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Fo|d

TO
Pequest Ior Pre||m|nary Fmp|oyment Data
/$oIoguorJ Tho ConIiJonIio/ NoIuro DI Tho oIo Dn Thix RouoxI/
SIandard Forn 76
Revsed AugusI 100S
U.S. OIIce oI Personne| hanagenenI
DaIe OI Ths RequesI Type or print the name and address of the activity to which this
request is being sent and your return address at the bottom.
To Whom It May Concern:
The person named below is tentatively selected for an appointment
in this agency. Please complete this form using the instructions on
page 4 and mail to the address at the bottom of this form.
Part I -- To be Comp|eted y Act|v|ty Pequest|ng InIormat|on
1. Nane oI TenIaIve Se|ecIee (Lasr, Firsr, Midd/e} 2. Soca| SecurIy Nunber S. DaIe oI BrIh
4-A. TI|e oI PosIon Ior vhch TenIaIve|y Se|ecIed B. Pay P|an and OccupaIon Code C. Grade or Leve|
6. Agency n vhch PosIon s LocaIed (Enrer Code From B/ock 47 on SF 5O} 6. Personne| OIIce IhaI Servces Ihe PosIon (Enrer Code From B/ock 48 on SF 5O}
7. EnIry on DuIy (EOD} DaIe Desred by Ihs AcIvIy
S-A. Nane oI Person RequesIng InIornaIon B. RequesIer's TI|e
Fo|d
C. RequesIer's SgnaIure D. DaIe Sgned E. RequesIer's Te|ephone Nunber (inc/ude Area Code}
0. AddIona| DaIa RequesIed
Please Return This Completed Request To:
PAGE 1
Prevous EdIon s Usab|e
NSN 7640-00-6S2-6760
U.S.
No Yes
Yes No
Part III -- To be Comp|eted y Act|v|ty C|v|ng InIormat|on
(Complete the following and provide any additional data requested in Item 9, Part I. Follow the instructions on page 4.)
Sect|on A -- Ident|I|cat|on Shown on Personne| Pecords
1. Nane (Lasr, Firsr, Midd/e} 2. Soca| SecurIy Nunber S. DaIe oI BrIh
Sect|on -- SF 50 Data
4-A. Enp|oynenI SIaIus
CurrenI|y on Ihe Ro||s oI Ths Agency SeparaIed (Speciry Dare} SeparaIon IncenIve Pad
B. LocaIon oI OPFihRPF
On F|e n Ths OIIce
On F|e n AnoIher OIIce
(Nane and Address OI ThaI
SenI Io NPRC (Speciry Dare}
OIIce)
6. PosIon TI|e
6. Pay P|an 7.Occ. Code S.Grade or Leve| 0.SIep or RaIe 10. ToIa| Sa|ary 11.Pay Bass
12-A. Basc Pay 12-B. Loca|Iy Ad|. 12-C. ReIenIon A||ov. 12-D.Supv'y DIIerenIa|12-E. Ava|ab|Iy Pay 12-F. AUO
1S. Nane and LocaIon oI PosIon's OrganzaIon
14.VeIerans PreIerence 17. FEGLI Code and Coverage (II Code "B", enIer daIe oI vaver cance||aIon) 16. Tenure 16. VP Ior RIF
1S. AnnuIanI 10. Pay RaIe 20. ReIrenenI P|an 21. Servce Conp. 22. vork Schedu|e 2S. PosIon
IndcaIor DeIernnanI DaIe (Leave} Occuped
24. DuIy SIaIon 26. Agency Code 26. Pers. OIIce Code
Sect|on C -- Dther Personne| Data
2S. Year Degree AIIaned S0. CIzenshp 27. EducaIon Leve| 20. Acadenc Dscp|ne S1. VeIerans SIaIus
OIher
Sect|on D -- Pet|rement Data
S2-A. Branch oI Servce B. ReIred Rank C. Check One and SpecIy DaIe
TransIerred Io
ReIred F|eeI Reserve
D. CredIab|e h|Iary Servce SS-A. Cv|an ReIrenenI DaIe B. ReIrenenI SysIen Payng AnnuIy
Years honIhs
S4. Frozen Servce S6 FERS Coverage
Years honIhs Covered AuIonaIca||y Never Covered E|ecIed FERS
Sect|on F -- Crade and Pay Data
S6.DaIe EnIered CurrenI Grade S7.DaIe oI LasI vIhn-Grade SS.II vGI vas Dened, DaIe oI S0.DaIe oI LasI Oua|Iy SIep Increase
and SIepiRaIe Increase (VG/} Dena| (OSI)
40-A. HghesI Prevous Gradei C. Sa|ary Ior ThaI GradeiSIep B. DaIes He|d
SIep He|d
Fron To
D.vas Sa|ary Based on 41-A. Is Ihe App|canI Nov on Grade ReIenIon?
Yes--CIe AuIhorIy
Speca| AuIhorIy?
No--Go Io Ien 42.
C. DaIe Tvo-Year Perod oI Grade ReIenIon 42. Is Ihe App|canI Nov on Pay ReIenIon? B. ReIaned Pay P|an, Grade, and SIep or RaIe
Began
Fron To
RaIngs oI Record
4S-A. II NoI LsIed Above, HghesI Sa|ary He|d on a Federa| ApponInenI B. DaIes He|d
Sect|on F -- PerIormance Data
46. Leve| PaIIern Perod 46. Leve| PaIIern Perod 47. Leve| PaIIern Perod 44. Leve| PaIIern Perod
PAGE 2
No
Sect|on C -- Appo|ntment Data
4S.NaIure oI AcIon (NOA} Ior B. AuIhorIy Ior ThaI ApponInenI C. DaIe
40.II Ihe Enp|oyee s Nov Career or Has He|d Career ApponInenI n Ihe B. NaIure oI AcIon and AuIhorIy Ior ApponInenI ThaI Begn ThaI
ConpeIIve Servce, DaIes Served Io AIIan Career Tenure
Fron To
60.II Ihe Enp|oyee Has NoI He|d a Career ApponInenI, DaIe oI hosI 61. AuIhorIy Ior ThaI ApponInenI
RecenI Career-CondIona| ApponInenI
Sect|on H -- Probat|on Data
62-A. The Enp|oyee s Nov Servng An InIa| ApponInenI Perod ThaI B. Has A|ready Conp|eIed InIa| ApponInenI ProbaIon Perod
Began on (Monrn/Day/Year}
Endng
6S.OIher ProbaIonary Perods
Supervsory
hanagera|
SES
DaIe Began DaIe Conp|eIed NoI Conp|eIed EenpI
Sect|on I -- UnIavorab|e Data
64.Does OPFihRPF ConIan Renova|, Suspenson, Dscharge or Change Io
66.Is There UnIavorab|e InIornaIon n OIher
F|es, e.g., LeIIers oI varnng,
AdnonshnenI, Reprnand, SuIab|Iy or
LeIIer oI Decson on an Adverse AcIon?
Yes
No
Don'I
No Yes
Begnnng
66. II "Yes" Io OuesIon 64 or 66, Nane oI Person Io ConIacI Ior hore B. Te|ephone Nunber (/ndicare DSN onJ Commercia/ -- Snov Area Code}
InIornaIon
Sect|on J -- FFH Data
67.Enro||nenI SIaIus
Cance||ed. Enro||ed.
Shov DaIe vaved. Shov DaIe vaved. Shov DaIe Ine|gb|e
Shov Code
Sect|on K -- Secur|ty Data
6S-A. hosI RecenI InvesIgaIon
NAC BI LBI
NACI SBI hBI PRI
B. DaIe InvesIgaIon Conp|eIed
D. Leve| oI CurrenI C|earance C.OIher Type oI InvesIgaIon--Ep|an
60-A. II InvesIgaIon s Pendng, Shov Iype, DaIe InIaIed and Agency ConducIng II
C. Te|ephone Nunber (/ndicare DSN onJ Commorcio/ -- $how Aroo CoJo/ B.Nane oI SecurIy OIIcer Io ConIacI Ior hore InIornaIon
Sect|on l -- Serv|ce Db||gat|on
60-A. Does Enp|oyee Have an Ob|gaIon Io Renan n GovernnenI Servce Ior a SpecIc Perod Because oI B. DaIe Ob|gaIon Epres
Tranng Receved?
No Yes. Ep|an
61-A. Does Enp|oyee Have an Ob|gaIon Because oI a RecruInenI or Re|ocaIon Bonus, a GovernnenI-Pad B. DaIe Ob|gaIon Epres
hove or a SIudenI Loan RepaynenI?
Yes. Ep|an
Sect|on M -- Fmp|oyee Payro|| and Thr|It Sav|ngs P|an Data
62-A. Enp|oyee's Payro|| OIIce Address B. Payro|| OIIce Nunber (8-Digir /denrirying Number}
C.Person Io ConIacI Ior Leave and Pay InIornaIon
D.Te|ephone Nunber (indicare DSN onJ commercia/ -- Snov Area Code}
6S-A. Year-To-DaIe Basc Pay B. Year-To-DaIe Earnngs
$
As OI (Dare}
$
As OI (Dare}
64.Year-To-DaIe FICA DeducIons 64. Year-To-DaIe FICA DeducIons 66.Year-To-DaIe FHIT (Medicare} DeducIons
$ As OI (Dare} $ As OI (Dare}
66.Is Enp|oyee CurrenI|y on LvOP? 67-A. Does Enp|oyee Have B. II "Yes", Shov Nunber oI
Begnng DaIe.
No Yes NTE DaIe. No Yes
PAGE S
Weeks and Beginning Date.
6S.ThrII Savngs P|an
Code Code
honIh Year honIh Year
YES
6S-A. TSP Servce
ConpuIaIon DaIe
B. TSP VesIng C.TSP SIaIus
D.TSP SIaIus DaIe E. Does Enp|oyee Have a Loan?
Day Day
NO (Circ/e One}
F. II Yes, Provde Ihe Fo||ovng InIornaIon Ior Each Loan
(Circ/e One}
AccounI Nunber AccounI Nunber Per veek|y Bveek|y honIh|y
PaynenI AnounI. $ PaynenI AnounI. $
Per veek|y Bveek|y honIh|y
60.TSP A||ocaIon
60-A. PercenIage oI Basc Pay
.00
B. vho|e Do||ar AnounI
OR $
C.C FUND-GOV'T
SECURITIES
.00
D.F FUND-FIXED
INCOhE INDEX
.00
E. C FUND-COhhON
STOCK INDEX
.00
F. TOTAL
100.00%
70-A. Nane and SgnaIure oI OIIca| CerIIyng TSP InIornaIon B. DaIe Sgned
Sect|on N--los|ng Agency Pe|ease Data
71-A. Is EOD DaIe n ParI I, IIen 7, AccepIab|e?
C.Nane oI Person Io Ca|| To Dscuss Re|ease DaIe
72-A. Nane oI Person Gvng InIornaIon
C.TI|e
D.SgnaIure and DaIe Sgned
Instructions for Activity
Requesting Information
Use the SF 75 to obtain pre-employment information when the
applicant's Official Personnel Folder (OPF) or Merged Records
Personnel Folder (MRPF) is not available for review. This most
often occurs when the applicant works for a different agency,
when the applicant works in the same agency but receives
personnel service from another office, when the applicant's
OPF/MRPF is on file in another agency even though the
applicant is not employed there, or when the applicant's
OPF/MRPF has been retired to the National Personnel Records
Center (NPRC) but the last employer has most of the information
needed.
Use the information provided on the SF 75 to: (1) verify
information on the applicant's application; (2) make decisions
regarding the applicant's eligibility for appointment, pay and
benefits; and (3) to complete the processing necessary.
The SF 75 may not be used for any other purposes (such as to
obtain references or to voucher a prospective employee). Be
sure to request SF 75 information sufficiently in advance of the
projected date of the action to enable the office that receives the
form to complete and return it or to provide the information by
telephone before the effective date of the employment action.
You may request SF 75 information by telephone or be mail.
When requesting the information by mail, complete Part I and
circle the items in Part II that are needed. If additional
information is required (e.g., dates of a detail, the number of
hours an intermittent employee has been in pay and duty status,
etc.), list it in Item 9 of Part I.
After you receive the SF 75 information, follow your agency's
procedures to refer the form to the personnel specialist who will
effect the appointment
B. II UnaccepIab|e, Shov Ear|esI Possb|e Re|ease DaIe
D.Te|ephone Nunber (/indicare DSN onJ commercia/ -- Snov Area Code}
B. Address (Bui/ding, Srreer, Ciry, Srare, Z/P Code}
E. Te|ephone Nunber (/ndicare DSN onJ commercia/ -- Snov Area Code}
Instructions for Activity
Providing Information
The name of the person on whom information is requested is in
Part I, Item 1, of this form. Use the most recent SF 50 on which
the data appear to complete Part II, Sections A and B. Use the
OPF/MRPF, Employment Performance Folder (EPF), and the
agency information systems that include adverse action, and
agency security/suitability files to complete Part II. Contact the
Payroll office to complete this Part as well. Review both the right
(long-term records) side of the OPF/MRPF and left (temporary
records).
Instructions for Filing the SF 75
Agencies must prepare an accounting of disclosure for release of
information outside the agency, unless the agency as the
employee's prior written consent to release the information. This
should be done for each system of records used to prepare the
information. The accounting of disclosure for OPF information
should be put on the right side of the OPF/MRPF. The
accounting of disclosure need only be a statement that "SF 75
information on (name of employee) was disclosed to (name and
address of agency) on (date)." If the gaining office has the
employee's written consent to get pre-employment information
from the current agency, no accounting of disclosure is
necessary. Example: OF 306 includes a section where
applicant consents to release of information about ability and
fitness by employers, etc.
PAGE 4
has the has the
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