Contractor Employee Biographical Data Sheet: The Privacy Act Statement Is Found at The End of This Form

OMB Control No: 0412-0520; Expiration Date: 3/31/2021
CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET

The Privacy Act Statement is found at the end of this form.
1. Name (Last, First, Middle) 2. Contractor’s Name
Valencia Gomez Anderson
3. Employee’s Address (include ZIP code) 4. Contract Number 5. Position Under Contract
Carrera 73 a # 38-55 sur Bogota D.C ZIP Code 110841
6. Proposed Salary 7. Duration of Assignment
Cop$ /dia
Cop$ /mes
8. Telephone Number (include area code) 9. Place of Birth 10. Citizenship (If non-U.S. citizen, give visa status)
(+57) 321 803 71 85 Bogota D.C Colombiano
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 Instruction on Page 2)
Proficiency Proficiency
NAME AND LOCATION OF INSTITUTION MAJOR DEGREE DATE LANGUAGE
Speaking Reading
Pregrado
Actual –
Corporacion Universitaria Iberoamericana Administracion -
Proceso Español 5/S 5/R
Dg 67 ## 5 - 27, Bogotá Financiera Profesion
de Grado
al
Tecnologo
Servicio nacional de Aprendizaje (SENA) Tecnolog
Gestion 2014 Español 5/S 5/R
Av. Caracas #No. 13-80, Bogotá ia
Empresarial
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.
EMPLOYER’S NAME AND ADDRESS Dates of Employment (D/M/Y) Annual Salary

POSITION TITLE
POINT OF CONTACT &TELEPHONE # From To Cop$
15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)

Dates of Employment
EMPLOYER’S NAME AND ADDRESS Days at Daily Rate
SERVICES PERFORMED (D/M/Y)
POINT OF CONTACT &TELEPHONE # From To Rate Cop$
Tempo S.A.S Bogota

Labor contratada Carrera 15 # 92-36 OF 301 08/05/2019 24/03/2020 330 $ 40.660
Tel: 3613561-6105498
Ventas y Servisios S.A

Termino Indefinido Carrera 45 # 197-75 01/06/2018 08/05/2019 330 $ 40.000
Tel: 2862400
Contrato Aprendizaje Tetra Tech ARD 06/03/2017 05/09/2017 180 $ 25.590
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.
AID 1420-17 (03/2019) Page 1 of 2

Signature of Contractor’s Representative Date
AID 1420-17 (03/2019) Page 1 of 2

INSTRUCTION
Indicate your language proficiency in block 13 using the following numeric Interagency Language Roundtable levels (Foreign Service Institute
Levels). Also, the following provides brief descriptions of proficiency levels 2, 3, 4, and 5. “S” indicates speaking ability and “R” indicates
reading ability. For more in-depth description of the levels refer to ADS 438
2. Limited working proficiency
S Able to satisfy routine special demands and limited work requirements.
R Sufficient comprehension to read simple, authentic written material in a form equivalent to usual printing or typescript on familiar
subjects within familiar contexts.
3. General professional proficiency
S Able to speak the language with sufficient structural accuracy and vocabulary to participate effectively in most formal and informal
conversations on practical, social, and professional topics.
R Able to read within a normal range of speed and with almost complete comprehension of a variety of authentic prose material on
unfamiliar subjects.
4. Advanced professional proficiency
S Able to use the language fluently and accurately on all levels normally pertinent to professional needs.
R Able to read fluently and accurately all styles and forms of the language pertinent to professional needs.
5. Functionally native proficiency
S Speaking proficiency is functionally equivalent to that of a highly articulate well-educated native speaker and reflects the cultural
standards of a country where the language is natively spoken .
R Reading proficiency is functionally equivalent to that of the well-educated native reader.
PAPERWORK REDUCTION ACT INFORMATION
The information requested by this form is necessary for prudent management and administration of public funds under USAID contracts. The
information helps USAID estimate logistic support and allowances, the educational information provides an indication of qualifications, the salary
information is used as a means of cost monitoring and to help determine reasonableness of proposed salary.
PAPERWORK REDUCTION ACT NOTICE
Public reporting burden for this collection of information is estimated to average thirty minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to:
United States Agency for International Development

Bureau for Management
Office of Acquisition and Assistance
Policy Division (M/OAA/P)
Washington, DC 20523-7100;
and
Office of Management and Budget

Paperwork Reduction Project (0412-0520)
Washington, DC 20503
PRIVACY ACT STATEMENT
Authority: Foreign Assistance Act, Pub. L. 87-165, as amended; and 48 CFR Ch. 7 - AIDAR,
Purpose: To collect, use, maintain, and disclose information to determine the qualifications of an individual for a specific contract position and to
determine the reasonableness of proposed salary or consultant rate for the services proposed under the contract.
Routine Uses: The personal information is used by USAID to maintain administrative records and to perform other administrative functions inherent in
the administration of the contract. This information will be used by USAID Contracting Officers and will not be disclosed outside USAID.
Disclosure: Contractor employees/consultants under USAID cost-reimbursement contracts must submit personal, employment history, educational
and salary data as specified in the form. Providing personal information is voluntary. However, failure to provide any of the requested information may
delay or prevent approval of the individual proposed under the specific contract.
AID 1420-17 (03/2019) Page 1 of 2

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OMB Control No: 0412-0520; Expiration Date: 3/31/2021

CONTRACTOR EMPLOYEE BIOGRAPHICAL DATA SHEET

14. EMPLOYMENT HISTORY

EMPLOYER’S NAME AND ADDRESS Dates of Employment (D/M/Y) Annual Salary

15. SPECIFIC CONSULTANT SERVICES (give last three (3) years)

Tempo S.A.S Bogota

Ventas y Servisios S.A

17. CONTRACTOR'S CERTIFICATION (To be signed by responsible representative of Contractor)

AID 1420-17 (03/2019) Page 1 of 2

AID 1420-17 (03/2019) Page 1 of 2

2. Limited working proficiency

S Able to satisfy routine special demands and limited work requirements.

3. General professional proficiency

4. Advanced professional proficiency

5. Functionally native proficiency

R Reading proficiency is functionally equivalent to that of the well-educated native reader.

PAPERWORK REDUCTION ACT INFORMATION

PAPERWORK REDUCTION ACT NOTICE

United States Agency for International Development

Office of Management and Budget

AID 1420-17 (03/2019) Page 1 of 2

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