Form OPM 1655-A OPM 1655-A Geographic Preference Statement for Senior Administrativ

United States Office of Personnel Management

OMB No. 3206-0248
Expiration: 09/30/2027

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, or Email to aljprogram@opm.gov.
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

Hawaii
Idaho
Illinois
Indiana
Iowa

Washington, DC,
Metro Area

Kansas

(Rockville, MD;
Alexandria, VA;
Arlington, VA; Falls
Church, VA;
Washington, DC)

Louisiana

Kentucky

Maine
Maryland
Massachusetts

Alabama

Michigan

Alaska

Minnesota

Arizona

Mississippi

Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia

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

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

OPM Form 1655-A
September 2024

Page 1

United States Office of Personnel Management

OMB No. 3206-0248
Expiration: 09/30/2027

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. 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
The public reporting burden to complete this information collection is estimated at 25 minutes per response,
including time for reviewing instructions, searching data sources, gathering, and maintaining the data needed,
and the completing and reviewing the collected information. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a currently valid OMB Control
Number and expiration date. Send comments regarding this burden estimate or any other aspect of this
collection information, including suggestions for reducing this burden to the U.S. Office of Personnel
Management, ATTN: ALJ Program at aljprogram@opm.gov. Current information regarding this collection of
information including all background materials can be found at https:/www.reginfo.gov/public/do/PRAMain
by using the search function to enter either the title of the collection ALJ Program or the OMB Control Number
3206-0248.

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 (mm/dd/yyyy)

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

OPM Form 1655-A
September 2024

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