Standard Form 171 Personal Qualifications Statement, Customs Security Officer applicant (Marine Corps background)
Document date 17 December 1970
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Id: Cooper-Part-26:035-038
Subject: Cooper Files: Cooper-Part-26:035-038 Document: Standard Form 171 Personal Qualifications Statement, Customs Security Officer applicant (Marine Corps background) Id: Cooper-Part-26:035-038 Page: https://cooper.theunsolved.net/documents/Cooper-Part-26%3A035-038 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. 35–38 (DB Cooper-7188–7191), Form, dated 17 Dec 1970 — cooper.theunsolved.net/documents/Cooper-Part-26%3A035-038
PERSONAL QUALIFICATIONS STATEMENT Budget Bureau Approved 50-R0387
1a. Kind of position (job) you are filing for (or title of examination) Customs Security Officer b. Announcement number [blank] 7. Birth date Month | Day | Year 8. Social Security b6 Per BOC b7C Per BOC
c. Options for which you wish to be considered (if listed in examination announcement) [blank]
d. Primary place(s) you wish to be employed Open
2. Home telephone Area Code | Number 3. Business telephone Area Code | Number b6 Per BOC 4. Name (Last) (First) (Middle) (Maiden if any) [X] Mr. [ ] Miss [ ] Mrs.
5. Number and street, R.D., or Post Office box number
10. Lowest pay or grade you will accept PAY $_____ per _____ OR b6 Per BOC b7C Per BOC
6. City | State | ZIP Code
11. Are you willing to travel? (Check one) [NO] [SOME] [OFTEN] X
12. When will you be available? [blank]
13. Will you accept: YES NO (A) Temporary appointment of —1 month or less? X —1 to 4 months? X —4 to 12 months? X (B) Less than full time work? (Less than 40 hours per week) X
(C) Will you accept a job in: YES NO —Washington, D.C.? X —any place in the United States? X —outside of the United States? X —only in (specify):
14. EDUCATION (A) Did you graduate from high school or will you graduate within the next nine months? [X] YES/[IN/AT] | NO | HIGHEST GRADE COMPLETED X
(B) Name and location (city and State) of last high school attended b6 Per BOC
(C) Name and location (city, State, and ZIP Code if known) of college or university. (If you expect to graduate within 9 months, give MONTH and year you expect degree.)
Dates attended | Years completed | Credits completed From | To | Day | Night | Semester | Quarter | Type of | Year of hours hours degree degree [blank rows]
(D) Chief undergraduate college subjects Credits completed Semester | Quarter hours hours [blank rows]
(E) Chief graduate college subjects Credits completed Semester | Quarter hours hours [blank rows]
(F) Major field of study at highest level of college work [blank]
(G) Other schools or training (for example, trade, vocational, armed forces, or business). Give for each the name and location (city, State, and ZIP Code b6 Per BOC of school, dates attended, subjects studied, certificates and any other pertinent data [blank]
15. HONORS, AWARDS, AND FELLOWSHIPS RECEIVED [blank]
16. FOREIGN LANGUAGES Enter foreign languages and indicate your knowledge of each by placing "X" in proper columns Reading | Speaking | Understanding | Writing Excl Good Fair | Excl Good Fair | Excl Good Fair | Excl Good Fair [blank rows]
17. Special qualifications and skills (licenses; skills with machines, patents or inventions; publications — do not submit copies unless requested, public speaking, b6 Per BOC memberships in professional or scientific societies; typing or shorthand speed; etc.) [blank]
DB Cooper-7188
THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER Standard Form 171 (Formerly SF 57) July 1968 U.S. Civil Service Commission
PLEASE BE SURE TO READ ATTACHED INSTRUCTIONS BEFORE COMPLETING ITEM 18 18. EXPERIENCE (Start with your PRESENT[redacted] and work back) May inquiry be made of your present employer regarding your character, qualifications, and record of employment? YES [ ] NO [X]
Dates of employment (month, year) From _______ To PRESENT TIME Exact title of position: [blank] If Federal service, classification series and grade: [blank] Salary or earnings: Starting $ _______ per _______ Present $ _______ per _______ Avg. hrs. per week: [blank] Place of employment City: [blank] State: [blank] Number and kind of employees supervised: [blank] Kind of business or organization (manufacturing, accounting, insurance, etc.): [blank] Name and title of immediate supervisor: [blank] Name of employer (firm, organization, etc.) and address (including ZIP Code, if known): [blank] Area Code and phone No. if known: [blank] Reason for wanting to leave: [blank] Description of work: [blank] For agency use (skill codes, etc.): [blank]
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Dates of employment (month, year) From [redacted] Exact title of position: [redacted] If Federal service, classification series and grade: b6 Per BOC
Salary or earnings: Starting $75.00 per month Final $600.00 per month Avg. hrs. per week: NA Place of employment City: Santa Ana State: Calif. Number and kind of employees supervised: 50-80 Enlisted Kind of business or organization: U.S. Marine Corps Name and title of immediate supervisor: [redacted] b6 Per BOC Name of employer: U.S. Marine Corps, Washington DC b7C Per BOC Area Code and phone No. if known: [blank] Reason for leaving: Transferred to the Fleet Marine Corps Reserve Description of work: b6 Per BOC
personell
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Dates of employment (month, year) From _______ To _______ Exact title of position: [blank] If Federal service, classification series and grade: [blank] Salary or earnings: Starting $ [illegible] per [illegible] Final $ _______ per _______ Avg. hrs. per week: [blank] Place of employment City: [blank] State: [blank] Number and kind of employees supervised: [blank] Kind of business or organization (manufacturing, accounting, insurance, etc.): [blank] Name and title of immediate supervisor: [blank] Name of employer (firm, organization, etc.) and address (including ZIP Code, if known): [blank] Area Code and phone No. if known: [blank] Reason for leaving: [blank] Description of work: [blank]
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IF YOU NEED ADDITIONAL EXPERIENCE BLOCKS USE STANDARD FORM 171-A OR BLANK SHEETS SEE INSTRUCTION SHEET DB Cooper-7189
ATTACH SUPPLEMENTAL SHEETS OR FORM HERE Answer all questions correctly and fully
19. If you have ever been employed by the federal government as a civilian, give your last: Grade | Job Title [redacted] | [redacted]
20. Birth place City [redacted] State (or Foreign Country) [redacted]
21. Legal or voting residence (State) b6 Per BOC b7C Per BOC
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22. 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. Co[redacted] [redacted] | [redacted] | USMC(R) b6 Per BOC b7C Per BOC [redacted] | [redacted] | Lt. USMC [redacted] | Same as above | MSGT USMC
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23. VETERAN PREFERENCE. 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 E below. [X] Yes [ ] No
B. List for all active military service: 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 34. [ ] Yes [X] No b6 Per BOC b7C Per BOC
D. Do you claim 5-point preference based on active duty in the armed forces?..................................... [ ] Yes [X] No
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?..................... [ ] Yes [X] No
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
24. Are you a citizen of the United States?................................................ If "No," give country of which you are a citizen: [X] Yes [ ] No
25. 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?................................................ [X marking in No column]
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 at the time of your membership?
26. 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," concerning any one of these, give details in Item 34. [X marking in No column]
27. Within the last five years have you been fired from any job for any reason?............................. [X marking in No column]
28. Within the last five years have you quit a job after being notified that you would be fired?............. If your answer to 27 or 28 above is "Yes," give details in Item 34. Show the name and address (including ZIP Code) of employer, approximate date, and reasons in each case. This information should agree with your answers in Item 18. EXPERIENCE. [X marking in No column]
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29. Have you ever been convicted of an 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.)......... [X marking in No column]
30. While in the military service were you ever convicted by general court-martial?......................... If your answer to 29 or 30 is "Yes," give details in Item 34. Show for each offense: (1) date; (2) charge; (3) place; (4) court; and (5) action taken. [X marking in No column]
31A. 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 instruction sheet.)................................ [X marking in Yes column]
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 such relatives: (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 appointment held by the relative(s) you live with or have lived with within the past 12 months. [X marking in No column]
32. 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. [X marking in No column]
33. Are you an official or employee of any State, territory, county, or municipality?....................... If "Yes," give type of position or name of office, and location, in Item 33. Include whether elected or appointed. [X marking in No column]
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DB Cooper-7190
14. Space for detailed answers. Indicate form numbers or which answers apply. Item No 2 Discription of work cont. b6 Per BOC
[REDACTED - black circle] [REDACTED - black circle]
14G
26 32
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If more space is required, use full sheets of paper approximately the same size as this page. Write on EACH sheet your name, birth date, and examination (or position) title. Attach all sheets to this Statement at the top of Page 3.
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 25 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 b6 Per BOC I CERTIFY that all of the statements made in this Statement b7C Per BOC are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. DATE SIGNED 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):
[Grid with columns:] Announcement No. | Name | Material [ ] | Submitted [ ] | Returned [ ] | Entered Register | Preference | Age Rating | [guess: Grade] | [guess: Final Rating] | 3 Points (Vet) | 10 Points Comp. Dis. | Other 10 Points | Dual | Being Investigated | THIS SPACE FOR USE OF APPOINTING OFFICER ONLY | [ ] 10 Pt. Comp. Disb. [ ] 10 Pt. Other | Preference has been verified through proof that the separation was under honorable conditions, and other proof as required. | Date
[ ] Appt. [ ] Nonpet. Reasons: Form Reviewed: Form Approved: Option
Initials and Date [ ] 5-Pt.
Signature and Title Agency
CSC Form 4-5 rev 8/67 DB Cooper-7191
Serials: 50-R0387