Heading and executive details
A year after CY in the title, the name of the executive, position title, current pay rate (ES-) and the recertification period from and to.
GSA3622
Senior Executive Service Recertification
- Agency
- GSA
- Revision
- Rev. 6/1991
- Fillable fields
- 39
- Pages
- 2
- Official source
- GSA form page
- Checked
- October 20, 2026
GSA Form 3622: Senior Executive Service Recertification
GSA Form 3622, Senior Executive Service Recertification, is a General Services Administration form. Its heading and footer read GENERAL SERVICES ADMINISTRATION and GSA FORM 3622 (6-91), and GSA hosts it in its forms library, where the page lists a current revision date of 06/1991.
The two-page form records a recertification for a career appointee in the Senior Executive Service. Page one prints the standard for recertification and the supervising official's recommendation to recertify, conditionally recertify or not recertify, with any pay rate adjustment. Page two holds the executive's acknowledgement, a block signed by the Performance Review Board (PRB) chairperson, a block for the approving official, annual SES performance ratings and awards.
Every signature line belongs to the executive, the supervising official, the PRB chairperson or the approving official. The form prints no instructions, OMB number or privacy statement. You can fill it out free in your browser on this page and download the result without an account.
What's on GSA Form 3622
Standard for recertification
Item 1 lists five areas of excellence, from planning toward goals to fair and equitable treatment, including EEO. Item 2 adds three more where they apply: savings, quality with reduced resources and leadership.
Supervising official's recommendation
Recertify, conditionally recertify or not recertify, a recommended pay rate adjustment to ES- or no adjustment, then a signature, title and date.
Executive's acknowledgement
Three statements to check one of: request a higher level review, submit a statement of accomplishments to the PRB, or not submit one. Then the executive's signature and date.
PRB and approving official blocks
Two more sets of the same three recommendation boxes and pay rate lines, signed by the PRB chairperson and by the approving official.
Ratings and awards
Three year lines with a performance rating level for each, and a box for awards and other recognitions.
How to complete GSA Form 3622
- 1
Fill in the heading
Enter the year after CY, the executive's name and position title, the current ES pay rate and the recertification period.
- 2
Record the supervisor's recommendation
The supervising official checks one box, enters a pay rate adjustment or marks none, and signs. The form says written justification and supporting documentation are attached for a conditional or not recertify recommendation.
- 3
Executive acknowledges
The executive checks one of the three acknowledgement statements and signs and dates it.
- 4
PRB chairperson signs
The PRB chairperson checks a recommendation and pay rate choice and signs. The block says the executive was given the rationale and an opportunity to appear or send a statement when the recommendation is to conditionally recertify or not recertify.
- 5
Approving official signs
The approving official checks a recommendation and pay rate choice in the last block and signs and dates it.
- 6
Add ratings and awards
Enter the annual SES performance rating levels by year and list awards and other recognitions.
Why fill Form GSA3622 on indox
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Routing and what the form says
Where it goes
The form prints no address. The executive's acknowledgement refers to submission to the Performance Review Board.
Time stated on the form
One acknowledgement statement says the executive will submit a statement of accomplishments to the PRB within 15 days from the date of the acknowledgement.
What the decision is based on
The form says the recommendations are based on the executive's overall performance against the standard stipulated in law, regulation, and GSA's written procedures, including ratings, awards, development activities and factors in GSA's SES recertification plan.
Edition
The footer reads GSA FORM 3622 (6-91). GSA's page lists no authority or regulation, and the form prints no instructions, OMB number or privacy statement.
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Who fills out GSA Form 3622?
The form names these roles in its signature and acknowledgement blocks.
Official sources and the blank
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Questions about Form GSA3622
Who issues GSA Form 3622?
The heading and footer read GENERAL SERVICES ADMINISTRATION and GSA FORM 3622 (6-91). GSA hosts it in its forms library.
What recommendations does the form offer?
Each of the three recommendation blocks offers recertify, conditionally recertify or not recertify, plus a recommended pay rate adjustment to ES- or no pay rate adjustment.
What can the executive choose after the supervisor's recommendation?
The form lists three statements: request a higher level review before submission to the Performance Review Board, submit a statement of accomplishments within 15 days, or not submit a statement.
What is attached to a conditionally recertify or not recertify recommendation?
The supervising official's block says the required written justification specifying the standard for recertification not met and other relevant supporting documentation are attached.
Who provides the performance ratings on the form?
The form says the annual SES performance ratings are to be provided by the Executive Resources Staff.
Are there instructions for GSA Form 3622?
The PDF prints none beyond the text in each block. GSA's page lists a current revision date of 06/1991 and no authority or regulation.