ANSWER ITEMS 24 THROUGH 33 BY PLACING AN "X" IN THE PROPER COLUMN
4. Are you a citizen of the United States?... Yes [X] If "No," give country of which you are a citizen:
5. Before answering this question read Item 25 in the attached instructions. A. Are you now, or within the last ten years have you been, a member of: (1) The Communist Party, U.S.A., or any subdivision of the Communist Party, U.S.A.? (2) An organization that to your present knowledge advocates the overthrow of the constitutional form of government of the United States by force or violence or other unlawful means? B. If your answer to Item A(1) or A(2) is "Yes," write your answers to the following questions in Item 34 or on a separate piece of paper. (1) The name of the organization? (2) The dates of your membership? (3) Your understanding of the aims and pur- poses of the organization or the name of your membership?
6. To insure that you are not placed in a position which might impair your health, or which might be a hazard to you or to others, we need information about the following: Do you have, or have you had, heart disease, a nervous breakdown, epilepsy, tuberculosis, or diabetes?... If your answer is "Yes," answering any one of these, give details in Item 34.
7. Within the last five years have you been fired from any job for any reason?... 8. Within the last five years have you quit a job after being notified that you would be fired?... If your answer to 7 or 8 is also a "Yes," give details in Item 34. Show the name and address (including ZIP Code) of employer, approximate date, and reasons in each case. Your references should agree with your answers in Item 18. EXPERIENCE.
9. Have you ever been convicted or in offense against the law or forfeited collateral, or are you now under charges for any offense against the law? (You may omit: (1) traffic violations for which you paid a fine of $30.00 or less; and (2) any offense com- mitted before your 21st birthday which was finally adjudicated in a juvenile court or under a Youth Offender law.)...
10. While in the military service were you ever convicted by general court-martial?... If your answer to 9 or 10 is "Yes," give details in Item 34. Show for each offense: (1) date; (2) charge; (3) place; (4) court; and (2) action taken.
A. Does the United States Government employ in a civilian capacity or as a member of the Armed Forces any relative of yours (by blood or marriage)? (See Item 31 in the attached instructions sheet.) B. Do you live with, or within the past 12 months have you lived with, any of these relatives who are employed in a civilian capacity? If your answer to A is "Yes," give in Item 34 for each relative: (1) full name; (2) present address (including ZIP Code); (3) relationship; (4) department, agency, or branch of the Armed Forces. If your answer to B is "Yes," also give the kind of apartment held by the relative(s) you live with or have lived with within the past 12 months.
Do you receive or have you applied for retirement pay, pension, or other compensation based upon military or federal civilian service? If your answer is "Yes," give details in Item 34.
Are you an official or employee of any State, territory, county, or municipality? If "Yes," give type of position or cause of [illegible], and indicate, in Item 33, [illegible] whether elected or appointed.
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DB Cooper-6645
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b6 Per BOC b7C Per BOC
PLEASE BE SURE TO READ ATTACHED INSTRUCTIONS BEFORE COMPLETING THIS [illegible]
5 EXPERIENCE (Start with your PRESENT po[sition] of work had)
An inquiry be made of your present employer regarding [illegible] character, qualifications, and record of employment YES NO X
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Dates of employment (month, year) From To PRESENT TIME Pay or earnings Starting $ per Present $ per [illegible] and title of immediate supervisor
Area Code and phone No. if known reason for wanting to leave description of work
Exact title of position
If Federal service, classification series and grade
Age. brt. Place of employment Number and kind of em- Kind of business or organization per work City ployees supervised (manufacturing, accounting, [illegible], State etc.)
Name of employer (firm, organization, etc.) and address (including ZIP Code, if known)
Area Code and phone No. if known reason for wanting to leave description of work
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Dates of employment (month, year) Exact title of position If Federal service, classification series and grade From Pay or earnings Age. brt. Place of employment Number and kind of em- Kind of business or organization per work ployees supervised (manufacturing, accounting, [illegible], starting $75.00 per month Co Sa[illegible]a Ann 50-80. Inlisted U.S. Marine Corps [guess: Enlisted] sal $600.00 per month NA State Calif.
[illegible] of immediate supervisor Name of employer (firm, organization, etc.) and address (including ZIP Code, if known) U.S. Marine Corps, Washington DC Area Code and phone No. if known reason for leaving Transferred to the Fleet Marine Corps Reserve description of work
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personell Dates of employment (month, year) Exact title of position If Federal service, classification series From To and grade Pay or earnings Age. brt. Place of employment Number and kind of em- Kind of business or organization per work ployees supervised (manufacturing, accounting, [illegible], starting $ per City etc.) State sal $ per [illegible] title of immediate supervisor Name of employer (firm, organization, etc.) and address (including ZIP Code, if known)
Area Code and phone No. if known reason for leaving description of work
For agency use (skill codes, etc.)
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b6 Per BOC b7C Per BOC b6 Per BOC
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IF YOU NEED ADDITIONAL EXPERIENCE BLOCKS USE STANDARD FORM 171-A OR BLANK SHEETS SEE INSTRUCTION SHEET
DB Cooper-6646
[illegible partial text at top edge] for [illegible] items. Indicate item number and each [illegible] cycle No. ___ Description of work cont.
[Empty lined rows for continuation of work description]
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[If space is required, use full sheets of paper approximately the same size as this page. Write on EACH sheet your name, both date, and examination number/s title. Attach all sheets to this Statement at the top of Page 1]
ATTENTION: READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS STATEMENT
A false answer to any question in this Statement may be grounds for not employing you, or for dismissing you after you begin work, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Sec. 1001). All statements are subject to investigation, including a check of your fingerprints, police records, and former employers. All the information you give will be considered in reviewing your Statement and is subject to investigation. A false answer to Items 23 A or B could deprive you of your right to an annuity when you reach retirement age in addition to the penalties described above.
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CERTIFICATION I CERTIFY that all of the statements made in this Statement true, complete, and correct to the best of my knowledge belief, and are made in good faith
SIGN: [redacted] DATE: Dec. 17, 1970
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DO NOT WRITE IN THIS BLOCK—FOR USE OF EXAMINING OFFICE ONLY
Refer for medical action [ ] Medical action Approved by [ ] Disapproved (reason)
— DB Cooper-6647
[Grid with column headers, partially legible:] Senior [ ] Approv. [ ] Disapprov. Form Reviewed / Item Approved / Option [ ] Referred [ ] Advanced [illegible columns] Initials / [illegible] / 5 Years (Yes) / 10 Points / Comp. Dis / Old / 10 Points / Dual / [illegible] / Drug / [illegible]
THIS SPACE FOR USE OF APPOINTING OFFICER ONLY [ ] 3 Pt. [ ] 10 Pt. Comp. Disab. [ ] 10 Pt. Other Preference has been verified through proof that the separation was under honorable conditions, and other proof as required.
Signature and Title Agency
499 416-60943 1 1960 204-470
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b6 Per BOC b7C Per BOC