Form OPM 1655A OPM 1655A Geographic Peference Statement for Senior Adminstrative

United States Office of Personnel Management Form Approved:

OMB No. 3206-0248

Geographic Preference Statement for

Senior Administrative Law Judge Applicant

Instructions: Type or print clearly in black or blue ink. In the boxes below, indicate with an "X" each location where you would be available to serve as a Senior Administrative Law Judge (SALJ). You may show availability for any locations listed. You will be considered only for positions where you have indicated your availability. Submit form to: Administrative Law Judge Program Office, U.S. Office of Personnel Management, 1900 E Street, NW, Washington, DC 20415.

Name (Last, First, MI)

Address (Street, City, State, Zip Code)

All Locations

Check this box only if you are interested in all locations.

All Locations

Washington, DC, Metro Area

(Rockville, MD;

Alexandria, VA;

Arlington, VA;

Falls Church, VA;

Washington, DC)

Alabama

Alaska

Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois

Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire

New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico

Rhode Island
South Carolina
South Dakota
Tennessee
Texas

Utah
Vermont
Virginia
Washington
West Virginia

Wisconsin

Wyoming

Privacy Act Statement

The information on this form is collected pursuant to 5 U.S.C. § 3323(b) and 5 CFR 930.201 et seq. This completed form allows us to refer your application to Federal agencies that have SALJ positions where you may want to work. In addition, this record may be used to develop statistics and studies concerning our SALJ Program. Supplying this information is voluntary, but if you do not provide it you may lose job opportunities because we may not be able to properly refer your application.

Public Burden Statement

We estimate the public reporting burden for this collection will vary from 15 to 25 minutes, including time for reviewing instructions, searching existing data sources, gathering data, and completing and reviewing the information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management (OPM), Administrative Law Judge Program Office, ALJ Program Manager, Washington, DC 20415-7900. The OMB number, 3206-0248, is currently valid. OPM may not collect this information and you are not required to respond, unless this number is displayed. Do not send completed application forms to this address.

Reasonable Accommodation

Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate. Applicants requiring reasonable accommodation for any part of the hiring process should contact the appointing agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis.

THE FEDERAL GOVERNMENT IS AN EQUAL OPPORTUNITY EMPLOYER

Signature

Date

5 U.S.C. § 3323(b) OPM Form 1655-A

5 CFR 930.201 et seq May 2018