Form OPM 1655 OPM 1655 Application for Senior Administrative Law Judge

United States Office of Personnel Management

Form Approved:
OMB No. 3206-0248

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: Federal ALJs who retired from the Federal Government, and who are currently receiving a 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 Digits of SSN

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

6. Are you a U.S. Citizen?
Yes

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

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

No

8. Retirement Date (mm/dd/yyyy)

9. Are you a Civil Service annuitant?
No

CSA Claim Number:

FERS

Yes

|

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?"
Yes

CSRS

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?
Yes

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

No

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:
Part Time

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

15. Are you willing to travel?
Full Time

Page 1

Yes

No

OPM Form 1655
September 2024

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. 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.govinfo.gov/content/pkg/PAI-2021-OPM-interim/xml/PAI-2021-OPM-interim.xml#routine.
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 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,
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

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

Date

Page 2

OPM Form 1655
September 2024