Eligible employees must submit a completed RPL registration form to their servicing human resources office on or before the Reduction-in-Force separation date or, if eligible under Title 5, Code of Federal Regulations § 330.203(b), within 30 calendar days after the date of injury compensation benefits cease; or the date the Department of Labor denies an appeal for continuation of injury compensation benefits.

Bureau:___________________ Duty Station City:__________________ State:_____________

Name:___________________________________

Address: Street ____________________________________________________________

City ___________________________ State __________ ZIP Code__________

Telephone #: Home: ________________ Work: ________________ Cell: ____________

Date of RIF Separation: _________________ Tour of Duty: Full-time ______ Other _______

Are you available: For Part-Time Positions? Yes ______ No _______

For Non-Permanent Positions? Yes ______ No _______ 

Current series and grade/band: ____________Applicable grade/band conversion: ___________________

Current promotion potential: _________________

List the Positions for which you qualify and are available.

(qualification determinations will be made by the servicing human resources office based on the qualification requirements of individual positions)

Title Series Acceptable Grades

Highest Lowest

A. ________________________ _______ _______ __ ______

B. ________________________ _______ _______ __ ______

C. ________________________ _______ _______ __ ______

D. ________________________ _______ _______ __ ______

E. ________________________ _______ _______ __ ______

Note: There is no restriction on the number of positions that can be listed

______________________________________ _______________

Registrant’s Signature Date 

_______________________________________________________________________________ 

For Servicing Human Resources Office Use Only:

Registration Received: ____/____/____ Registrant Added to RPL: _____________

Comments: _____________________________________________________________________ 

(Include specifics on promotion potential of the position from which separated and any other pertinent information)

HR Point of Contact: _______________________ Telephone: ______________________ 

Tenure Group:

30% Disabled Veteran: ______ 1 – AD Career _____ 2 – AD Career-Conditional

 Veteran: _____ 1– A Career _____ 2 – A Career-Conditional

 Non-Veteran: _____ 1– B Career _____ 2 – B Career-Conditional