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Bio Data Form
Bio Data Form
AID 1420-17 (04/2007) Page 1 of 2
OMB Control No. 0412-0520; Expiration Date: 02/28/2014
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 code)
9. Place of Birth
10. Citizenship (If non-U.S. citizen, give visa status)
11. Names, Ages, and Relationship of Dependents to Accompany Individual to Country of Assignment
13. LANGUAGE PROFICIENCY (see Instruction on Page 2)
NAME AND LOCATION OF INSTITUTION
MAJOR
DEGREE
DATE
LANGUAGE
Proficiency
Speaking
Proficiency
Reading
2/S
2/R
2/S
2/R
2/S
2/R
14. EMPLOYMENT HISTORY
1. Give last three (3) years. List salaries separate 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.
POSITION TITLE
EMPLOYER’S NAME AND ADDRESS
POINT OF CONTACT &TELEPHONE #
Dates of Employment (M/D/Y)
Annual Salary
From
To
Dollars
15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)
SERVICES PERFORMED
EMPLOYER’S NAME AND ADDRESS
POINT OF CONTACT &TELEPHONE #
Dates of Employment (M/D/Y)
Days at
Rate
Daily Rate
In Dollars
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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