Supplemental Employment Application
Campus Supplemental Employment Application
Instructions
Please read all information before filling out and signing this application. Complete this application as accurately and thoroughly as possible by printing or typing your responses in the blank fields next to each question.
Complete all sections. Although you may have submitted a resume, your resume will not be considered a substitute for your responses on the Employment Application or this Supplemental Application. We appreciate your interest in KPMG. Please advise us if, because of a disability, you need assistance completing this form. If you have any questions, please contact your recruiter.
Return this completed, signed and dated form to HumanResourcesServiceCenter (HRSC) Background Administration via either fax to 214-853-5205 or email attachment to . For faxes, please include a fax cover sheet with a contact number or email address in case follow-up on your application is needed.
Please read before completing application
KPMG LLP, (the US member firm of KPMG International), is an equal opportunity employer. All applicants are considered for employment based upon their skills and abilities without regard to race, color, religion, gender, national origin, age, disability, marital status, sexual orientation, or veteran status. As required by the Immigration Reform and Control Act, you must establish proof of eligibility to work in the United States.
Personal Data(REQUIRED for tracking purposes)
Your Name (Last, First,MI) / Social Security Number / --Street Address / Home Phone / --
City / State / Zip
E-Mail Address
Other Personal Data
Yes / No / 1. Have you ever been convicted of a crime or pled guilty to a criminal charge, including any felonies, misdemeanors, offenses, infractions or violations under federal, state, county, military, or municipal law? This does not include: arrests without convictions; convictions that have been legally expunged or sealed; motor vehicle violations (other than Driving Under the Influence or Driving While Intoxicated/Impaired) for which the only penalty imposed was a fine of $300 or less; a guilty plea to a misdemeanor where the case has been legally dismissed; or any matter that you are not required to disclose under applicable law.IMPORTANT: The existence of a criminal record does not constitute an automatic bar to employment. The nature, date, andsurrounding circumstances will be considered in regards to all criminal matters. However, any deceptive or untruthful answer will result in the rejection of your application for employment or the withdrawal of any offer already extended or accepted. If you areuncertain whether you need to disclose a matter, contact your recruiter.
Answer this question only if you responded “yes” to the above. / 2. Please list below the date and place of the offense, the charge, and the disposition.
Note: Californiaresidents are not required to disclose misdemeanor convictions for possession of marijuana that occurred more than two years prior to today’s date. Massachusetts residents are not required to disclose convictions of a first offense for drunkenness, simple assault, speeding, a minor traffic offense, an affray, or disturbing the peace.
Yes / No / 3a. Are you working or have you ever worked for the U.S Government, a contractor or subcontractor of the U.S. Government, or on a U.S. Government Contract?
Answer 3b and 3c only if you answered “yes” to 3a, otherwise proceed to “Education Update” below
Yes / No / 3b. Are you or did you serve as a contracting officer; source selection authority; member of a source selection board; chief of either a financial or technical evaluation team; program manager or deputy program manager;
Yes / No / 3c. Did you make an award decision on a contract in which KPMG was the prime contractor or a subcontractor, and the value, including all option years, could have been $10 million or more?
If you responded “Yes” toeither3b or 3c, please complete the Pre-Employment Questionnaire Related to Federal Employment or Contracting form attached as a supplement to this application in addition to completing the remainder of this application below.
Education Update
School Type / School Name / City / State / Major Courseof Study / Degree or Certificate Earned (as of the date of this application) / DegreeHigh School / Yes / No
College #1 / Yes / No
College #2 / Yes / No
GraduateSchool / Yes / No
Other / Yes / No
Employment Update
List all employers you have had since filing your Employment Application with KPMG. Begin with your current employer. If necessary, additional information may be printed on the back of this page.Name of firm or company / Your Title / Start Date / End Date
Street Address / City
State / Country / Zip Code / Phone Number / --
Supervisor’s Name / Supervisor’s Title
Duties Performed
Is this a federal, state, or local government job (e.g. county government, municipal government, or school district government) paid directly by the government entity? / Yes / No
Reason for Leaving / Ending Annualized or Hourly Salary / $
When may we contact this employer? / Now / After I advise you I have resigned
Account for any interval(s) of unemployment since completing the Employment Application
Dates / From / To / ReasonDates / From / To / Reason
List any licenses or certificates you have earned since completing the Employment Application
License or Certificate / Date issued / Issuing Authority / County / State / Active Yes/No / License/Certificate Expiration DateYes / No
Yes / No
If license(s) or certification(s) is/are not active, please explain the current status and any plans for renewal/reactivation:
For this Supplemental Employment Application to be valid,
you must read and sign the Statement of Accuracy below:
I hereby certify that the information I have provided in an application and any documents attached, including transcripts, are complete and accurate to the best of my knowledge. I realize that falsification of this employment application OR ANY OTHER SUPPLEMENTAL EMPLOYMENT APPLICATIONS, and/or giving incomplete information herein, as well as falsification of other documents provided may result in the withdrawal of any employment offer, as well as the immediate termination of my employment now or in the future. I also understand that employment by KPMG is conditional upon the completion of an Authorization for Release of Information and other employment documents determined as necessary by KPMG. I hereby authorize and consent to the investigation of all statements contained in this application OR ANY OTHER DOCUMENTS PROVIDED BY ME INCLUDING A RESUME OR SUPPLEMENTAL EMPLOYMENT APPLICATIONS and authorize all persons and companies named above and their agents to release any and all records and information pertaining to my employment history, police record, education background, military service, or personal reputation and hereby release all parties from liability for damage for providing this information.
I understand that my employment with KPMG is “at will” and terminable pursuant to the terms of the employment affidavit I sign. If I become employed by KPMG my employment and compensation are for no definite period and, regardless of the time and manner of payment of my wages, salary or other benefits, my employment and compensation can be terminated at any time, with or without cause and with or without notice at either the option of the Firm or myself. I further understand that there are no other arrangements, agreements or understanding, oral or in writing, relating to the understanding set out in this paragraph and that the understanding set out herein supersedes any prior contrary statements. I further understand that any purported modifications to the understanding set out in this paragraph will not be effective unless in writing and personally signed by a representative of KPMG having actual authority to do so.
Signature: Today’s Date:
Updated 1-7-10
© 2010 KPMG LLP, a U.S. limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International, a Swiss cooperative. All rights reserved.
Supplemental Employment Application
Pre-Employment Questionnaire Related to
Federal Employment or Contracting
Note: Please complete this form only if you responded “Yes” toeither Question 3b or Question 3c of the Supplemental Employment Application
Last Name: / First Name:City: / State: / Zip Code:
Instructions
Please read all information before filling out and signing this application. Complete this application as accurately and thoroughly as possible by writing your responses in the blank field next to each question.
1. Please identify any and all government entities or the contractor(s) or subcontractor(s) for whom you are working or have ever worked, including the name of the government entity, positions held (including your General Schedule, Senior Executive Schedule, or Executive Schedule Grade), and dates, and also please identify each contract worked on by name or program. If you held more than one position and/or grade, please list each separately.Government Entity / Position Held and Grade / Start-End Dates Worked / Contract(s) Working/Worked On
If you need additional space, please attach additional pages.
2. Looking back from today through the past three (3) years, please check the applicable box(es) and complete one or more of the following items (a), (b), (c), (d), (e), or (f), as applicable:
a). I serve or served as a contracting officer, source selection authority, member of a source selection board or the chief of either the financial or technical evaluation team on a procurement awarded to KPMG that, including all option years, could have exceeded $10 million. Identify the following:
Procurement/Contract
Your Role
Last Day of Service
b). I serve or served as a contracting officer, program manager, or deputy program manager on a contract in which KPMG was the contractor that, including all option years, could have exceeded $10 million. Identify the following:
Procurement/Contract
Your Role
Last Day of Service
c). I was involved in making an agency decision to award or modify a KPMG contract, subcontract, task order, or delivery order over $10 million or I approved a contract payment or payments to KPMG in excess of $10 million (in aggregate). Identify the following:
Procurement/Contract
Your Role
Last Day of Service
d). I made a decision to establish overhead or other rates applicable to a KPMG contract or contracts valued in excess of $10 million.
Procurement/Contract
Your Role
Last Day of Service
e). I made a decision to pay or settle a claim in excess of $10 million with KPMG.
Procurement/Contract
Your Role
Last Day of Service
f). I am not serving and have never served in any capacity described in (a) through (e) above for a procurement or contract in excess of $10 million awarded to KPMG.
3. Please check the applicable box below:
My duties for the U.S. Government include or included working on procurements or contracts and KPMG is/was a bidder for a procurement or holds a contract or subcontract on which I work or worked. I have disqualified/will disqualify (circle one) myself from further participation in any procurement or contract in which KPMG is involved by notifying my immediate supervisor and my designated agency ethics official in writing about my employment contacts with KPMG. I will provide KPMG with a copy of my request for disqualification.
My duties for the U. S. Government do not or did not include participating in a procurement or a contract in which KPMG is a bidder or contract holder.
4. For each government entity listed in response to question 1, describe any matter of any kind (e.g., contract, program, policy, regulation, litigation, or investigation) on which you had any responsibility that involved KPMG. Describe the matter, your role, and give the approximate dates of your involvement.
Matter / Role or Position / Dates of Involvement
5. If you are currently employed by the U.S. Government, please answer the following:
Would you be entitled to terminal, transition, or separation leave payments or associated TDY?
What is the length of time any such payment would continue?
6. If you currently are, or were, a Department of Defense official, please answer the following:
Yes / No / 6a. Did you work on a procurement valued at more than $10 million while you were either in an Executive Schedule or Senior Executive Service position?
Yes / No / 6b. Did you serve as a program manager, deputy program manager, contracting officer, source selection authority, member of the source selection evaluation board, or chief of the financial or technical evaluation team for any contract over $10 million?
If the answer is yes to either 6a or 6b, please provide details below including dates:
7. Please check the applicable box below:
Yes / No / Have you received an opinion from an ethics officer regarding your post-employment limitations, including any pledge if you are an Obama administration appointee?
If Yes, please provide a copy
For this questionnaire to be valid, you must read and sign this
Statement of Accuracy
I hereby certify that the information I have provided in this questionnaire and in any documents attached, including transcripts, is complete and accurate to the best of my knowledge. I realize that falsification of this questionnaire, and/or giving incomplete information herein, as well as falsification of other documents provided by me may result in the withdrawal of any employment offer, as well as the immediate termination of my employment now or in the future. I also understand that employment with KPMG is conditional upon the completion of an Authorization for Release of Information and other employment documents as necessary, determined by KPMG. I hereby authorize and consent to the investigation of all statements contained in this questionnaire and authorize all persons and companies named above and/or their agents to release any and all records and information pertaining to my employment history, police record, education background, military service, or personal reputation, and hereby release all parties from liability for damage for providing this information.
I understand that my employment with KPMG is “at will” and terminable pursuant to the terms of the employment affidavit I sign. If I become employed by KPMG my employment and compensation are for no definite period and, regardless of the time and manner of payment of my wages, salary or other benefits, my employment and compensation can be terminated at any time, with or without cause and with or without notice at either the option of the Firm or myself. I further understand that there are no other arrangements, agreements or understanding, oral or in writing, relating to the understanding set out in this paragraph and that the understanding set out herein supersedes any prior contrary statements. I further understand that any modification to the understanding set out in this paragraph will not be effective unless in writing and personally signed by a representative of KPMG having actual authority to approve such modification.
I realize that falsification of this questionnaire, falsification of other documents provided by me, and/or the giving of incomplete information in this questionnaire may result in the withdrawal of any employment offer and/or the immediate termination of my employment now or in the future.
Signature: Today’s Date:
Updated 1-7-10
© 2010 KPMG LLP, a U.S. limited liability partnership and a member firm of the KPMG network of independent member firms affiliated with KPMG International, a Swiss cooperative. All rights reserved.