U.S. Department of State OMB APPROVAL NO.

1405-0189
EXPIRES: 5/31/2019
APPLICATION FOR EMPLOYMENT AS A
ESTIMATED BURDEN: 1 Hour
LOCALLY EMPLOYED STAFF OR FAMILY MEMBER
(This application is for positions recruited by the U.S. Mission under the
Office of Overseas Employment’s Interagency Local Employment Recruitment Policy)

POSITION
1. Position Title 2. Grade
MANAGEMENT ASSISTANT FSN-08 / FP-06
(Stated on the vacancy announcement as ‘Position’) (Stated on the vacancy announcement as FP-XX or FSN-
XXXX-XX )
3. Vacancy Announcement Number 4. Date Available for Work (mm-dd-yyyy)
17-XXX 02-01-2017 / ONE MONTH NOTICE PERIOD
(Stated at top of vacancy announcement as ’17-XXX’) REQUIRED
(Provide your Joining availability date considering notice
period clause with the current organization or travel
plans or leave plans, if any or for any other reason
whatsoever)

PERSONAL INFORMATION
5. Last Name(s)/Surnames First Name Middle Name
KUMAR AJAY NMN (NO MIDDLE NAME)

(Must provide your complete name)

6. Other Names Used

N/A (NOT APPLICABLE)
7. Current Address 8. Phone Numbers
HOUSE NO.12/24, 1ST FLOOR, HIMGIRI APPARTMENTS, KAROL BAGH, Day 011-XXXXXXX Ext 9999
DELHI 110009 NEAR DESHBANDHU COLLEGE. Evening 91-999-999-9999
(Provide your complete current address, including apartment number, Mobile 91-999-999-9999
building number, and other residential identifiers) (Must provide your daytime, evening, and cellular contact numbers,
including country, regional, area, or city codes, as appropriate)
9. E-mail Address
ABC@XYZ.COM
(Provide your Email ID (personal /Official or both) and those who do not have an email id are advised to create one as the HR Office
communicates mostly via. Email. In case, you’re not contactable via email then the HR Office would contact via mobile/phone numbers)
10. Are you a U.S. Citizen?
Yes No (Must check the appropriate box)

11. Do you have permanent U.S. Resident status (green card)?

Yes No (Must check the appropriate box)
If yes, provide number.

12a. U.S. Social Security Number (for U.S. Citizens/Permanent U.S. Residents) N/A

and/or

12b. Country Identification Number (For those who do not have SSN) 1234 5678 9123 (ADHAAR CARD NO.) (Example: Passport Number, PAN
No., Adhaar Number, or any other Country Identification Number etc.)

(Please ensure that correct information is entered above. Details provided will be kept confidential with the HR office.

Must attach a copy of any one of the document that confirms your Country Identification Number (for example: Social Security Card,
Passport, PAN Card, Voter’s ID, Adhaar Card, Valid Driving License etc. In case you fail to do so, your application will not be considered.)
 13. Are you legally eligible to work in this country?
Yes No (Must check the appropriate box)
If yes, Mission HR may require verification of eligibility. Please attach copies of all documentation that confirms your legal eligibility to work in
this country (e.g., work permit, residency permit).

(Please answer ‘yes’ or ‘no’ for your eligibility to work in the country where the Mission is located i.e. India.

Must attach a copy of any one of the document that confirms your legal eligibility to work in India (for example: Work Permit, Residency
Permit, Passport, PAN Card, Voter’s ID, Adhaar Card, Valid Driving License etc. In case you fail to do so, your application will not be
considered.)

14. If you are applying for a position that includes driving a U.S. Government vehicle, do you have a current and valid driver’s license?
Yes No Not Applicable (Must check the appropriate box)

(If you’re applying for a vacancy that requires driving license then you must attach a copy of the license in the absence of which your application
will not be considered. In case your license has expired, Please include renewal receipt if an application for renewal has been submitted to
transport authorities. Application with an expired license and without renewal receipt will not be considered.)

If yes, Class/Type of License LMV (Commercial) & HMV (Commercial) and Transport (Mention all categories of licenses that you possess)

If yes, have you operated a vehicle without incident for the past three years?
Yes No (Must check the appropriate box)
DS-174 Page 1 of 6
05-2016

15. What days are you available to work as part of a regularly scheduled work week? (Check all that apply.)
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
(Must check the appropriate boxes)

{Select your work week availability carefully and in reference to position requirements as this will be a determining factor for the
different kinds of positions like full time/part time and When actually Employed (WAE)}
16. Do any of your relatives or members of your household work for the United States Government? Yes No
(Must check the appropriate box)
If yes, provide the details below. If you need more space, use an additional sheet of paper. (See Instructions for Completing the
DS-174 for the definition of relatives and members of household.)

(It is a must to provide details of your relative(s) or member(s of your household working in U.S. Government in the below
column. Withholding such information may result in disqualification of the application at any stage whether before or after the
hiring process.

Relatives and members of household include father, mother, husband, wife, unmarried partner of the opposite or same sex, son,
daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law,
brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and half sister.

Only those relative(s) or member(s) should be mentioned who work with the U.S Government anywhere across the globe.)

Name Relationship Agency, Position, and Location

(for example) MR. VIJAY KUMAR BROTHER STATE DEPARTMENT, CONSULAR ASSISTANT, NEW DELHI

U.S. CITIZEN ELIGIBLE FAMILY MEMBER (USEFM) AND U.S. VETERANS HIRING PREFERENCE
17. Are you claiming preference in hiring under U.S. law and policy based upon your status as either a U.S. Citizen Eligible Family
Member (USEFM) or U.S. Veteran? See instructions for Completing the DS-174 for additional information about the USEFM and
U.S. Veterans hiring preference. (Check only one.)

U.S. Citizen EFM U.S. Veteran

U.S. Citizen EFM and also a U.S. Veteran Neither a U.S. Citizen EFM, nor a U.S. Veteran
(Must check the appropriate box)

Have you invoked this preference for a prior position at this post/Mission? Yes No (Must check the
appropriate box)

If yes, which agency? Date (mm-dd-yyyy)

If claiming eligibility for U.S. Veteran preference, you must attach a copy of your most recent DD-214, Certificate of Release or
Discharge from Active Duty. If claiming conditional eligibility for U.S. Veterans preference, you must submit proof of conditional
eligibility.
EDUCATION
18. Graduate School Dates Attended Did you Degree/Diploma Major Subject
Name of School, City, State or (mm-yyyy) graduate?
Country (State the start (Check
(Mention the complete name of and end ‘month appropriate box (State the
the and year’ for all for complete name (State all the
university/School/Institute/Vocational the educational completion/non- of the Major
School for all the columns below qualifications) completion of Degree/Diploma Subjects)
including City, State and Country) the ‘respective /Professional ACCOUNTS,
ARGI COLLEGE, DELHI UNIVERSITY, DELHI, From 06-2003 education’ for all course or any INCOME TAX,
INDIA To 05-2006 the columns other MATHS,
ECONOMICS,
below) Graduation
LAW, BUSINESS
Course. Mention
th th STUDIES
Yes 12 /10 for
No High School and
(Must check the Under
appropriate box) graduation
columns)
Undergraduate College/University Dates Attended Did you Degree/Diplom Major Subject
BACHELOR OF MATHS,
Name of School, City, State or (mm-yyyy) graduate? a
COMMERCE ACCOUNTS,
Country 12TH
(HONOURS) BUSINESS STUDIES, ENGLISH,
FATHER AGNEL SCHOOL, LAJPAT From 04-2002 Yes (COMMERCE) /
NAGAR, NEW DELHI, INDIA SENIOR ECONOMICS
To 03-2003 No
(Must check the SECONDARY
appropriate box)

High School/GED or Country Dates Attended Did you If no, highest grade level completed.
Equivalent (mm-yyyy) graduate?
Name of School, City, State or 10TH / ENGLISH, MATHS, SCIENCE, HINDI
Country From 04-2000 Yes
FATHER AGNEL SCHOOL, LAJPAT To 03-2001 No
NAGAR, NEW DELHI, INDIA (Must check the
appropriate box)
 Other, e.g. Technical/Vocational Dates Attended Did you Certificate/Diplo Major Subject
School (mm-yyyy) graduate? ma
Name of School, City, State or MS OFFICE, C++, UNIX,
Country From 06-2006 Yes VISUAL BASIC
NIIT, SOUTH EXTENSION, NEW DELHI To 05-2007 No GNIIT
(Must check the
appropriate box)
DS-174 Page 2 of 6

LANGUAGES
19. List your languages, the appropriate competency levels, and your primary/first spoken/native language using the language
standards below. You may only identify one primary/first spoken/native language.
Language Indicators
Level I Basic Knowledge
Level II Limited Knowledge
Level III Good Working Knowledge
IV Fluent
Level V Professional Translator/Interpreter

(Must mention the ‘level of proficiency’ for Speaking, Reading and Writing for all your Languages. This is one of the important
determining factors for application to be qualified for language proficiency requirement of the position as stated on the vacancy
announcement.)

Language Level To: Speak Read Write

IV
IV IV
Primary - HINDI

IV IV
ENGLISH IV

IV
PUNJABI III II

WORK EXPERIENCE
20. Include all work experience, paid and voluntary. Start with your present or most recent work experience. When describing
work, list specific duties/responsibilities and accomplishments. Include supervisory responsibilities and the number of employees
supervised. Go into as much detail as possible for work experience that directly relates to the advertised position. Include all
periods of unemployment and the reason. (Use additional pages, as needed.)
20a. WORK EXPERIENCE
20a. Job Title (If U.S. Government, include the series and grade)
ADMINISTRATIVE ASSISTANT, FSN-06 STEP-03

(Mention your current designation)

Mention the work experience dates (month and year) and Hours per week for all experiences. This would be required to
determine whether you have the required no. of years of work experience or not.)
From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Currency Hours per Week
07-2015 CURRENTLY WORKING INR 3, 99, 543 40 HRS.
Employer’s Name and Address Supervisor’s Name and Contact Information
U.S EMBASSY, POLITICAL OFFICE, NEW DELHI, INDIA Name MR. RAJESH KUMAR
Phone Number 24198000 Ext 9999
E-mail Address 24198000 Ext 9999
 Were you a supervisor in this position? Yes No May HR contact your supervisor? Yes No
(Must check the appropriate box) (Must check the appropriate box)
If yes, how many people did you supervise?

Describe your major duties/responsibilities and accomplishments.

-Provide the full range of secretarial duties including typing, formatting, drafting, and archiving correspondence related to Government of India
clearances, visa letters, and protocol invitations.
-Facilitate all kind of correspondence for all Mission India wide programs.
-Assist Senior Human Resources Officer in the compilation of the financial reports, budgets, plans, etc. of the Management section.
-Primary point of contact to receive calls, mails and couriers on behalf of the Assistant Management Officer.
-Keep log of all outgoing mail and invitations as well.
-Arrange/request Conferences, DVCs and presentation setups.
- Maintain online MS-Outlook calendar, scheduling meetings.
-Arranging travel and accommodation as a travel arranger.
-Maintaining visitor relations, arrange their access to Embassy premises and escort them as required.
-Arrange/book vehicle for official trips through GSO Motor Pool for Management Officer and other staff members.
-Keep a tab on the available office supplies, stationery, office equipment, etc. and make arrangement for placing a new order. Maintain petty
cash transaction records of section.

Reason(s) for Leaving (Do not write “N/A” or “not applicable”.)

N/A (CURRENTLY WORKING)
(Please mention the reason for leaving, if not currently working with the organization)
(Elaborate your responsibilities for all your work experience to get a better understanding of your profile. Applications with
minimal or no work experience description will get disqualified)
DS-174 Page 3 of 6

20b. WORK EXPERIENCE

20b. Job Title (If U.S. Government, include the series and grade)

From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Currency Hours per Week

Employer’s Name and Address Supervisor’s Name and Contact Information

Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes No May HR contact your supervisor? Yes No
If yes, how many people did you supervise?
Describe your major duties/responsibilities and accomplishments.

Reason(s) for Leaving (Do not write “N/A” or “not applicable”.)

20c. WORK EXPERIENCE

20c. Job Title (If U.S. Government, include the series and grade)
 From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Currency Hours per Week

Employer’s Name and Address Supervisor’s Name and Contact Information

Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes No May HR contact your supervisor? Yes No
If yes, how many people did you supervise?
Describe your major duties/responsibilities and accomplishments.

Reason(s) for Leaving (Do not write “N/A” or “not applicable”.)

DS-174 Page 4 of 6

20d. WORK EXPERIENCE

20d. Job Title (If U.S. Government, include the series and grade)

From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Currency Hours per Week

Employer’s Name and Address Supervisor’s Name and Contact Information

Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes No May HR contact your supervisor? Yes No
If yes, how many people did you supervise?
Describe your major duties/responsibilities and accomplishments.

Reason(s) for Leaving (Do not write “N/A” or “not applicable”.)

LICENSE, SKILLS, TRAINING, MEMBERSHIP, AND RECOGNITION

 21. List professional licenses, certifications, typing/keyboard skills, computer skills, formal and online training, and other skills and abilities you
consider relevant to the position. Include the license or certification number and attach a copy if the license or certification is a requirement of
the position. If licensed in the U.S., please list the state of issuance. If licensed in another country, please list the province/state/region and
country of issuance. (Use additional pages, as necessary.)
For example: COMPUTER SKILLS: KNOWLEDGE OF COMPUTER DATABASES AND SOFTWARE PACKAGES SUCH AS MS-WORD (ADVANCED), MS
EXCEL (INTERMEDIATE), POWER POINT (BASIC), EMAIL (ADVANCED) and CD-ROM (INTERMEDIATE) APPLICATION.

22. List professional organizations, associations, awards, honors, fellowships, and publications you consider significant.
For example: GROUP FRANKLIN AWARD, GROUP MERITORIOUS HONOR AWARD

REFERENCES
23. List three personal references who are not relatives or former supervisors who can speak knowledgeably of your work performance.
Name Address Telephone Occupation
(For example) ROBIN KUMAR 9-321, ADARSH NAGAR, NEW DELHI 011-9999-9999 SERVICE
RANI SHARMA D287, VISHAL NAGAR, NEW DELHI 011-9999-9999 HOUSEWIFE
DEEPAK KUMAR 13/12, WESTEND, NEW DELHI 011-9999-9999 BUSINESS
SIGNATURE AND CERTIFICATION
24. I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete,
and made in good faith. I understand that false or fraudulent information on or attached to this application may be grounds for not hiring me, or
for termination/dismissal after I begin work, and may be punishable by fine or imprisonment according to this country’s law or U.S. law. I
understand that any information I voluntarily provide on or attached to this application may be investigated.
Signature Date (mm-dd-yyyy)
AJAY KUMAR (Signatures not mandatory when submitting the 01-01-2017
application via email)

DS-174 Page 5 of 6

CONTINUATION – WORK EXPERIENCE

20 . Job Title (If U.S. Government, include the series and grade)

From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Currency Hours per Week

Employer’s Name and Address Supervisor’s Name and Contact Information

Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes No May HR contact your supervisor? Yes No

If yes, how many people did you supervise?

Describe your major duties/responsibilities and accomplishments.

 Reason(s) for Leaving (Do not write “N/A” or “not applicable”.)

CONTINUATION – WORK EXPERIENCE

20 . Job Title (If U.S. Government, include the series and grade)

From (mm-yyyy) To (mm-yyyy) Salary per Year in U.S. Dollars or Local Currency Hours per Week

Employer’s Name and Address Supervisor’s Name and Contact Information

Name
Phone Number
E-mail Address
Were you a supervisor in this position? Yes No May HR contact your supervisor? Yes No

If yes, how many people did you supervise?

Describe your major duties/responsibilities and accomplishments.

Reason(s) for Leaving (Do not write “N/A” or “not applicable”.)

DS-174 Page 6 of 6