OPM 1655 w/changes OPM 1655 w/changes

Form Approved:
OMB No. 3206-0248

United States Office of Personnel Management

Application for Senior Administrative Law Judge
Description of the Senior Administrative Law Judge (SALJ) Program: The SALJ Program allows retired Administrative
Law Judges (ALJs) to be reemployed on a temporary and intermittent basis to complete hearings of one or more specified case(s) in
accordance with the Administrative Procedure Act of 1946. Upon appointment, and while reemployed, the retired ALJ is referred to
as a SALJ. (See 5 U.S.C. § 3323(b), and 5 CFR 930.201, et seq)
Who Can Apply: Retired Federal ALJs who retired from formerly employed by the Federal Government, and who are currently
receiving an federal annuity under the Civil Service Retirement System (CSRS) or the Federal Employee Retirement System
(FERS). Retired ALJs are required to demonstrate through proper documentation that they are licensed and authorized to practice
law under the laws of a State, the District of Columbia, the Commonwealth of Puerto Rico, or other territorial court established under
the Constitution. Judicial status is acceptable in lieu of "active" status in States that prohibit sitting judges from maintaining "active"
status to practice law. Being in "good standing" is also acceptable in lieu of "active" status in States where the licensing authority
considers "good standing" as having a current license to practice law. If eligible, the U.S. Office of Personnel Management (OPM) will
place the retired ALJs name on its SALJ Master List for referral to a hiring agency for possible reemployment. Placement on the
SALJ Master List is not a guarantee of reemployment.
Instructions: Type or print clearly in black or blue ink. Complete the application and Geographic Preference Statement for Senior
Administrative Law Judge Applicant (OPM Form 1655-A). Submit your application and requested documentation to:
Administrative Law Judge Program Office, U.S. Office of Personnel Management, 1900 E Street, NW, Washington, DC 20415.

1. Name (Last, First, MI)

2. Last 5 dDigits of SSN

3. Telephone Numbers
Daytime (
)
Other (
)
5. Email Address (if available)

4. Address (Street, City, State, ZIP Code)

6. Are you a U.S. Citizen?

7. Highest Grade and Step/Level and Rate as ALJ

O Yes
O No
8. Retirement Date (mm/dd/yyyy)

9. Are you a Civil Service annuitant?
O No

O Yes

O FERS

CSA Claim Number:

|

If yes, list the state(s) and /or jurisdiction(s) where you currently
meet the licensure requirements (attach proof of licensure):

10. Do you meet the licensure requirements described
above in "Who Can Apply?"
O Yes

O CSRS

O No

11. Since the date of your original appointment as an ALJ,
have you ever been disciplined or cited for breach
of ethics or unprofessional conduct by, or been the
subject of a complaint to, any court, administrative
agency, bar association, disciplinary committee, or
other professional group?
O Yes
O No

If yes, in which jurisdiction: Please describe the nature and
outcome of the proceeding (if needed, please attach a separate
sheet to this form):

12. List your ALJ experience. If desired, attach a resume to this form.
From (mm/yyyy)

To (mm/yyyy)

Title

Grade/Level

Employer (Agency)

Location (City/State)

13. For which agencies are you interested in conducting hearings?

14. Availability to work:
O Part Time O Full Time
5 U.S.C. § 3323(b)
5 CFR 930.201 et seq

15. Are you willing to travel?
O Yes
O No
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OPM Form 1655
May 20148

Form Approved:
OMB No. 3206-0248

United States Office of Personnel Management

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. The
primary use of the information is to determine eligibility for reemployment as a SALJ. The information may be
disclosed to appropriate Federal, State, or local agencies when relevant to civil, criminal, or regulatory
investigations or prosecutions; in judicial or administrative proceedings; to congressional offices; and to
Federal agencies for employment or security reasons. For the complete list of circumstances when ALJ
Application records may be disclosed pursuant to a routine use under the Privacy Act, see the OPM/Central-6
system of records notice at http://www.ofr.gov/Privacy /agencies.aspx. The routine uses that may be made
of this information are in the system notice for the OPM/Central-6 system of records under the Privacy Act,
published at https://www.gpo.gov/fdsys/pkg/PAI-2015-OPM/xml/PAI-2015-OPM.xml#central6, with an
additional routine use published at https://www.federalregister.gov/articles/2015/11/30/2015-30309/privacyact-of-1974-routine-use-implementation-system-of-records. Your Social Security Number (SSN) is requested
under the authority of Executive Order 9397, which requires the SSN for the purpose of uniform, orderly
administration of personnel records. Providing this information is voluntary, however, failure to provide the
requested information will prevent processing of the application. The effect of not providing all other
requested information will result in us not being able to process your application.

Public Burden Statement
We estimate the public reporting burden for this collection will vary from 30 to 45 minuteswith an average of 15
minutes per response, 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, 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.

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
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 reemployment as a SALJ is subject to
investigation of suitability in accordance with 5 CFR Part 731. In addition, I understand that
reemployment is subject to conflict of interest and security investigation requirements by the appointing agency.
Signature

Date

Print Form

5 U.S.C. § 3323(b)
5 CFR 930.201 et seq

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OPM Form 1655
May 20148