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: Human Capital Leadership & Merit System Accountability Division, Administrative Law Judge Program, 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. R All Locations Washington, DC, Metro Area R Washington, DC, Metro Area (Rockville, MD; Arlington, VA; Falls Church, VA; Washington, DC) Region 1 - Boston R All Region 1 R Hartford, CT R New Haven, CT R Boston, MA R Springfield, MA R Portland, ME R Manchester, NH R Providence, RI R Other _______________ Region 2 - New York R All Region 2 R Newark, NJ R Voorhees, NJ R Albany, NY R Bronx, NY R Brooklyn, NY R Buffalo, NY R Jericho, NY R New York, NY R Queens, NY R Rochester, NY R Syracuse, NY R White Plains, NY R Mayaquez, PR R Ponce, PR R San Juan, PR R Other _______________ Region 3 - Philadelphia R All Region 3 R Dover, DE R Baltimore, MD R Elkins Park, PA R Harrisburg, PA R Johnstown, PA R Philadelphia, PA R Philadelphia (East), PA R Pittsburgh, PA R Wilkes-Barre, PA R Charlottesville, VA R Norfolk, VA R Richmond, VA R Roanoke, VA R Charleston, WV R Huntington, WV R Morgantown, WV R Other _______________ Region 4 - Atlanta R All Region 4 R Birmingham, AL R Florence, AL R Mobile, AL R Montgomery, AL R Fort Lauderdale, FL R Jacksonville, FL R Miami, FL R Orlando, FL R Tampa, FL R Atlanta, GA R Atlanta (North), GA R Macon, GA R Savannah, GA R Lexington, KY R Louisville, KY R Middlesboro, KY R Paducah, KY R Hattiesburg, MS R Jackson, MS Region 4 ­ Atlanta (cont'd.) R Tupelo, MS R Charlotte, NC R Greensboro, NC R Raleigh, NC R Charleston, SC R Columbia, SC R Greenville, SC R Chattanooga, TN R Kingsport, TN R Knoxville, TN R Memphis, TN R Nashville, TN R Other _______________ Region 5 - Chicago R All Region 5 R Chicago (South), IL R Evanston, IL R Oakbrook Terrace, IL R Orland Park, IL R Peoria, IL R Evansville, IN R Fort Wayne, IN R Indianapolis, IN R Detroit, MI R Flint, MI R Grand Rapids, MI R Lansing, MI R Oak Park, MI R Minneapolis, MN R Cincinnati, OH R Cleveland, OH R Columbus, OH R Dayton, OH R Madison, WI R Milwaukee, WI R Other _______________ 5 U.S.C. § 3323(b) 5 CFR 930.201 et seq Page 1 OPM Form 1655-A January 2008 American LegalNet, Inc. www.FormsWorkFlow.com United States Office of Personnel Management Form Approved: OMB No. 3206-0248 Region 6 - Dallas R All Region 6 R Fort Smith, AR R Little Rock, AR R Alexandria, LA R Metairie, LA R New Orleans, LA R Shreveport, LA R Albuquerque, NM R McAlester, OK R Oklahoma City, OK R Tulsa, OK R Dallas (Downtown), TX R Dallas (North), TX R Fort Worth, TX R Houston, TX R Houston (Downtown), TX R San Antonio, TX R Other _______________ Region 7 - Kansas City R All Region 7 R West Des Moines, IA R Kansas City, KS R Wichita, KS R Creve Coeur, MO Region 7 - Kansas City (cont'd.) R Springfield, MO R St. Louis, MO R Omaha, NE R Other _______________ Region 8 - Denver R All Region 8 R Denver, CO R Billings, MT R Fargo, ND R Rapid City, SD R Sioux Falls, SD R Salt Lake City, UT R Other _______________ Region 9 - San Francisco R All Region 9 R Phoenix, AZ R Tucson, AZ R Downey, CA R Fresno, CA R Long Beach, CA R Los Angeles (Downtown), CA R Los Angeles (West), CA Region 9 - San Francisco (cont'd.) R Oakland, CA R Orange, CA R Pasadena, CA R Sacramento, CA R San Bernardino, CA R San Diego, CA R San Francisco, CA R San Jose, CA R San Rafael, CA R Santa Barbara, CA R Stockton, CA R Honolulu, HI R Las Vegas, NV R Other _______________ Region 10 - Seattle R All Region 10 R Eugene, OR R Portland, OR R Seattle, WA R Spokane, WA R Other ______________ 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 with an average of 10 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 (OPM), OPM Forms Officer, 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 Print Form 5 U.S.C. § 3323(b) 5 CFR 930.201 et seq Save Form Page 2 Clear Form OPM Form 1655-A January 2008 American LegalNet, Inc. www.FormsWorkFlow.com