Form 5 National Agency Check Questionnaire for Peace Corps Volu

Peace Corps
Form 5
Revised September 2005

Form approved

O.M.B. NO. 0420-0001

Expired 8/31/07

cy Check Questionnaire for Peace Corps Volunteer
Background lnvestigation

Privacy Act Statement
The Privacy Act of 1974 (5 U.S.C. 552a) requires
that all Federal agencies inform individuals from
whom information is collected of: (a) the authority
for collecting the information; (b) the purpose(s) for
which the information will be used; (c) the routine
use(s) of the information; and (d) the effect on the
individual of not providing all or any part of the
requested information.
(a) The collection of information requested on the
attached form is authorized by provisions of the
Peace Corps Act, as amended, (22 U.S.C. 2519)
which requires the Director of the Peace Corps to
insure that the assignment of Volunteers is consistent with the national interest in accordance
with standards and procedures established by the
President.
(b) The information requested will be used to determine your qualification to serve as a Peace Corps
Volunteer. During the processing of your application, the information you provide will be sent to the
Office of Personnel Management (OPM) to initiate
a National Agency Check (NAC). The NAC is a
check of the files at OPM, the Federal Bureau of
lnvestigation and other agencies which might have
pertinent records pertaining to your activities. Any
data accumulated will be compared to your Peace
Corps application, and any inconsistencies may be
further investigated. Should investigations reveal
that you have provided the Peace Corps with any
information that is false, intentionally misleading,
purposefully incomplete or otherwise indicative that
your assignment may not be in the best interest of
the United States, you may be disqualified or terminated from service.
(c) lnformationyou furnish on the attached form may
be routinely disclosed for the following reasons:
1. To officers or employees of the Peace Corps
having a need for such record in the official
performance of their duties;
2. To the Office of Personnel Management for a
personnel investigation as part of the Peace
Corps selection process;
3. To any person from whom information is

requested in the course of an investigation to
the extent necessary to identify you, to inform
the person of the nature and purpose of the
investigation, and to identify the type of information requested;
4. When required under the provisions of the
Freedom of lnformation Act (5 U.S.C. 552) and
Privacy Act of 1974 (5 U.S.C. 552a);
5. To either House of Congress or to a subcommittee or committee (joint or of either House)
to the extent the subject matter falls within its
jurisdiction;
6. To the Bureau of the Census for the uses pursuant to Title 13;
7. To the Comptroller General or any of hidher
authorized representatives in the course of
their performance of duties of the General
Accounting Office;
8. To law enforcement agencies in connection
with authorized law enforcement activ~ty;
9. Pursuant to an order of a court of competent
jurisdiction provided that any such record is
disclosed under such compulsory legal process and subsequently made public by the
court which issued it;
10. To a court magistrate or administrativetribunal
or appropriate jurisdiction and to opposing
counsel in the course of settlement negotiations;
11. To other Federal agencies having an interest in
employing an applicant or volunteer after service for purposes of a security investigation;
12. To a Congressional office, constituent or otherwise, in response to an inquiry made at the
request of an individual to whom the record
pertains; and
13. To the National Archives and Records
Administration in authorized records management inspection.
(d) The information requested on the attached
form is necessary to conduct a background investigation. Disclosure of the requested information,
including your social security number, is voluntary.
Failure to provide sufficient information on which to
conduct an investigation may result in the rejection
of your application for Peace Corps service.

READ INSTRUCTIONS ON BACK OF THIS PAGE

Instructions
All responses must be printed in black ink. The completed form will be photocopied and clarity is essential. If the form is not
clearly written, it will have to be resubmitted and this may delay your placement. Print all responses with care. Make corrections neatly. Do not extend any response beyond the edge of the space provided within the answer box.
If you need more space for an answer, continue on a separate sheet of paper, the same size at this page (8.5" x 11"). At the
top of each continuation sheet print your name, social security number and the words "Peace Corps NAC Questionnaire
continuation." Be sure and indicate the number(s) of the questions to which you are responding. Sign and date each continuation sheet. Attach three (3) copies of each continuation sheet behind the last page of the questionnaire.
Itbm 1 : Print your full name in the following order - MST, FIRST, MIDDLE, if you are a "Sr.", "Jr.", "Ill", etc., skip one space after
your middle name and enter the appropriate designation. If you have initials only, enter each initial in the appropriate block
and print (10) after the initial for INITIAL ONLY. If you have no middle name, enter NMN in the block under "Middle".

Examples:
Normal Entry
1 . Applicant's Name

Last

First

DOE

Middle

JOHN

CARR Sr.

Initials Only
1. Applicant's Name

Last

First

DOE

Middle

c (10)

A (10)

No Middle Name
1 . Applicant's Name

~ast

First

M~ddle

JOHN

DOE

NMN

ltem 2: Print your social security number (SSN).
ltem 3: Print your date of birth (DOB) using numbers, for example, December 5, 1948, should be printed:

ltem 4: Print other names you have used and the dates (month and year) the names were used, such as maiden names,
names by former marriages, aliases, nicknames, or former names changed legally or otherwise. Print "NEE" before
maiden names.
Item 5: Print your place of birth. Enter the cityltown and county. If you were not born in the U.S.A. or its territories, print
the name of the foreign country where you were born. If you were born in the U.S.A. or its territories, fill in the box
marked "State" with the appropriate abbreviation from the list below:

Coding for States, District of Columbia, and U.S. Territories (Item5)
Hawaii . . . . . . . .HI Massachusetts .MA New Mexico . . .NM South Dakota .
Idaho . . . . . . . . .ID Michigan . . . . . .MI New York . . . . . .NY Tennessee . . .

Alabama . . . . . .AL
Alaska . . . . . . . .AK
Arkansas . . . . .AR
Arizona. . . . . .AZ
California . . . . .CA
Colorado . . . . .CO
Connecticut . . .CT
Delaware . . . . .DE
Florida . . . . . . . .FL
Georgia . . . . . .GA

Illinois . . . . . . . . .lL
Indiana . . . . . . . .IN
Iowa . . . . . . . . . .lA
Kansas . . . . . . .KS
Kentucky . . . . . .KY
Louisiana . . . . .LA
Maine . . . . . . . .ME
Maryland . . . . . MD

Minnesota . . . .MN
Mississippi . . . .MS
Missouri . . . . . .MO
Montana . . . . . .MT
Nebraska . . . . .NE
Nevada . . . . . . .NV
New Hampshire NH
New Jersey . . . .NJ

American Samoa -AS District of Columbia - DC Guam - GU
Puerto Rico - PR Trust Territory Virgin Islands - VI

North Carolina .NC
North Dakota . .ND
Ohio . . . . . . . . .OH
Oklahoma . . . . .OK
Oregon . . . . . . .OR
Pennsylvania . . .PA
Rhode Island . . .RI
South Carolina .SC

.SD
.TN
Texas . . . . . . . . .TX
Utah.. . . . . . . . UT
Vermont . . . . . . .VT
Virginia . . . . . . .VA
Washington . . .WA
West Virginia . .WV
Wisconsin . . . . .WI
Wyoming . . . . .WY

Northern Mariana Islands - CM

ltem 6: Print an X in the appropriate box.
ltem 7: Read the certification. Sign and date page 1 (OPM copy). Be sure to sign and date all continuation sheets.
When you have completed all items, including signature and date, carefully detach the last copy (Applicant's Copy) and return
pages 1 through 3 to the Peace Corps. Keep "Applicant's Copy" for your records.

National Agency Check Questionnaire for Peace Corps Volunteer Background Investigation
(Washington, D.C.20526)
RESPONSES MUST BE IN BLACK INK - SEE INSTRUCTIONS

CERTIFICATION
Date

OPM COPY

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National Agency Check Questionnaire for Peace Corps Volunteer Background Investigation
(Washington, D.C. 20526)
RESPONSES MUST BE IN BLACK INK - SEE INSTRUCTIONS

is true and c~mpleteto the best ofmy knowledge and
belief and is made in good faith.

CERTIFICATION
Date

Signature

NAC FILE

National Agency Check Questionnaire for Peace Corps Volunteer Background Investigation
(Washington, D.C. 20526)
RESPONSES MUST BE IN BLACK INK - SEE INSTRUCTIONS

is true and complete to the best of my knowledge and
belief and is made in good faith.

CERTIFICATION

APPLICANT FOLDER

I
I
~ a t i o n a l - ~ ~ e Check
n c y Questionnaire for Peace ~ o r ~ s v o l u n t e Background
er
Investigation
1
(Washington, D.C. 2052q)
RESPONSES MUST BE IN BLACK INK - SFE INSTRUCTIONS

I certify that all information given,by me in this form
is true and complete to the best of my knowledge and
belief and is made in good faith.

I

II

1

Date

I

APPLICANT COPY

Signature