Contractor Employee Biographical Data Sheet
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2OMB Control No. 0412-0520
CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET
1. Name (Last, First, Middle)
2. Contractor's Name
3. Employee's Address (include Zip Code)
4. Contract Number
5. Position Under Contract
6. Proposed Salary
7. Duration of Assignment
8. Telephone Number (include area
9. Place of Birth
10. Citizenship (if non-U.S. citizen, give visa status)
code)
11. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment
12. EDUCATION (include all college or university degrees)
13. LANGUAGE PROFICIENCY (see
instructions on reverse)
NAME AND LOCATION OF INSTITUTION
MAJOR
DEGREE DATE
LANGUAGE
Speaking Reading
14. EMPLOYMENT HISTORY
1. Give last three (3) years. List salaries separately for each year. Continue on separate sheet of paper if required to list all employment related to duties of proposed assignment.
2. Salary definition - basic periodic payment for services rendered. Exclude bonuses, profit-sharing arrangements, commissions, consultant fees, extra or overtime work payments, overseas
.
differential, or quarters, cost of living or dependent education allowances
EMPLOYER' S NAME AND ADDRESS
POSITION TITLE
Dates of Employment
Annual Salary
POINT OF CONTACT & TELEPHONE #
(M/D/Y)
From
To
Dollars
15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)
EMPLOYER' S NAME AND ADDRESS
SERVICES PERFORMED
Dates of Employment
Days
Daily Rate
POINT OF CONTACT & TELEPHONE #
(M/D/Y)
at
in Dollars
Rate
From
To
16. CERTIFICATION: To the best of my knowledge, the above facts as stated are true and correct
Signature of Employee
Date
17. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)
Contractor certifies in submitting this form that it has taken reasonable steps (in accordance with sound business practices) to verify the information contained in this form. Contractor
understands that USAID may rely on the accuracy of such information in negotiating and reimbursing personnel under this contract. The making of certifications that are false, fictitious, or
fraudulent, or that are based on inadequately verified information, may result in appropriate remedial action by USAID, taking into consideration all of the pertinent facts and circumstances,
ranging from refund claims to criminal prosecution.
Signature of Contractor's Representative
Date
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