Sf85

Form approved:
O.M.B. No. 3206-0005
NSN 7540-00-634-4035
85-111

Standard Form 85
Revised September 1995
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

Questionnaire for Non-Sensitive Positions
Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on page 5 and the
release on page 6. If you have any questions, call the office that gave you the form.

Purpose of this Form
The U.S. Government conducts background investigations
to establish that applicants or incumbents either employed
by the Government or working for the Government under
contract, are suitable for the job. Information from this form
is used primarily as the basis for this investigation. Complete
this form only after a conditional offer of employment has
been made.

Giving us the information we ask for is voluntary. However, we may not be able to complete your investigation, or
complete it in a timely manner, if you don't give us each item
of information we request. This may affect your placement
or employment prospects.

2. Type or legibly print your answers in black ink (if your form
is not legible, it will not be accepted). You may also be asked
to submit your form in an approved electronic format.
3. All questions on this form must be answered. If no
response is necessary or applicable, indicate this on the form
(for example, enter "None" or "N/A"). If you find that you
cannot report an exact date, approximate or estimate the date
to the best of your ability and indicate this by marking
"APPROX." or "EST."
4. Any changes that you make to this form after you sign it
must be initialed and dated by you. Under certain limited
circumstances, agencies may modify the form consistent with
your intent.

Authority to Request this Information
The U.S. Government is authorized to ask for this
information under Executive Order 10577, sections 3301
and 3302 of title 5, U.S. Code; and parts 5, 731 and 736 of
Title 5, Code of Federal Regulations.
Your Social Security number is needed to keep records
accurate, because other people may have the same name
and birth date. Executive Order 9397 also asks Federal
agencies to use this number to help identify individuals in
agency records.

5. You must use the State codes (abbreviations) listed on the
back of this page when you fill out this form. Do not abbreviate
the names of cities or foreign countries.
6. The 5-digit postal ZIP codes are needed to speed the
processing of your investigation. The office that provided the
form will assist you in completing the ZIP codes.
7. All telephone numbers must include area codes.

The Investigative Process
Background investigations are conducted using your
responses on this form and on your Declaration for Federal
Employment (OF 306) to develop information to show
whether you are reliable, trustworthy, and of good conduct
and character. Your current employer must be contacted
as part of the investigation, even if you have previously
indicated on applications or other forms that you do not want
this.

8. All dates provided on this form must be in Month/Day/Year
or Month/Year format. Use numbers (1-12) to indicate
months. For example, June 10, 1978, should be shown as
6/10/78.
9. Whenever "City (Country)" is shown in an address block,
also provide in that block the name of the country when the
address is outside the United States.

Instructions for Completing this Form
1. Follow the instructions given to you by the person who
gave you the form and any other clarifying instructions
furnished by that person to assist you in completion of the
form. Find out how many copies of the form you are to turn
in. You must sign and date, in black ink, the original and
each copy you submit.

10. If you need additional space to list your residences or
employments/self-employments/unemployment or education,
you should use a continuation sheet, SF 86A. If additional
space is needed to answer other items, use a blank piece of
paper. Each blank piece of paper you use must contain your
name and Social Security Number at the top of the page.

Final Determination on Your Eligibility
Final determination on your eligibility for a position is the
responsibility of the Office of Personnel Management or
the Federal agency that requested your investigation. You
may be provided the opportunity personally to explain,
refute, or clarify any information before a final decision is
made.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides
that knowingly falsifying or concealing a material fact is a
felony which may result in fines of up to $10,000, and/or 5
years imprisonment, or both. In addition, Federal agencies
generally fire, or disqualify individuals who have materially
and deliberately falsified these forms, and this remains a
part of the permanent record for future placements. Your
trustworthiness is a very important consideration in
deciding your suitability. Your prospects of placement are

better if you answer all questions truthfully and completely. You
will have adequate opportunity to explain any information you
give us on the form and to make your comments part of the
record.
Disclosure of Information
The information you give us is for the purpose of determining
your suitability for Federal employment; we will protect it from
unauthorized disclosure. The collection, maintenance, and
disclosure of background investigative information is governed by
the Privacy Act. The agency which requested the investigation
and the agency which conducted the investigation have
published notices in the Federal Register describing the systems
of records in which your records will be maintained. You may
obtain copies of the relevant notices from the person who gave
you this form. The information on this form, and information we
collect during an investigation may be disclosed without your
consent as permitted by the Privacy Act (5 USC 552a (b)) and as
follows:

PRIVACY ACT ROUTINE USES
1. To the Department of Justice when: (a) the agency or any component thereof, or (b)
any employee of the agency in his or her official capacity; or (c) any employee of the
agency in his or her individual capacity where the Department of Justice has agreed to
represent the employee; or (d) the United States Government is a party to litigation or
has interest in such litigation, and by careful review, the agency determines that the
records are both relevant and necessary to the litigation and the use of such records
by the Department of Justice is therefore deemed by the agency to be for a purpose
that is compatible with the purpose for which the agency collected the records.

5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this
system of records contains information relevant to the retention of an employee, or the
retention of a security clearance, contract, license, grant, or other benefit. The other
agency or licensing organization may then make a request supported by written
consent of the individual for the entire record if it so chooses. No disclosure will be
made unless the information has been determined to be sufficiently reliable to support
a referral to another office within the agency or to another Federal agency for criminal,
civil, administrative, personnel, or regulatory action.

2. To a court or adjudicative body in a proceeding when: (a) the agency or any
component thereof; or (b) any employee of the agency in his or her official capacity; or
(c) any employee of the agency in his or her individual capacity where the Department
of Justice has agreed to represent the employee; or (d) the United States Government
is a party to litigation or has interest in such litigation, and by careful review, the
agency determines that the records are both relevant and necessary to the litigation
and the use of such records is therefore deemed by the agency to be for a purpose
that is compatible with the purpose for which the agency collected the records.

6. To contractors, grantees, experts, consultants, or volunteers when necessary to
perform a function or service related to this record for which they have been engaged.
Such recipients shall be required to comply with the Privacy Act of 1974, as amended.

3. Except as noted in Question 14, when a record on its face, or in conjunction with
other records, indicates a violation or potential violation of law, whether civil, criminal,
or regulatory in nature, and whether arising by general statute, particular program
statute, regulation, rule, or order issued pursuant thereto, the relevant records may be
disclosed to the appropriate Federal, foreign, State, local, tribal, or other public
authority responsible for enforcing, investigating or prosecuting such violation or
charged with enforcing or implementing the statute, rule, regulation, or order.
4. To any source or potential source from which information is requested in the course
of an investigation concerning the hiring or retention of an employee or other
personnel action, or the issuing or retention of a security clearance, contract, grant,
license, or other benefit, to the extent necessary to identify the individual, inform the
source of the nature and purpose of the investigation, and to identify the type of
information requested.

7. To the news media or the general public, factual information the disclosure of
which would be in the public interest and which would not constitute an unwarranted
invasion of personal privacy.
8. To a Federal, State, or local agency, or other appropriate entities or individuals, or
through established liaison channels to selected foreign governments, in order to
enable an intelligence agency to carry out its responsibilities under the National
Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order
12333 or any successor order, applicable national security directives, or classified
implementing procedures approved by the Attorney General and promulgated
pursuant to such statutes, orders or directives.
9. To a Member of Congress or to a Congressional staff member in response to an
inquiry of the Congressional office made at the written request of the constituent about
whom the record is maintained.
10. To the National Archives and Records Administration for records management
inspections conducted under 44 USC 2904 and 2906.
11. To the Office of Management and Budget when necessary to the review of private
relief legislation.

STATE CODES (ABBREVIATIONS)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia

AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA

Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland

HI
ID
IL
IN
IA
KS
KY
LA
ME
MD

Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey

MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ

New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina

NM
NY
NC
ND
OH
OK
OR
PA
RI
SC

South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

SD
TN
TX
UT
VT
VA
WA
WV
WI
WY

American Samoa
Trust Territory

AS
TT

District of Columbia
Virgin Islands

DC
VI

Guam

GU

Northern Marianas

CM

Puerto Rico

PR

PUBLIC BURDEN INFORMATION
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including 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 the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Reports and Forms Management Officer,
U.S. Office of Personnel Management, 1900 E Street, N.W., Room CHP-500, Washington, D.C. 20415. Do not send your completed form to this address.

QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS

Standard Form 85
Revised September 1995
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
OPM
USE
ONLY

Form approved:
O.M.B. No. 3206-0005
NSN 7540-00-634-4035
85-111

Codes

Case Number

Agency Use Only (Complete items A through K using instructions provided by USOPM)

A Type of

B Extra

Investigation

E

Geographic
Location

I

OPAC-ALC
Number

K Requesting

C Nature of

Coverage

F

Month

D Date of

Action Code

Day

Year

Action

G SON

Position
Title

H SOI

Data and/or
J Accounting
Agency Case Number

Name and Title

Signature

Telephone Number

Date

Official

Persons completing this form should begin with the questions below.

FULL
NAME

1

l
l

Last Name

3

l

PLACE OF BIRTH

Middle Name

4

a

c

Day

Year

SOCIAL SECURITY NUMBER

OTHER NAMES USED
Give other names you used and the period of time you used
m the (for example: your maiden name, name[s] by a former marriage, former name[s], alias[es],
or nickname[s]). If the other name is you
r maiden name, put "nee" in front of it.
Name

Month/Year Month/Year

Name

To
Month/Year Month/Year

#2

7

Month

State Country (if not in the United States)

#1

6

BIRTH

Jr., II, etc.

Use the two letter code for the State
.
County

2 DATE OF

If you are a "Jr.," "Sr.," "II," etc., enter this in the box after
your middle name.

First Name

City

5

l

If you have only initials in your name, use them and state (IO).
If you have no middle name, enter "NMN."

Name

Month/Year Month/Year

Name

To
Month/Year Month/Year

#3
#4

To

To

(Mark one box)

SEX

Female

CITIZENSHIP
Mark the box at the right
that reflects your current
citizenship status, and
follow its instructions.

Male

b

I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession.

Answer Items b and d

I am a U.S. citizen, but I was NOT born in the U.S.

Answer Items b, c, and d

I am not a U.S. citizen.

Answer Items b and e

Your Mother's Maiden
Name

UNITED STATES CITIZENSHIP If you are a U.S. Citizen, but were not born in the U.S., provide information about one or more of the following proofs of your citizenship.
Naturalization Certificat
e
(Where were you naturalized?)
Court

City

State

Certificate Number

Month/Day/Year Issued

State

Certificate Number

Month/Day/Year Issued

Citizenship Certificat
e
(Where was the certificate issued?)
City
State Department Form 240 - Report of Birth Abroad of a Citizen of the United States
Give the date the form
was prepared and give
an explanation if needed.

Month/Day/Year

Explanation

U.S. Passport
This may be either a current or previous U.S. Passport.

If you are (or were) a dual citizen of the United States and another
country, provide the name of that country in the space to the right.

d

DUAL CITIZENSHIP

e

ALIEN If you are an alien, provide the following information:
Place You
Entered the
United States:

City

Passport Number

Country

State Date You Entered U.S. Alien Registration Number
Month Day
Year

Clear Form

Month/Day/Year Issued

Country(ies) of Citizenship

Page 1

8

WHERE YOU HAVE LIVED
List the places where you have lived, beginning with the most recent (#1) and working back 5 years. All periods must be accounted for in your list. Be sure to
indicate the actual physical location of your residence: do not use a post office box as an address, do not list a permanent address when you were actually living
at a school address, etc. Be sure to specify your location as closely as possible: for example, do not list only your base or ship, list your barracks number or
home port. You may omit temporary military duty locations under 90 days (list your permanent address instead), and you should use your APO/FPO address if
you lived overseas.
For any address in the last 3 years, list a person who knew you at that address, and who preferably still lives in that area (do not list people for residences
completely outside this 3-year period, and do not list your spouse, former spouses, or other relatives).
Month/Year Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

Name of Person Who Knows You

Street Address

Apt. #

City (Country)

State

ZIP Code

Month/Year Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

Name of Person Who Knew You

Street Address

Apt. #

City (Country)

State

ZIP Code

Month/Year Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

Name of Person Who Knew You

Street Address

Apt. #

City (Country)

State

ZIP Code

Month/Year Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

Name of Person Who Knew You

Street Address

Apt. #

City (Country)

State

ZIP Code

Month/Year Month/Year

Street Address

Apt. #

City (Country)

State

ZIP Code

Street Address

Apt. #

City (Country)

State

ZIP Code

#1

To

#2

Present

To

#3

To

#4

To

#5

To

Name of Person Who Knew You

9

WHERE YOU WENT TO SCHOOL
List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 5 years. List all College or
University degrees and the dates they were received. If all of your education occurred more than 5 years ago, list your most recent education beyond high
school, no matter when that education occurred.
l Use one of the following codes in the "Code" block:

1 - High School

2 - College/University/Military College

3 - Vocational/Technical/Trade School

l For correspondence schools and extension classes, provide the address where the records are maintained.

Month/Year

Month/Year

Code

Name of School

Degree/Diploma/Other

Month/Year Awarded

#1
To
Street Address and City (Country) of School

Month/Year

Month/Year

Code

State

Name of School

Degree/Diploma/Other

ZIP Code

Month/Year Awarded

#2
To
Street Address and City (Country) of School

Month/Year

Month/Year

Code

State

Name of School

Degree/Diploma/Other

ZIP Code

Month/Year Awarded

#3
To
Street Address and City (Country) of School

Enter your Social Security Number before going to the next page

Page 2

State

ZIP Code

10

YOUR EMPLOYMENT ACTIVITIES
List your employment activities, beginning with the present (#1) and working back 5 years. You should list all full-time work, part-time work, military
service, temporary military duty locations over 90 days, selt-employment, other paid work, and all periods of unemployment. The entire 5-year period must
be accounted for without breaks, but you need not list employments before your 16th birthday.
l Code. Use one of the codes listed below to identify the type of employment:

1234-

Active military duty stations
National Guard/Reserve
U.S.P.H.S. Commissioned Corps
Other Federal employment

5 - State Government (Non-Federal employment)
6 - Self-employment (Include business name
and/or name of person who can verify)

7 - Unemployment (Include name
of person who can verify)
8 - Federal Contractor (List Contractor, not Federal agency)

9 - Other

l Employer/Verifier Name. List the business name of your employer or the name of the person who can verify your self-employment or unemployment in

this block. If military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate
listings to reflect changes in your military duty locations or home ports.
l Previous Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same location. After entering the

most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines
provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning
the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of employment on the lines
below that information.
Month/Year

#1

Month/Year
To

Code Employer/Verifer Name/Military Duty Location

Your Position Title/Military Rank

Present
City (Country)

State

ZIP Code

Telephone Number

Street Address of Job Location (if different than Employer's Address)

City (Country)

State

ZIP Code

Telephone Number

Supervisor's Name & Street Address (if different than Job Location)

City (Country)

State

ZIP Code

Telephone Number

PREVIOUS PERIODS
OF ACTIVITY (Block #1)

Employer's/Verifier's Street Address

Month/Year

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

To
Month/Year
To
Month/Year
To

Month/Year

#2

Month/Year

Code Employer/Verifier Name/Military Duty Location

Your Position Title/Military Rank

To

City (Country)

State

ZIP Code

Telephone Number

Street Address of Job Location (if different than Employer's Address)

City (Country)

State

ZIP Code

Telephone Number

Supervisor's Name & Street Address (if different than Job Location)

City (Country)

State

ZIP Code

Telephone Number

PREVIOUS PERIODS
OF ACTIVITY (Block #2)

Employer's/Verifier's Street Address

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

To
Month/Year
To
Month/Year
To

Month/Year

#3

Month/Year

Month/Year

Code Employer/Verifier Name/Military Duty Location

Your Position Title/Military Rank

To

City (Country)

State

ZIP Code

Telephone Number

Street Address of Job Location (if different than Employer's Address)

City (Country)

State

ZIP Code

Telephone Number

Supervisor's Name & Street Address (if different than Job Location)

City (Country)

State

ZIP Code

Telephone Number

PREVIOUS PERIODS
OF ACTIVITY (Block #3)

Employer's/Verifier's Street Address

Month/Year

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

To
Month/Year
To
Month/Year
To

Enter your Social Security Number before going to the next page

Page 3

YOUR EMPLOYMENT ACTIVITIES (CONTINUED)
Month/Year

#4

Month/Year

Code Employer/Verifier Name/Military Duty Location

Your Position Title/Military Rank

To

City (Country)

State

ZIP Code

Telephone Number

Street Address of Job Location (if different than Employer's Address)

City (Country)

State

ZIP Code

Telephone Number

Supervisor's Name & Street Address (if different than Job Location)

City (Country)

State

ZIP Code

Telephone Number

PREVIOUS PERIODS
OF ACTIVITY (Block #4)

Employer's/Verifier's Street Address

Month/Year

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

To
Month/Year
To
Month/Year
To

Month/Year

#5

Month/Year

Code Employer/Verifier Name/Military Duty Location

Your Position Title/Military Rank

To

City (Country)

State

ZIP Code

Telephone Number

Street Address of Job Location (if different than Employer's Address)

City (Country)

State

ZIP Code

Telephone Number

Supervisor's Name & Street Address (if different than Job Location)

City (Country)

State

ZIP Code

Telephone Number

PREVIOUS PERIODS
OF ACTIVITY (Block #5)

Employer's/Verifier's Street Address

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

To
Month/Year
To
Month/Year
To

Month/Year

#6

Month/Year

Month/Year

Code Employer/Verifier Name/Military Duty Location

Your Position Title/Military Rank

To

City (Country)

State

ZIP Code

Telephone Number

Street Address of Job Location (if different than Employer's Address)

City (Country)

State

ZIP Code

Telephone Number

Supervisor's Name & Street Address (if different than Job Location)

City (Country)

State

ZIP Code

Telephone Number

PREVIOUS PERIODS
OF ACTIVITY (Block #6)

Employer's/Verifier's Street Address

11

#1

Month/Year

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

Month/Year

Position Title

Supervisor

To
Month/Year
To
Month/Year
To

PEOPLE WHO KNOW YOU WELL
List three people who know you well and live in the United States. They should be good friends, peers, colleagues, college roommates, etc., whose
combined association with you covers as well as possible the last 5 years. Do not list your spouse, former spouses, or other relatives, and try not to list
anyone who is listed elsewhere on this form.

Name

Dates Known
Month/Year
Month/Year
To

Home or Work Address

#2

Name

City (Country)
Dates Known
Month/Year
Month/Year
To

Home or Work Address

#3

Name

Dates Known
Month/Year
Month/Year
To

Enter your Social Security Number before going to the next page

City (Country)

State

ZIP Code

State

ZIP Code

State

ZIP Code

Telephone Number
( ) Day
( ) Night

City (Country)

Home or Work Address

Page 4

Telephone Number
( ) Day
( ) Night

Telephone Number
( ) Day
( ) Night

12

YOUR SELECTIVE SERVICE

Yes

No

Yes

No

a Are you a male born after December 31, 1959? If "No," go to 13. If "Yes," go to b.
b Have you registered with the Selective Service System? If "Yes", provide your registration number. If "No," show the reason for your
legal exemption below.

Registration Number

Legal Exemption Explanation

YOUR MILITARY

13

a Have you served in the United States military?
b Have you served in the United States Merchant Marine?
List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of
service (#1) and work backward. If you had a break in service, each separate period should be listed.
Code. Use one of the codes listed below to identify your branch of service:
1 - Air Force

2 - Army

3 - Navy

4 - Marine Corps

5 - Coast Guard

6 - Merchant Marine

7 - National Guard

O/E. Mark "O" block for Officer or "E" block for Enlisted.
Status. "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use an
"X": use the two-letter code for the state to mark the block.
Country. If your service was with other than the U.S. Armed Forces, identify the country for which you served.
Month/Year

Month/Year

Code

Service/Certificate #

O E
Active

Active
Reserve

Status
Inactive
Reserve

Country
National Guard
(State)

To

To

14

Yes

No

ILLEGAL DRUGS
In the last year, have you used, possessed, supplied, or manufactured illegal drugs? When used without a prescription, illegal drugs include
marijuana, cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), stimulants (cocaine, amphetamines, etc.), depressants
(barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.). (NOTE: Neither your truthful response nor information
derived from your response will be used as evidence against you in any subsequent criminal proceeding.)
If you answered "Yes," provide information relating to the types of substance(s), the nature of the activity, and any other details relating to your
involvement with illegal drugs. Include any treatment or counseling received.
Month/Year

Month/Year Type of Substance

Explanation

To
To
To

Continuation Space
Use the continuation sheet(s) (SF86A) for additional answers to items 8, 9, and 10. Use the space below to continue answers to all other items and any information
you would like to add. If more space is needed than is provided below, use a blank sheet(s) of paper. Start each sheet with your name and Social Security number.
Before each answer, identify the number of the item.

After completing this form you should review your answers to all questions to make sure the form is
complete and accurate, and then sign and date the following certification and sign and date the release on page 6.

Certification That My Answers Are True
My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and
are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or
imprisonment or both. (See section 1001 of title 18, United States Code).
Signature (Sign in ink)

Date

Enter your Social Security Number before going to the next page

Page 5

Form approved:
O.M.B. No. 3206-0005
NSN 7540-00-634-4035
85-111

Standard Form 85
Revised September 1995
U.S. Office of Personnel Management
5 CFR Parts 731 and 736

UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF INFORMATION
Carefully read this authorization to release information about you, then sign and date it in black ink.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized
Federal agency conducting my background investigation, to obtain any information relating to my
activities from schools, residential management agents, employers, criminal justice agencies, retail
business establishments, or other sources of information. This information may include, but is not
limited to, my academic, residential, achievement, performance, attendance, disciplinary,
employment history, and criminal history record information.
I Understand that, for some sources of information, a separate specific release will be needed, and
I may be contacted for such a release at a later date.
I Authorize custodians of records and sources of information pertaining to me to release such
information upon request of the investigator, special agent, or other duly accredited representative
of any Federal agency authorized above regardless of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for
official use by the Federal Government only for the purposes provided in this Standard Form 85,
and may be redisclosed by the Government only as authorized by law.
Copies of this authorization that show my signature are as valid as the original release signed by
me. This authorization is valid for two (2) years from the date signed.

Signature (Sign in ink)

Full Name (Type or Print Legibly)

Other Names Used
Current Address (Street, City)

Page 6

Date Signed

Social Security Number
State ZIP Code

Home Telephone Number
(Include Area Code)