Guide

SF 85P Content Guide_revised for 30 Day Notice-FINAL DMS.DOC

SF 85P Questionnaire for Public Trust Positions and SF 85PS Supplemental Questionnaire for Selected Positions

Guide

OMB: 3206-0258

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3206-0258 can be found here:

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Questionnaire for Public Trust Positions

OMB No. 3206–XXXX
Form: SF 85P

Interactive/Branching

Electronic Questionnaire

Questionnaire

Content Guide

(DRAFT for 30 Day Notice)

OFFICE OF PERSONNEL MANAGEMENT

Questionnaire for Public Trust Positions, SF 85P

Questionnaire for Public Trust Positions

Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the office that provided you the form.

All questions on this form must be answered completely and truthfully in order that the Government may make the determinations described below on a complete record. Penalties for inaccurate or false statements are discussed below. If you are a current civilian employee of the federal government: failure to answer any questions completely and truthfully could result in an adverse personnel action against you, including loss of employment; with respect to Sections 21, 25, and 27, however, neither your truthful responses nor information derived from those responses will be used as evidence against you in a subsequent criminal proceeding.

Note: If you complete the SF 85P, an Authorization for Release of Medical Information Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) will be provided to you only in the event information arises in an investigation that requires further inquiry for resolution, and only to resolve such issues. This release authorizes an investigator to ask your health practitioner(s) only the questions specified on the release concerning mental health consultations of which the practitioner might be aware. If you are completing the SF 85P with the supplemental SF 85P-S, this release will be provided to you if you respond “yes” to the question regarding Your Medical Record. You may also be asked to complete a specific release if more detailed information is needed from your provider.

Purpose of this Form

This form will be used by the United States (U.S.) Government in conducting background investigations and reinvestigations of persons under consideration for, or retention of, public trust positions as defined in 5 CFR 731. This form may also be used by agencies in determining whether a subject performing work for, or on behalf of, the Government under a contract should be deemed eligible for logical or physical access when duties to be performed by an employee of a contractor are equivalent to the duties performed by an employee in a public trust position. For applicants, this form is to be used only after a conditional offer of employment has been made. This form is not to be used for National Security sensitive positions.

Providing this information is voluntary. If you do not provide each item of requested information, however, we will not be able to complete your investigation, which will adversely affect your eligibility for a public trust position or your ability to obtain or retain Federal or contract employment, or logical or physical access. It is imperative that the information provided be true and accurate, to the best of your knowledge. Any information that you provide is evaluated on the basis of its currency, seriousness, relevance to the position and duties, and consistency with all other information about you. Withholding, misrepresenting, or falsifying information may affect your eligibility for a public trust position, or your ability to obtain or retain Federal or contract employment. In addition, withholding, misrepresenting, or falsifying information may affect your eligibility for physical and logical access to federally controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also negatively affect your employment prospects and job status, and the potential consequences include, but are not limited to, removal, debarment from Federal service, or prosecution.

This form is a permanent document that may be used as the basis for future investigations, suitability or fitness for Federal employment, fitness for contract employment, or eligibility for physical and logical access to federally controlled facilities or information systems. Your responses to this form may be compared with your responses to previous SF 85P questionnaires.

The investigation conducted on the basis of information provided on this form may be selected for studies and analyses in support of evaluating and improving the effectiveness and efficiency of the investigative and adjudicative methodologies. All study results released to the general public will delete personal identifiers such as name, social security number, and date and place of birth.

Authority to Request this Information

Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under Executive Orders 10450, and 10577, 13467, and 13488; sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 731, and 736 of title 5, Code of Federal Regulations (CFR), and Federal information processing standards..

Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397.

The Investigative Process

Background investigations for public trust positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and loyal to the U.S. The information that you provide on this form and your Declaration for Federal Employment (OF 306) may be confirmed during the investigation. The investigation may extend beyond the time covered by this form, when necessary to resolve issues. Your current employer may be contacted as part of the investigation, although you may have previously indicated on applications or other forms that you do not want your current employer to be contacted. If you have a security freeze on your consumer or credit report file, then we may not be able to complete your investigation, which can adversely affect your eligibility for a public trust position or your ability to obtain Federal or contract employment. To avoid such delays, you should must request that the consumer reporting agencies lift the freeze in these instances.

In addition to the questions on this form, inquiry also is made about your adherence to security requirements your honesty and integrity, falsification, misrepresentation, and any other behavior, activities, or associations that tend to demonstrate a person is not reliable, trustworthy, or loyal.

After a suitability determination is made, you may also be subject to periodic reinvestigations to ensure your continuing suitability for employment.

Your Personal Interview

Some investigations will include an interview with you as a routine part of the investigative process. The investigator may ask you to explain your answers to any question on this form. This provides you the opportunity to update, clarify, and explain information on your form more completely, which often assists in completing your investigation. It is imperative that the interview be conducted immediately as soon as possible after you are contacted. Postponements will delay the processing of your investigation, and declining to be interviewed may result in your investigation being delayed or canceled.

For the interview, you will be required to provide photo identification, such as a valid state driver's license. You may be required to provide other documents to verify your identity, as instructed by your investigator. These documents may include certification of any legal name change, Social Security card, passport, and/or your birth certificate. You may also be asked to provide documents regarding information that you provide on this form, or about other matters requiring specific attention. These matters include (a) alien registration or naturalization documentation; (b) delinquent loans or taxes, bankruptcies, judgments, liens, or other financial obligations; (c) agreements involving child custody or support, alimony, or property settlements; (d) arrests, convictions, probation, and/or parole; or (e) other matters described in court records.

Instructions for Completing this Form (Electronic)

1. Follow the instructions provided to you by the office that gave you this form and any other clarifying instructions, provided by that office, to assist you with completion of this form. You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.

2. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box, unless otherwise noted.

3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the country dropdown feature.

4. When entering a U.S. address or location, select the state or territory from the "States" dropdown list that will be provided. For locations outside of the U.S. and its territories, select the country in the "Country" dropdown list and leave the "State" field blank.

5. Do not abbreviate the names of cities or foreign countries.

6. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes.

7. For telephone numbers in the U.S., ensure that the area code is included.

8. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use the dropdown lists to select the month and day. The year should be entered as a four character number (i.e., 1978 or 2001.), or selected from a dropdown list. If you are unable to report an exact date, approximate or estimate the date to the best of your ability, and indicate this by checking the "Est." box.

Instructions for Completing this Form (Paper Form Only)

1. Follow the instructions, provided to you by the office that gave you this form and any other clarifying instructions provided by that office to assist you with completion of this form. You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.

2. Type or legibly print your answers in ink. If the form is not legible, it will not be accepted. You may also be asked to submit your form using the approved electronic format.

3. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form with "N/A," unless otherwise noted.

4. Any changes that you make to this form, after you sign it, must be initialed and dated by you. Under extremely limited circumstances, agencies may modify your response(s) with your consent.

5. You must use the Location 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. Whenever "City (Country)" is indicated in an address block, also provide the name of the country in that same block when the address is outside the U.S.

7. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes.

8. For telephone numbers in the U.S., ensure that the area code is included.

9. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use numbers (01-12) to indicate months. For example, July 29, 1968, should be written as 07/29/1968. If you are unable to report an exact date, approximate or estimate the date to the best of your ability, and indicate "APPROX." or "EST" in the field.

10. If additional space is required for an explanation or to list your residences, employment/self- employment/unemployment, or education, you should use a continuation sheet, SF 86A.

If additional space is required to answer other items, use a continuation sheet or a blank sheet(s) of paper. Include your name and SSN at the top of each blank sheet (s) used.

Final Determination on Your Suitability

Final determination on your suitability for a public trust position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made. The United States Government does not discriminate on the basis of prohibited categories, including but not limited to race, color, religion, sex (including pregnancy and gender identity), national origin, disability, and sexual orientation, when making determinations of suitability for a public trust position.

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 and/or up to five (5) years imprisonment. 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 prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any information you provide on this form and to make your comments part of the record.

Disclosure Information

The information you provide is for the purpose of investigating you for a position, and the information will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. The information you provide on this form, and information collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C. 552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register. The office that gave you this form will provide you a copy of its routine uses.

Privacy Act Routine Uses

For Judicial/Administrative Proceedings—To disclose information to another Federal agency, to a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency, when the Government is a party to the judicial or administrative proceeding. In those cases where the Government is not a party to the proceeding, records may be disclosed if a subpoena has been signed by a judge.
For National Archives and Records Administration—To disclose information to the National Archives and Records Administration for use in records management inspections.
Within OPM for Statistical/Analytical Studies—By OPM in the production of summary descriptive statistics and analytical studies in support of the function for which the records are collected and maintained, or for related workforce studies. While published studies do not contain individual identifiers, in some instances the selection of elements of data included in the study may be structured in such a way as to make the data individually identifiable by inference.
For Litigation—To disclose information to the Department of Justice, or an OPM agency representative in a proceeding before a court, adjudicative body, or other administrative body before which OPM is authorized to appear, when: (1) OPM, or any component thereof; or (2) Any employee of OPM in his or her official capacity; or (3) Any employee of OPM in his or her individual capacity where the Department of Justice or OPM has agreed to represent the employee; or (4) The United States, when OPM determines that litigation is likely to affect OPM or any of its components,; is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or OPM is deemed by OPM to be relevant and necessary to the litigation provided, however, that the disclosure is compatible with the purpose for which records were collected.
For the Merit Systems Protection Board—To disclose information to officials of the Merit Systems Protection Board or the Office of the Special Counsel, when requested in connection with appeals, special studies of the civil service and other merit systems, review of OPM rules and regulations, investigations of alleged or possible prohibited personnel practices, and such other functions, e.g., as promulgated in 5 U.S.C. 1205 and 1206, or as may be authorized by law.
For the Equal Employment Opportunity Commission—To disclose information to the Equal Employment Opportunity Commission when requested in connection with investigations into alleged or possible discrimination practices in the Federal sector, compliance by Federal agencies with the Uniform Guidelines on Employee Selection Procedures or other functions vested in the Commission and to otherwise ensure compliance with the provisions of 5 U.S.C. 7201.
For the Federal Labor Relations Authority—To disclose information to the Federal Labor Relations Authority or its General Counsel when requested in connection with investigations of allegations of unfair labor practices or matters before the Federal Service Impasses Panel.
To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government having a need to evaluate qualifications, suitability, and loyalty to the United States Government and/or a security clearance or access determination.
To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government, when such agency, office, or establishment conducts an investigation of the individual for purposes of granting a security clearance, or for the purpose of making a determination of qualifications, suitability, or loyalty to the United States Government, or access to classified information or restricted areas.
To designated officers and employees of agencies, offices, and other establishments in the executive, judicial, or legislative branches of the Federal Government having the responsibility to grant clearances to make a determination regarding access to classified information or restricted areas, or to evaluate qualifications, suitability, or loyalty to the United States Government, in connection with the performance of a service to the Federal Government under a contract or other agreement.
To the intelligence agencies of the Department of Defense, the National Security Agency, the Central Intelligence Agency, and the Federal Bureau of Investigation for use in intelligence activities.
To any source from which information is requested in the course of an investigation, 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.
To the appropriate Federal, state, local, tribal, foreign, or other public authority responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order where OPM becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.
To an agency, office, or other establishment in the executive, legislative, or judicial branches of the Federal Government in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the conducting of a security or suitability investigation of an individual, the classifying of jobs, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency’s decision on the matter.
To provide information to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual. However, the investigative file, or parts thereof, will only be released to a congressional office if OPM receives a notarized authorization or signed statement under 28 U.S.C. 1746 from the subject of the investigation.
To the Office of Management and Budget at any stage in the legislative coordination and clearance process in connection with private relief legislation as set forth in OMB Circular No. A-19.
To disclose information to contractors, grantees, experts, consultants, or volunteers performing or working on a contract, service, or job for the Federal Government.
For agencies that use adjudicative support services of another agency, at the request of the original agency, the results will be furnished to the agency providing the adjudicative support.
To provide criminal history record information to the FBI, to help ensure the accuracy and completeness of FBI and OPM records.

**LOCATION CODES (PAPER FORM ONLY, Electronic forms to use dropdown lists)**

Alabama AL, Alaska AK, Arizona AZ, Arkansas AR, California CA, Colorado CO, Connecticut CT, Delaware DE, District of Columbia DC, Florida FL, Georgia GA, Hawaii HI, Idaho ID, Illinois IL, Indiana IN, Iowa IA, Kansas KS, Kentucky KY, Louisiana LA, Maine ME, Maryland MD, Massachusetts MA, Michigan MI, Minnesota MN, Mississippi MS, Missouri MO, Montana MT, Nebraska NE, Nevada NV, New Hampshire NH, New Jersey NJ, New Mexico NM, New York NY, North Carolina NC, North Dakota ND, Ohio OH, Oklahoma OK, Oregon OR, Pennsylvania PA, Rhode Island RI, South Carolina SC, South Dakota SD, Tennessee TN, Texas TX, Utah UT, Vermont VT, Virginia VA, Washington WA, West Virginia WV, Wisconsin WI, Wyoming WY American Samoa AS, Guam GU, Northern Mariana Islands MP, Puerto Rico PR, Virgin Islands of the U.S. VI

Public Burden Information (Electronic)

Public burden reporting for this collection of information is estimated to average 75 155 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 OPM Forms Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Washington, DC 20415. The OMB clearance number, 3206-XXXX, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

*************PUBLIC BURDEN INFORMATION (PAPER FORM ONLY)**********

Public Burden Information

Public burden reporting for this collection of information is estimated to average 75 155 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 OPM Forms Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Washington, DC 20415. Do not send your completed form to this address; send it to the office that provided you the form. The OMB clearance number, 3206-XXXX, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

--------------------END OF INSTRUCTION PAGES -------------------

PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), or removal and debarment from Federal Service.	YES	NO

Agency Use Block “AUB”

Investigating agency user only			Codes: (FIPC CODES)				Case Number:
FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION PROVIDED IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE, THOSE DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.
A – Type of Investigation		B – Extra coverage / advanced results			C – Sensitivity Risk level			D – Access / Eligibility
E – Nature of action code		F – Date of action			G – Geographic location			H – Position code
I – Position title		J – SON (Submitting Office Number )
K – Location of Official Personnel Folder _ None _ NPRC _ At SON _e-OPF _ Other						Other address / web address of e-OPF			Zip Code
L – SOI (Security Office Identifier)
M – Location of Security Folder _ None _ NPI _ At SOI _e-OPF _ Other						Other address			Zip Code
N – IPAC	O – TAS	P – Obligating document number			Q - BETC	R – Accounting data and /or Agency case number
S – Investigative requirement _Initial _Reinvestigation				T – Requesting Official: Name, Title, Signature, Email Address, Telephone, Date
U – Secondary Requesting Official: Name, Title, Email Address, Telephone Number
V – Applicant Affiliation _ FED CIV _ CON _ MIL _ Other
W – Deployment/PCS (if Imminent): (Paper form not formatted just open block, Electronic Formatted collecting the below information) From-To Dates, Reason(s) for temporary duty assignment, point of contact at location, address/unit/duty location
Agency Special Instructions for the Investigative Service Provider: e-QIP Only – Used in place of a hardcopy cover memo

Beginning of Questionnaire

FOR REFERENCE ONLY, NOT A FORM FOR COMPLETION

Section 1 – Full Name

Provide your full name. If you have only initials in your name, provide them and indicate “Initial only”. If you do not have a middle name, indicate “No Middle Name”. If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Last

First

Middle

Suffix

Section 2 – Date of Birth

Provide your date of birth.

Date (Estimated)

Section 3 – Place of Birth

Provide your Place of birth.

City

County

State

Country

Section 4 – SSN

Provide your U.S. Social Security Number.

□ Not applicable _ _ _-_ _-_ _ _ _

Section 5 – Other Names Used

Provide your other names used and the period of time you used them (for example: your maiden name, name(s) by a former marriage (s), former name(s), alias (es), or nickname(s)).

Have you used any other names?

YES

Branch

If Yes to “Other Names”

(Multiple Entries Allowed)

Provide your other name used and the period of time you used it [for example: your maiden name, name by a former marriage, former name, alias, or nickname]. If you have only initials in your name, provide them and indicate “Initial only.” If you do not have a middle name, indicate “No Middle Name” (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Provide other name used.

Last

First

Middle

Suffix

Maiden name?

Yes

Provide dates used.

From Date (Estimated)

To Date (Estimated/Present)

Provide the reason(s) why the name changed.

Reason: (Free Text)

Summary of other names used:

Do you have additional names to enter?

Yes (Yes adds another entry)

No (Required to pass validation)

Section 6 – Your Identifying Information

Provide your Identifying Information

Height

(feet)

(inches)

Weight (in pounds)

Hair Color

Eye Color

Sex (M/F)

Section 7 – Your Contact Information

Provide your contact information

Home email address

Email (Free Text)

Work email address

Email (Free Text)

Home telephone number

Work telephone number

Mobile/Cell telephone number

Section 8 – U.S. Passport Information

Do you possess a U.S. passport (current or expired)?

YES

Branch

If Yes to “passport”

Provide the following information for the most recent U.S. passport you currently possess:

Provide your passport number

Passport (Free Text)

Click HERE for U.S. State Department passport help. http://travel.state.gov/passport

Provide the issue date of passport.

Date (Estimated)

Provide the expiration date of passport.

Date (Estimated)

Provide the name in which passport was first issued.

Last

First

Middle

Suffix

Section 9 – Citizenship

Select the box that reflects your current citizenship status and click Save.

Provide your current citizenship status: □ I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.

□ I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country. □ I am a naturalized U.S. citizen. □ I am not a U.S. citizen.

Branch

Foreign Born to U.S. Parents in a Foreign Country

You answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.

Provide type of documentation of U.S. citizen born abroad.

(FS) 240, DS 1350 FS545, Other (Provide explanation)

Explanation

Provide document number for U.S. citizen born abroad:

Document Number (Free Text)

Provide the date the document was issued.

Date (Estimated)

Provide the place of issuance.

City

State

Country

Provide the name in which document was issued.

Last

First

Middle

Suffix

Provide your citizenship certificate number.

Certificate Number (Free Text)

Provide the place of issuance.

City

State

Court

Provide the date the certificate was issued.

Date (Estimated)

Provide the name in which the certificate was issued.

Last

First

Middle

Suffix

Were you born on a U.S. military installation?

YES

Branch If Yes

You answered that you were born on a U.S. military installation.

Provide the name of the base.

Name (Free Text)

Branch

Citizenship Naturalized U.S. Citizen

You answered that you are a naturalized U.S. citizen.

Provide the date of entry into the U.S.

Date (Estimated)

Provide the location of entry into the U.S.

City

State

Provide country(ies) of prior citizenship.

Country (Allows for Multiples)

Do/did you have a U.S. alien registration number?

YES

Branch If Yes

Provide your U.S. alien registration number.

Alien Registration Number (Free Text)

Provide your citizenship certificate number.

Citizenship Certificate Number (Free Text)

Provide the location of the court where the citizenship certificate was issued.

Court (Free Text)

Street

City

State

Zip

Provide the date the citizenship certificate was issued.

Date (Estimated)

Provide the name in which the citizenship certificate was issued.

Last

First

Middle

Suffix

Provide your naturalization certificate number.

Naturalization Certificate Number (Free Text)

Provide the location of the court where naturalization certificate was issued.

Court (Free Text)

Street

City

State

Zip

Provide the date the naturalization certificate was issued.

Date (Estimated)

Provide the name in which the naturalization certificate was issued.

Last

First

Middle

Suffix

Provide the basis of naturalization. - Based on my own individual naturalization application,

- By operation of law through my U.S. citizen parent. - Other (Provide explanation)

Explanation

Branch

Citizenship Not a U.S. citizen

Not a U.S. Citizen

Provide your residence status.

Status (Free Text)

Provide the date of entry into the U.S.

Date (Estimated)

Provide your country of citizenship.

Provide your place of entry in the U.S.

City (Free Text)

State

Provide your alien registration number.

Registration Number (Free Text)

Provide type of document issued. (I-94, etc.)

I-94, U.S. Visa, Other (Provide explanation)

Explanation

Provide document number:

Document Number (Free Text)

Provide the name in which the document was issued.

Last

First

Middle

Suffix

Provide the date document was issued.

Date (Estimated)

Provide the expiration date of visa.

Date (Estimated)

Section 10 – Dual/Multiple Citizenship & Foreign Passport Information

Do you now or have you EVER held dual/multiple citizenships?

YES

Branch

Dual/Multiple Citizenship

(Multiple Entries Allowed)

You answered “Yes” to having EVER held dual/multiple citizenship

Provide country of citizenship

During what period of time did you hold citizenship with this country?

Provide the date range that you held this citizenship; beginning with the date it was acquired through its termination or “Present,” whichever is appropriate.

From Date (Estimated)

To Date (Estimated/Present)

How did you acquire this non-U.S. citizenship you now have or previously had?

How (Free Text)

Branch

If Present/Current

Do you currently hold citizenship with this country?

YES

Provide explanation:

Summary of dual/multiple citizenships you have listed:

Do you have an additional citizenship to provide?

YES (Yes adds another entry)

NO (Required to validate)

Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?

YES

Branch

Foreign Passport (or Identity Card)

(Multiple Entries Allowed)

You responded “Yes” to having been issued a passport (or identity card for travel) by a country other than the U.S.

Provide the country in which the passport (or identity card) was issued.

Country:

Provide the date the passport (or identity card) was issued.

Date (Estimated)

Provide the place the passport (or identity card) was issued.

City

Country

Provide the name in which passport (or identity card) was issued:

Last

First

Middle

Suffix

Provide the passport (or identity card) number.

Passport# (Free Text)

Provide the passport (or identity card) expiration date.

Date (Estimated)

Have you EVER used this passport (or identity card) for foreign travel?

YES

Branch

(Multiple Entries Allowed)

Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each

Country

From Date (Estimated)

To Date (Est/Pres)

Do you have an additional foreign passport (or identity card) to report?

YES

(Yes adds another entry)

(Required to validate)

Section 11 – Where You Have Lived

List the places where you have lived beginning with your present residence and working back 7 years. Residences for the entire period must be accounted for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you

were not physically located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list residence before your 18th birthday unless to provide a minimum of 2 years residence history.

You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.

For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew you well for residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives.

Enter residence information. (Multiple Entries Allowed)

Provide dates of residence.

From Date (Estimated)

To Date (Estimated/Present)

Is/was this residence: □ Owned by you □ Rented or leased by you □ Military housing □ Other (Provide explanation)

Explanation (Free Text)

Provide the street address.

Street address and City

State and Zip Code or Country

Branch

Physical Location

You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:

Street Address/Unit/Duty Location:

City or Post Name

Provide State for ports in United States, or Country location.

State and Zip Code or Country

Branch

APO/FPO Address

You have indicated an address outside of the U.S.

Do/did you have an APO/FPO address while at this location

Yes

Branch If Yes

Provide APO/FPO address:

Address

APO or FPO

APO/FPO State Code

Zip Code

Branch

Person Who Knew you

(if address dates within last 3 years)

Provide the name of a neighbor or other person who knows you at this address.

Provide the full name:

Last

First

Middle

Suffix

Provide date of last contact:

Date (Estimated)

Provide your relationship to this person (check all that apply)

□ Neighbor □ Friend □ Landlord □ Business associate

□ Other (Provide explanation) Explanation (Free Text)

Provide the following contact information for this person :

Provide evening phone number for this person:

Number/Ext

Provide daytime phone number for this person:

Number/Ext

Provide cell/mobile phone number for this person:

Number/Ext

Provide e-mail address for this person:

Email (Free Text)

Provide street address for this person (including apt number).

Street address and City

State and Zip Code or Country

Branch

Physical Location

Street Address/Unit/Duty Location:

City or Post Name

Provide State for ports in United States, or Country location.

State and Zip Code or Country

Branch

APO/FPO Address

You have indicated an address outside of the U.S.

Does the person who knew you have an APO/FPO address?

Yes

Branch If Yes

Provide APO/FPO address:

Address

APO or FPO

APO/FPO State Code

Zip Code

Do you have an additional residence to report?

YES (Yes adds another entry)

NO (Required to validate)

Section 12 – Where You Went to School
Do not list education before your 18th birthday, unless to provide a minimum of two years education history. (Multiple Entries Allowed)
Have you attended any schools in the last 7 years?								YES	NO
Branch If Yes to Attending Schools	Have you received a degree or diploma more than 7 years ago?							YES	NO
	Branch If Yes to Receiving Degree	Provide the dates of attendance.		From Date (Estimated)	To Date (Estimated/Present)
		Select the most appropriate box to describe your school. □ High School □ College/University/Military College □ Vocational/Technical/Trade School □ Correspondence/Distance/Extension/Online School
		Provide the name of the school:			Name (Free Text)
		Provide the street address of the school. For correspondence/distance/ extension/online schools, provide the address where the records are maintained. For assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx			Street address and City
					State and Zip Code or Country
		For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago.
		Provide the name of person who knows/knew you at school (for correspondence/distance/extension/ online schools, list someone who knew you while you received this education): □ I don’t know						Name (Free Text)
		Provide current address for this person (including apartment number).
		Street address and City			State and Zip Code or Country
		Provide telephone number for this person.			Number/Ext
		Provide email address for this person: □ I don’t know			Email (Free Text)
		Did you receive a degree/diploma?						YES	NO
		Branch If Yes to Receiving Degree	Provide type of degrees(s)/diploma(s) received and date(s) awarded:
			Degree/diploma • High School Diploma • Associate’s • Bachelor’s • Master’s • Doctorate • Professional Degree (e.g. MD, DVM, JD) • Other		Other degree/diploma
					Other Degree (Free Text)
					Month / Year	Date (Estimated)
		Do you have additional education to enter (include education within the last 7 years, as well as degrees or diplomas more than 7 years ago)?			YES (Yes adds another entry)		NO (Required to validate)

Section 13a – Employment Activities – Employment & Unemployment Record

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

(Multiple Entries Allowed)

Select your employment activity: □ Active military duty station □ National Guard/Reserve □ USPHS Commissioned Corps

□ Other Federal employment □ State Government (Non-Federal employment) □ Self-employment □ Unemployment

□ Federal Contractor □ Non-government employment (excluding self-employment) □ Other (Provide explanation)

Other Type Explanation (Free Text)

Provide dates of employment.

From Date (Estimated)

To Date (Estimated/Present)

Branch

If Employment Type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps

Active Duty, National Guard/Reserve, or USPHS Commissioned Corps

Select the employment status for this position: □ Full-time □ Part-time

Provide your assigned duty station during this period.

Duty station (Free Text)

Provide your most recent rank/position title.

Rank/position (Free Text)

Provide address of duty station.

Street address and City

State and Zip Code or Country

Telephone number

Number/Ext.

Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment as entries below). Not Applicable □ (Multiple Entries Allowed)

Dates of employment

From Date (Estimated)

To Date (Estimated/Present)

Position title

Position (Free Text)

Supervisor

Supervisor (Free Text)

Branch

Physical Location

You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:

Street Address/Unit/Duty Location:

City or Post Name:

Provide state for ports in the United States, or country location.

State and Zip Code or Country

Branch

APO/FPO Address

You have indicated an address outside of the United States. Do you or did you have an APO/FPO address while at this location?

YES

Branch If Yes

Provide APO/FPO address:

Address

APO/FPO

APO/FPO State

Zip Code

Provide the name of your supervisor.

Supervisor name (Free Text)

Provide the rank/position title of your supervisor.

Supervisor rank/position (Free Text)

Provide the email address of your supervisor. □ I don’t know

Supervisor email (Free Text)

Provide the physical work location of your supervisor.

Street address and City

State and Zip Code or Country

Provide supervisor telephone number

Number/Ext.

Branch

Physical Location

You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your supervisor:

Street Address/Unit/Duty Location:

City or Post Name:

Provide state for ports in the United States, or country location.

State and Zip Code or Country

Branch

APO/FPO Address

You have indicated an address outside of the United States. Did/does your supervisor have an APO/FPO address while at this location?

YES

Branch if Yes

Provide APO/FPO address:

Address

APO/FPO

APO/FPO State

Zip Code

Branch

If Employment Type is Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other

Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other

Provide most recent position title.

Position (Free Text)

Select the employment status for this position: □ Full-time □ Part-time

Provide the name of your employer

Employer name (Free Text)

Provide the address of employer

Street address and City

State and Zip Code or Country

Provide telephone number

Number/Ext.

Dates of employment

From Date (Estimated)

To Date (Estimated/Present)

Position title

Position (Free Text)

Supervisor

Supervisor (Free Text)

Is/was your physical work address different than your employer’s address?

YES

Branch

Physical Location

Provide the work address where you are/were physically located.

Street address and City

State and Zip Code or Country

Provide telephone number:

Number/Ext.

Branch

Physical Location

Street Address/Unit/Duty Location:

City or Post Name:

Provide state for ports in the United States, or country location.

State and Zip Code or Country

Branch

APO/FPO Address

You have indicated an address outside of the United States. Do you or did you have an APO/FPO address while at this location?

YES

Branch if Yes

Provide APO/FPO address:

Address

APO/FPO

APO/FPO State

Zip Code

Provide the name of your supervisor.

Supervisor name (Free Text)

Provide the position title of your supervisor.

Supervisor position (Free Text)

Provide the email address of your supervisor. □ I don’t know

Supervisor email (Free Text)

Provide the physical work location of your supervisor.

Street address and City

State and Zip Code or Country

Provide supervisor telephone number

Number/Ext.

Branch

Physical Location

Street Address/Unit/Duty Location:

City or Post Name:

Provide state for ports in the United States, or country location.

State and Zip Code or Country

Branch

APO/FPO Address

You have indicated an address outside of the United States. Did/does your supervisor have an APO/FPO address while at this location?

YES

Branch if Yes

Provide APO/FPO address:

Address

APO/FPO

APO/FPO State

Zip Code

Branch

If Employment Type is Self-Employment

Self-Employment

Provide most recent position title.

Position (Free Text)

Select the employment status for this position: □ Full-time □ Part-time

Provide the name of your employment

Employment name (Free Text)

Provide the address of employer

Street address and City

State and Zip Code or Country

Provide telephone number

Number/Ext.

Is your physical work address different than your employment address?

YES

Branch

Physical Location

Provide the work address where you are/were physically located.

Street address and City

State and Zip Code or Country

Provide telephone number:

Number/Ext.

Branch

Physical Location

Street Address/Unit/Duty Location:

City or Post Name:

Provide state for ports in the United States, or country location.

State and Zip Code or Country

Branch

APO/FPO Address

You have indicated an address outside of the United States. Do you or did you have an APO/FPO address while at this location?

YES

Branch if Yes

Provide APO/FPO address:

Address

APO/FPO

APO/FPO State

Zip Code

Provide the name of someone that can verify your self-employment.

Last

First

Provide the address of this verifier.

Street address and City

State and Zip Code or Country

Provide the telephone number for this person

Number/Ext.

Branch

Verifier

Physical Location

You have indicated an APO/FPO address for your self employment verifier; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data for this person

Street Address/Unit/Duty Location:

City or Post Name:

Provide state for ports in the United States, or country location.

State and Zip Code or Country

Branch

Verifier

APO/FPO Address

You have indicated an address outside of the United States. Does your self employment verifier have an APO/FPO address?

YES

Branch if Yes

Provide APO/FPO address for this person:

Address

APO/FPO

APO/FPO State

Zip Code

Branch

If Employment Type is Unemployment

Unemployment

Provide the name of someone who can verify your unemployment activities and means of support

Last

First

Provide the address of this verifier.

Street address and City

State and Zip Code or Country

Provide the telephone number for this person

Number/Ext.

Branch

Verifier

Physical Location

You have indicated an APO/FPO address for your unemployment verifier; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data for this person:

Street Address/Unit/Duty Location:

City or Post Name:

Provide state for ports in the United States, or country location.

State and Zip Code or Country

Branch

Verifier

APO/FPO Address

You have indicated an address outside of the United States. Does your unemployment verifier have an APO/FPO address?

YES

Branch if Yes

Provide APO/FPO address for this person:

Address

APO/FPO

APO/FPO State

Zip Code

Branch

If Employment Type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, Unemployment, or Other

Provide the reason for leaving the employment activity.

Reason (Free Text)

For this employment have any of the following happened to you in the last seven (7) years?

• Fired • Quit after being told you would be fired • Left by mutual agreement following charges or allegations of misconduct • Left by mutual agreement following notice of unsatisfactory performance

YES

Branch

If Fired, Quit, Left by Mutual Agreement, or Left After Unsatisfactory Performance

(Multiple Entries Allowed)

Select the type of incident: • Fired • Quit after being told you would be fired

• Left by mutual agreement following charges or allegations of misconduct

• Left by mutual agreement following notice of unsatisfactory performance

Branch

If Fired

Provide the reason for being fired.

Reason (Free Text)

Provide the date you were fired.

Date (Estimated)

Branch

If Quit

Provide the reason for quitting.

Reason (Free Text)

Provide the date you quit after being told you would be fired.

Date (Estimated)

Branch

If Left after Charges

Provide the charges or allegations of misconduct.

Charges (Free Text)

Provide the date you left following charges or allegations of misconduct.

Date (Estimated)

Branch

If Left Unsatisfactory performance

Provide the reason(s) for unsatisfactory performance.

Reason (Free Text)

Provide the date you left by mutual agreement following a notice of unsatisfactory performance.

Date (Estimated)

In the last seven (7) years do you have another reason for leaving to report for this employment?

YES (Yes adds another entry)

NO (Required to validate)

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?

YES

Branch

If Disciplined, Warned, Reprimanded, or Suspended

(Multiple Entries Allowed)

Officially reprimanded, suspended, or disciplined for misconduct.

Provide the month and year you were warned, reprimanded, suspended or disciplined.

Date (Estimated)

Provide the reason(s) for being warned, reprimanded, suspended or disciplined

Reason (Free Text)

Do you have another instance of discipline or a warning to provide?

YES (Yes adds another entry)

NO (Required to validate)

Do you have an additional employment activity to enter?

YES (Yes adds another entry)

NO (Required to validate)

Section 13b – Employment Activities – Former Federal Service

Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?

YES

Branch

If Yes to Former Federal Service

(Multiple Entries Allowed)

Former Federal Service Detail

Provide dates of federal civilian employment.

From Date (Estimated)

To Date (Est/Present)

Provide the name of the federal agency for which you are/were employed.

Name

Provide your position title.

Position title (Free Text)

Provide the location of the agency

Street address and City

State and Zip Code or Country

Do you have additional former federal civilian employment, excluding military service, NOT indicated previously, to report?

YES (Yes adds another entry)

NO (Required to validate)

Section 13c – Employment Record

Have any of the following happened to you in the last seven (7) years at employment activities that you have not previously listed? (If Yes, you will be required to add an additional employment in Section 13a) • Fired from a job? • Quit a job after being told you would be fired?

• Have you left a job by mutual agreement following charges or allegations of misconduct?

• Left a job by mutual agreement following notice of unsatisfactory performance?

• Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as violation of a security policy?

YES

Section 14 – Selective Service Record
Were you born a male after December 31, 1959?				YES	NO
Branch If Yes to Born Male After 12/31/1959	Selective Service Registration
	Have you registered with the Selective Service System (SSS)		I don’t know	YES	NO
	Branch If Yes	The Selective Service website, www.sss.gov, can help provide the registration number for persons who have registered. Note: Selective Service Number is not your Social Security Number
		Provide registration number:	Registration number (Free Text)
	Branch If No	You responded 'No' to having registered with the Selective Service System (SSS)
		Provide explanation	Explanation (Free Text)
	Branch If I Don’t Know	You responded 'I don't know' to having registered with the Selective Service System (SSS)
		Provide explanation	Explanation (Free Text)

Section 15 – Military History

Have you EVER served in the U.S. Military?

YES

Branch

If Yes to Serving in the U.S. Military

(Multiple Entries Allowed)

You responded ‘Yes’ to having served in the U.S. Military:

Provide the branch of service you served in:

□ Army □ Army National Guard

□ Navy □ Air Force □ Air National Guard

□ Marine Corps □ Coast Guard

State if National Guard

Officer or enlisted:

□ Not Applicable

□ Officer

□ Enlisted

Provide your service number.

Provide your status

□ Active Duty □ Active Reserve

□ Inactive Reserve

Number (Free Text)

Provide your dates of service

From Date (Estimated)

To Date (Estimated/Present)

Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?

YES

Branch

If Yes to Discharged

You responded ‘Yes’ to being discharged from U.S. military service, to include Reserves

or National Guard; answer the following:

Provide the type of discharge you received: □ Honorable □ Dishonorable □ Under Other than Honorable Conditions □ General □ Bad Conduct □ Other (provide type)

Provide other discharge type:

Discharge explanation (Free Text)

Provide the date of discharge listed above

Date (Estimated

Branch If Discharge Not Honorable

Provide the reason(s) for the discharge.

Reason(s) (Free Text)

In the last 7 years, have you been subject to court martial or other disciplinary procedure under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain’s mast, Article 135 Court of Inquiry, etc?

YES

Branch

If Yes to Military Discipline

You responded ‘Yes’ to having been subject to court martial or other disciplinary procedure under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain’s mast, Article 135 Court of Inquiry, etc in the last 7 years.

Provide the date of the court martial or other disciplinary procedure.

Date (Estimated)

Provide a description of the Uniform Code of Military Justice (UCMJ) offense(s) for which you were charged.

Description (Free Text)

Provide the name of the disciplinary procedure, such as Court Martial, Article 15, Captain’s mast, Article 135 Court of Inquiry, etc.

Name

(Free Text)

Provide the description of the military court or other authority in which you were charged (title of court or convening authority, address, to include city and state or country if overseas).

Description

(Free Text)

Provide the description of the final outcome of the disciplinary procedure, such as found guilty, found not guilty, fine, reduction in rank, imprisonment, etc.

Description

(Free Text)

In the last 7 years do you have an additional instance of military discipline to report?

YES (Yes adds another entry)

NO (Required to validate)

Do you have additional military service to report?

YES (Yes adds another entry)

NO (Required to validate)

Have you EVER served, as a civilian or military member in a foreign country’s military, intelligence, diplomatic, security forces, militia, other defense force, or government agency?

YES

Branch

If Yes to Serving in a Foreign Military

(Multiple Entries Allowed)

You responded ‘Yes’ to having EVER served as a civilian or military member in a foreign country’s military, intelligence, diplomatic, security forces, militia, other defense force, or government agency.

During your foreign service, which organization were you serving under: □ Military (Army, Navy, Air Force, Marines, etc), Specify □ Intelligence Service □ Diplomatic Service □ Security Forces □ Militia □Other Defense Forces, Specify □ Other Government Agency, Specify

Provide the name of the foreign organization.

Name (Free Text)

Provide your period of service

From Date (Estimated)

To Date (Estimated/Present)

Provide the name of the country

Provide your highest position/rank held

Position held (Free Text)

Provide the division/department/office in which you served.

Division (Free Text)

Provide a description of the circumstances of your association with this organization.

Description (Free Text)

Provide a description of the reason for leaving this service.

Description (Free Text)

Section 16 – People Who Know You Well
Provide three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college roommates, associates, etc., who are collectively aware of your activities outside of your workplace, school, or neighborhood, and whose combined association with you covers at least the last seven (7) years. Do not list your spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form. (Multiple Entries Allowed)
Provide dates known	From Date (Est.)	To Date (Est./Present)		Provide full name		Last	First	Middle	Suffix
Provide rank/title □ Not applicable	Rank/title (Free Text)	Provide relationship to you: (Check all that apply) □ Neighbor □ Friend □ Work associate □ Schoolmate □ Other (Provide explanation)						Explanation (Free Text)
Provide phone number for this person. □ I don’t know								Telephone/Ext.
Provide mobile/cell phone number for this person. □ I don’t know								Telephone/Ext.
Provide e-mail address for this person. □ I don’t know								Email (Free Text)
Provide home or work address for this person.			Street address and City		State and Zip Code or Country
Do you have an additional person who knows you well to list?			YES (Yes adds another entry)		NO (Required to validate)

Section 17 – Marital StatusMarital/Relationship Status

Provide your current marital/relationship status with regard to civil marriage, legally recognized civil union, or legally recognized domestic partnership: □ Never entered into a civil marriage, legally recognized civil union, or legally recognized domestic partnership married □ Currently in a civil marriage □Currently in a legally recognized domestic partnership or legally recognized civil union □ Separated □ Annulled □ Divorced/Dissolved □ Widowed

Branch

If In A Marriage, Civil Union, or Domestic PartnershipMarried or Separated

You selected “Currently in a civil marriage,” “currently in a legally recognized civil union or legally recognized domestic partnershipMarried” or “Separated.” Complete the following about the person with whom you are in a civil marriage, legally recognized civil union, or legally recognized domestic partnership, or the person from whom you are currently separatedyour current spouse only.

Provide spouse’s full name

Last

First

Middle

Suffix

Provide spouse’s date of birth.

Date (Est.)

Provide spouse’s place of birth

City

County

State or Country

Branch

If Spouse the person is Foreign Born

For your foreign born spouseIf the person is foreign born, provide one type of documentation that he or she possesses and the document number. □ FS 240 or 545 □ DS 1350 □ U.S. Citizenship certificate □ U.S. Passport (current or most recent) □ Alien registration □ U.S. Naturalization certificate □ None (Provide explanation) □ Other (Provide explanation)

Explanation (Free Text)

Provide document number

Number (Free Text)

Provide your spouse’s U.S. Social Security Number. □ Not applicable _ _ _-_ _-_ _ _ _

Provide other names used by your spouse (such as maiden names, names by other marriages, nicknames, etc. and provide dates used for each name). □ Not applicable

Last

First

Middle

Suffix

□ Maiden Name

Dates Used

From Date (Estimated)

To Date (Estimated/Present)

Provide your spouse’s country(ies) of Citizenship

Provide date when you entered into your civil marriage, civil union, or domestic partnershipmarried.

Date (Estimated)

Provide place marriedlocation

City

County

State or Country

Provide your spouse’s current address, if different than your current address.

□ Use my current address.

Street address and City

State and Zip Code or Country

Provide telephone number. □ Use my current telephone number

Number/Ext

Provide email address

Email (Free Text)

Does your spousethe person have an APO/FPO address?

YES

Branch APO/FPO

Address

APO/FPO

APO State Code

Zip

Branch

Physical Location

You have indicated an APO/FPO address for your spouse; provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.

Provide physical location data for your spouse:

Street Address/unit/duty location

City/Post Name

State

Zip

Country

Are you separated from your spouse?

YES

Branch

If Separated

Provide date of separation.

Date (Estimated)

If legally separated, provide the location of the record. □ Not Applicable

City

State and Zip Code or Country

Do you have a former spouse (such as divorced, annulled, widowed, other former spouses)person from whom you are divorced/dissolved, annulled, or widowed to report?

YES

Branch

If Widowed, Divorced/

Dissolved, or Annulled

(Multiple Entries Allowed)

Provide information about your former spouse (such asany person from whom you are divorced/dissolved, annulled, or widowed, or other former spouses).

Provide the full name of your former spouse.

Last

First

Middle

Suffix

Provide the date of birth of your former spouse.

Date (Estimated

Provide the place of birth for your former spouse.

City

State

Country

Provide the country(ies) of citizenship for your former spouse.

Country

Provide the date your civil marriage, civil union, or domestic partnership was legally recognized.you married your former spouse.

Date (Estimated)

Provide the place marriedlocation.

City

State or Country

Provide the date divorced/dissolved, annulled or widowed

Date (Estimated)

Provide the status of this marriage

□ Divorced/Dissolved □ Widowed □ Annulled

Branch

If Divorced or Annulled

For your divorced or annulled marriage, Pprovide where the record of divorce/dissolution or annulment is located.

City

State and Zip Code or Country

Is this former spouseperson deceased?

I don’t know

YES

Branch If Not Deceased

For divorced or annulled marriage Pprovide last known address of the former spouseperson from whom you are divorced/dissolved or annulled. □ I don’t know

Street and City

State and Zip Code or Country

Do you have any additional person(s) from whom you are divorced/dissolved, annulled, or widowed former spouse (such as divorced, annulled, widowed, or other former spouses) to report?

YES

(Yes adds another entry)

(Required to validate)

A cohabitant is a person with whom you share bonds of affection, obligation, or other commitment, as opposed to a person with whom you live with for reasons of convenience (e.g. a roommate). If applicable, complete the following about your cohabitant. If your cohabitant was born outside the U.S., provide citizenship information.

Do you presently reside with a person, other than a spouse or legally recognized civil union/domestic partner, with whom you share bonds of affection, obligation, or other commitment, as opposed to a person with shom you live for reasons of convenience (e.g. a roommate) ? If so, complete the following. If the person was born outside the U.S., provide citizenship information.a cohabitant?

YES

Branch

If Yes to Residing With a Cohabitant

(Multiple Entries Allowed)

You have indicated that you currently have a cohabitant

Provide the cohabitant full name.

Last

First

Middle

Suffix

Provide the cohabitant date of birth.

Date (Estimated)

Provide the cohabitant place of birth.

City

State

Country

Branch If Cohabitant is Foreign Born

For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number. □ FS 240 or 545 □ DS 1350 □ U.S. Citizenship certificate □ U.S. Passport (current or most recent)

□ Alien registration □ U.S. Naturalization certificate□ None (Provide explanation) □ Other (Provide explanation)

Explanation (Free Text)

Provide document number

Number (Free Text)

Provide your cohabitant’s U.S. Social Security Number. □ Not applicable _ _ _-_ _-_ _ _ _

Provide other names used by your cohabitant (such as maiden names, names by other marriage, etc., and provide dates each name was used) □ Not applicable

Last

First

Middle

Suffix

□ Maiden Name

Dates Used

From Date (Estimated)

To Date (Estimated/Present)

Provide your cohabitant’s country(ies) of Citizenship

Provide date cohabitation began.

Date (Estimated)

Do you have an additional cohabitant to report?

YES (Yes adds another entry)

NO (Required to validate)

Section 18 – Relatives

Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.) Check all that apply. □ Mother □ Father □ Stepmother □ Stepfather □ Foster parent □ Child (including adopted/foster) □ Stepchild

Provide relative type. (Multiple Entries Allowed)

□ Mother □ Father □ Stepmother □ Stepfather □ Foster parent □ Child (including adopted/foster) □ Stepchild □ Brother □ Sister □ Stepbrother □ Stepsister

Provide your relative’s full name.

Last

First

Middle

Suffix

Provide your relative’s date of birth.

Date (estimated)

Provide your relative’s place of birth

City

State

Country

Provide your relatives country(ies) of citizenship

Branch - If Mother

Provide your mother’s maiden name. (□ same as listed)

Last

First

Middle

Suffix

Has this relative used any other names?

YES

Branch

If Other Names

(Multiple Entries Allowed)

Provide other names used and the period of time that your relative used them (such as maiden name by a former marriage, former name, alias, or nickname).

Last

First

Middle

Suffix

Maiden name?

YES

From Date (Estimated)

To Date (Estimated/Present)

Provide the reason(s) why the name changed

Reason

(Free Text)

Has this relative used any additional names?

YES (Yes adds another entry)

NO (Required to validate)

Is your relative deceased?

YES

Branch

If not Deceased

Provide your relative’s current address.

Street address and City

State and Zip Code or Country

Does this relative have an APO/FPO address?

I don’t know

YES

Branch If APO/FPO

Provide your relative’s APO/FPO address

Address

APO/FPO

APO/FPO State

Zip

Do you have an additional relative to enter?

YES (Yes adds another entry)

NO (Required to validate)

Section 19 – Foreign Countries You have Visited
Have you traveled outside the U.S. in the last seven (7) years?								YES	NO
Has your travel in the last seven (7) years been solely for U.S. Government business (i.e., no personal trips in conjunction with the official U.S. Government business)?								YES	NO
Branch If Having Traveled Outside the U.S. on Other than Official Business (Multiple Entries Allowed)	You responded to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official U.S. Government business.
	Provide the country visited	Provide the dates of your travel to this country.		From Date (Estimated)			To Date (Estimated)
	Provide the total number of days involved in the visit. □ 1-5 □ 6-10 □ 11-20 □ 21-30 □ More than 30 □ Many short trips
	Provide the purpose of the travel to this country (Check all that apply) □ Business/professional □ Volunteer activities □ Education □ Tourism □ Trade shows, conferences, and seminars □ Visit family or friends □ Other
	While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local customs or security service officials when entering or leaving this country? If yes provide explanation.				Explanation (Free Text)			YES	NO
	While traveling to or in this country, were you involved in any encounter with the police? If yes provide explanation.				Explanation (Free Text)			YES	NO
	While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign intelligence, terrorist, security, or military organizations? If yes provide explanation.				Explanation (Free Text)			YES	NO
	Do you have additional travel outside the U.S. in the last seven (7) years for other than solely U.S. Government business?		YES (Yes adds another entry)			NO (Required to validate)

Section 20 – Police Record

For this section report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an

expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.

Have any of the following happened? (If yes, you will be asked to provide details for each offense that pertains to the actions that are identified below.)

• In the past seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you? (Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs.)

• In the past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?

• In the past seven (7) years have you been charged with, convicted of, or sentenced forof a crime in any court? (Include all qualifying charges, convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).

• In the past seven (7) years have you been or are you currently on probation or parole?

• Are you currently on trial or awaiting a trial on criminal charges?

YES

Branch

If Yes to the Above Happening

(Multiple Entries Allowed)

Provide the date of offense.

Date (Estimated)

Provide a description of the specific nature of the offense.

Description (Free Text)

Did this offense involve any of the following? (Check all that apply)

□ Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common?

□ Involve firearms or explosives?

□ Involve alcohol or drugs?

YES

Provide the location where the offense occurred.

Street address and city

State and Zip Code or Country

Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other type of law enforcement official?

YES

Branch

If Yes to Being Arrested/Cited/Summoned

Arresting/citing/summoning agency

Provide the name of the law enforcement agency that arrested/cited/summoned you.

Name (free Text)

Provide the location of the law enforcement agency.

Street address and city

State and Zip Code or Country

As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?

YES

Branch - If No to Charged or Convicted

You responded ‘No’ to “As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?”

Provide Explanation

Explanation (Free Text)

Branch

If Yes to Charged or Convicted

Court information

Provide the name of the court.

Name of court (Free Text)

Provide the location of the court.

Street address and city

State and Zip Code or Country

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge dropped or “nolle pros,” etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser offense.

Felony/Misdemeanor

Felony, Misdemeanor, Other

Charge

Charge (Free Text)

Outcome

Outcome (Free Text)

Date (Month/Year)

Date

Were you sentenced as a result of this offense?

YES

Branch

If Yes to Being Sentenced

Conviction detail

Provide a description of the sentence.

Were you sentenced to imprisonment for a term exceeding 1 year?

YES

Were you incarcerated as a result of that sentence for not less than 1 year?

YES

If the conviction resulted in imprisonment, provide the dates that you actually were incarcerated. (Not Applicable □ )

From Date (Estimated)

To Date (Estimated/Present)

If conviction resulted in probation or parole, provide the dates of probation or parole. (Not Applicable □ )

From Date (Estimated)

To Date (Estimated/Present)

Branch

If No to Being Sentenced

Trial detail

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?

YES

Provide Explanation

Explanation (Free Text)

Do you have any other offenses where any of the following has happened to you?

• In the past seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you? (Do not include citations involving traffic infractions where the fine was less than $300 ~~$150~~ and did not include alcohol or drugs)

• In the past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?

• In the past seven (7) years have you been charged, convicted, or sentenced of a crime in any court? (Include all qualifying charges, convictions, or sentences in a Federal, state, local, military, or non-U.S. court even if previously listed on this form.)

• In the past seven (7) years have you been or are you currently on probation or parole?

• Are you currently on trial or awaiting a trial on criminal charges?

YES

(Yes adds another entry)

(Required to validate)

Other than those offenses already listed, have you EVER had the following happen to you?

• Have you EVER been convicted of an offense involving domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common?

YES

Branch

If Yes to the Above Happening

(Multiple Entries Allowed)

Provide the date of the offense.

Date (Estimated)

Provide a description of the specific nature of the offense.

Description of nature of offense (Free Text)

Did this offense involve any of the following? (Check all that apply)

□ Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common?

□

YES

Provide the name of the court.

Name of court (Free Text)

Provide the location of the court.

Street address and city

State and Zip Code or Country

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or charge dropped or “nolle pros,” etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser offense separately.

Felony/Misdemeanor

Felony, Misdemeanor, Other

Charge

Charge (Free Text)

Outcome

Outcome (Free Text)

Date Month/Year

Date

Were you sentenced as a result of these charges?

YES

Branch

If Yes to Being Sentenced

Conviction Detail

Provide a description of the sentence.

Sentence description (Free Text)

Were you sentenced to imprisonment for a term exceeding 1 year?

YES

Were you incarcerated as a result of that sentence for not less than 1 year?

YES

If the conviction resulted in imprisonment, provide the dates that you actually were incarcerated. (Not Applicable □ )

From Date (Estimated)

To Date (Estimated/Present)

If the conviction resulted in probation or parole, provide the dates of probation or parole. (Not Applicable □)

From Date (Estimated)

To Date (Estimated/Present)

Branch

If No to Being Sentenced

Trial detail

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense?

YES

Provide Explanation

Explanation (Free Text)

Do you have any other offenses to list where the following has EVER happened to you?

YES

(Yes adds another entry)

(Required to validate)

Is there currently a domestic violence protective order or restraining order issued against you?

YES

Branch

If Yes to Domestic Violence

(Multiple Entries Allowed)

You responded ‘Yes’ to currently having a domestic violence protective order or restraining order issued against you.

Provide explanation:

Explanation (Free Text)

Provide the date the order was issued.

Date (Estimated)

Provide the name of the court or agency that issued the order.

Name of court (Free Text)

Provide the location of the court or agency that issued the order.

Street address and city

State and Zip Code or Country

Do you have another domestic violence protective order or restraining order currently issued against you to report?

YES

(Yes adds another entry)

(Required to validate)

Section 21 – Illegal Use of Drugs and Drug Activity

You are required to answer the questions We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity.

In the last ~~year~~ seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug or controlled substance.

YES

Branch

If Yes to Illegally Using Drugs or Controlled Substances

(Multiple Entries Allowed)

You answered ‘Yes’ to in the last seven (7) years having illegally used a drug or controlled substance.

Provide the type of drug or controlled substance.

Explanation if other (Free Text)

□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

□ THC (Such as marijuana, weed, pot, hashish, etc.) □ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

□ Ketamine (Such as special K, jet, etc.) □ Narcotics (Such as opium, morphine, codeine, heroin, etc.)

□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)

□ Inhalants (Such as toluene, amyl nitrate, etc.) □ Other (Provide explanation):

Provide an estimate of the month and year of first use.

Date (Estimated)

Provide an estimate of the month and year of most recent use.

Date (Estimated)

Provide nature of use, frequency, and number of times used.

Nature of use (Free Text)

Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety?

YES

Was your use while possessing a security clearance?

YES

Do you intend to use this drug or controlled substance in the future?

YES

Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.

Explanation (Free Text)

Do you have an additional instance(s) of illegal use of a drug or controlled substance to enter?

YES

(Yes adds another entry)

(Required to validate)

In the last seven (7) years, have you been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of any drug or controlled substance?

YES

Branch

If Yes to Illegal Drug Activity

(Multiple Entries Allowed)

You answered ‘Yes’ to in the last seven (7) years having been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance.

Provide the type of drug or controlled substance.

If other explanation (Free Text)

□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

□ THC (Such as marijuana, weed, pot, hashish, etc.) □ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

□ Ketamine (Such as special K, jet, etc.) □ Narcotics (Such as opium, morphine, codeine, heroin, etc.)

□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)

□ Inhalants (Such as toluene, amyl nitrate, etc.) □ Other (Provide explanation):

Provide an estimate of the month and year of first involvement.

Date (Estimated)

Provide an estimate of the month and year of most recent involvement.

Date (Estimated)

Provide nature of and frequency of activity.

Nature of activity (Free Text)

Provide the reason(s) why you engaged in the activity.

Reason(s) (Free Text)

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety?

YES

Was your involvement while possessing a security clearance?

YES

Do you intend to engage in this activity in the future?

YES

Branch

If Yes to Future Activity

You have indicated that you plan to engage in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance in the future. Provide explanation.

Explanation (Free Text)

Do you have an additional instance(s) of having been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance to enter?

YES

(Yes adds another entry)

(Required to validate)

In the last seven (7) years, have you illegally used or otherwise been involved with a drug or controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety other than previously listed?

YES

Branch

If Yes to Use While in Law Enforcement

(Multiple Entries Allowed)

You responded ‘Yes’ to having in the last seven (7) years, have you illegally used, or otherwise been involved with a drug or controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety other than previously listed.

Provide a description of the drugs or controlled substances used and your involvement.

Description (Free Text)

Provide the dates of involvement/use.

From Date (Estimated)

To Date (Estimated/Present)

Provide an estimate the number of times you used and/or were involved this drug or controlled substance while employed in this capacity.

Estimate (Free Text)

Do you have an additional instance(s) of illegal use or involvement with a drug or controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety to enter?

YES

(Yes adds another entry)

(Required to validate)

In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of whether or not the drugs were prescribed for you or someone else?

YES

Branch

If Yes to Misuse of Prescription Drugs

(Multiple Entries Allowed)

You responded ‘Yes’ to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless of whether the drugs were prescribed for you or someone else.

Provide the name of the prescription drug that you misused.

Drug names (Free Text)

Provide the dates of involvement in the above.

From Date (Estimated)

To Date (Estimated/Present)

Provide the reason(s) for and circumstances of the misuse of the prescription drug.

Reasons (Free Text)

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety?

YES

Was your involvement while possessing a security clearance?

YES

Do you have an additional instance(s) of intentionally engaging in the misuse of prescription drugs in the last seven (7) years to enter?

YES

(Yes adds another entry)

(Required to validate)

In the last seven (7) years, have you been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or controlled substances?

YES

Branch

If Yes to Being Ordered Treatment for the Misuse of Drugs

(Multiple Entries Allowed)

You responded ‘Yes’ to having in the last seven (7) years, have you been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or controlled substances

Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or controlled substances? (Check all that apply)

□ An employer, military commander, or employee assistance program □ A medical professional

□ A mental health professional □ A court official / judge

□ I have not been ordered, advised, or asked to seek counseling or treatment by any of the above.

Provide explanation

Explanation (Free Text)

Did you take action to receive counseling or treatment?

YES

Branch If No to Action Taken

You have indicated that you did not receive treatment. Provide explanation.

Explanation (Free Text)

Branch

If Yes to Action Taken

Provide the type of drug or controlled substance for which you were treated.

□ Cocaine or crack cocaine (Such as rock, freebase, etc.)

□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

□ THC (Such as marijuana, weed, pot, hashish, etc.)

□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

□ Ketamine (Such as special K, jet, etc.)

□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)

□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

□ Steroids (Such as the clear, juice, etc.)

□ Inhalants (Such as toluene, amyl nitrate, etc.)

□ Other (Provide explanation):

Explanation (Free Text)

Provide the name of the treatment provider. (Last name, First name)

Name (Free Text)

Provide the address for this treatment provider.

Street address and city

State and Zip Code or Country

Provide a phone number for the treatment provider.

Number/Ext.

Provide the dates of treatment.

Date From (Estimated)

Date To (Estimated/Present)

Did you successfully complete the treatment?

YES

Branch If No to Successful Treatment

You have indicated that you did not successfully complete the treatment. Provide explanation.

Explanation (Free Text)

Do you have another instance of having been ordered, advised, or asked to seek drug or controlled substance counseling or treatment to enter?

YES

(Yes adds another entry)

(Required to validate)

In the last seven (7) years, have you voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance?

YES

Branch

If Yes to Voluntarily Seeking Treatment for the Misuse of Drugs

(Multiple Entries Allowed)

Voluntary treatment detail

Provide the type of drug or controlled substance for which you were treated.

□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

□ THC (Such as marijuana, weed, pot, hashish, etc.) □ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

□ Ketamine (Such as special K, jet, etc.) □ Narcotics (Such as opium, morphine, codeine, heroin, etc.)

□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)

□ Inhalants (Such as toluene, amyl nitrate, etc.) □ Other (Provide explanation):

Provide the name of the treatment provider. (Last name, First name)

Name (Free Text)

Provide the address for this treatment provider.

Street address and city

State and Zip Code or Country

Provide a phone number for the treatment provider.

Number/Ext.

Provide the dates of treatment.

Date From (Estimated)

Date To (Estimated/Present)

Did you successfully complete the treatment?

YES

Branch If No to Successful Treatment

You have indicated that you did not you successfully complete the treatment. Provide explanation.

Explanation (Free Text)

Do you have another instance of EVER voluntarily seeking counseling or treatment as a result of your use of a drug or controlled substance?

YES

(Yes adds another entry)

(Required to validate)

Section 22 – Use of Alcohol

In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your professional relationships, or resulted in intervention by law enforcement/public safety personnel?

YES

Branch

If negative impact

(Multiple Entries Allowed)

You responded ‘Yes’ to your alcohol use having had a negative impact on your work performance, your professional relationships, or resulted in intervention by law enforcement/public safety personnel.

Provide the month/year when this negative impact occurred.

Date (Estimated)

Provide an explanation of the circumstances and the negative impact.

Provide circumstances (Free Text)

Provide negative impact (Free Text)

Provide dates of involvement or use

From Date (Estimated)

To Date (Estimated/Present)

Has the use of alcohol had other negative impacts on your work performance, your professional relationships, or resulted in intervention by law enforcement/public safety personnel?

YES

(Yes adds another entry)

(Required to validate)

In the last seven (7) years have you been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol?

YES

Branch

If Yes to having been ordered, advised, or asked to seek counseling

(Multiple. Entries Allowed)

You responded ‘Yes” to having been ordered, advised or asked to seek counseling or treatment as a result of your use of alcohol.

Did you take action to seek counseling or treatment?

YES

Branch If No Action Taken

You responded ‘No’ to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.

Explanation (Free Text)

Branch If Yes to Taking Action

You responded ‘Yes’ to having taken action to seek counseling or treatment.

Provide the dates of counseling or treatment

From Date (Estimated)

To Date (Estimated/Present)

Provide the name of the individual counselor or treatment provider

Counselor name (Free Text)

Provide the full address of the counseling/treatment provider.

Provide telephone number

Number/Ext

Street address and city

State and Zip Code or Country

Did you successfully complete the treatment program?

YES

Branch If No to Successful Completion

You responded “No” to having successfully completed the treatment program. Provide explanation

Explanation (Free Text)

Do you have additional instances of having been ordered, advised or asked to seek counseling or treatment as a result of your use of alcohol to enter?

YES

(Yes adds another entry)

(Required to validate)

In the last seven (7) years, have you voluntarily sought counseling or treatment as a result of your use of alcohol?

YES

Branch

If Yes to

to Seeking Counseling

(Multiple Entries Allowed)

You responded ‘Yes’ to voluntarily seeking counseling or treatment.

Provide the dates of counseling or treatment

From Date (Estimated)

To Date (Estimated/Present)

Provide the name of the individual counselor or treatment provider.

Counselor name (Free Text)

Provide the full address of the counseling/treatment provider.

Street address and city

State and Zip Code or Country

Provide telephone

number

Number/Ext

Did you successfully complete the treatment program?

YES

Branch If Unsuccessful

You answered ‘No’ to having successfully completed the treatment program. Provide explanation:

Explanation (Free Text)

Do you have additional instances where you have voluntarily sought counseling or treatment as a result of your use of alcohol to enter?

YES

(Yes adds another entry)

(Required to validate)

Section 23 – Investigations and Clearance Record
Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a security clearance eligibility/access?									YES	NO
Branch If Yes to Having Ever Been Investigated (Multiple Entries Allowed)	You responded ‘Yes’ to the U.S. Government (or a foreign government) having investigated your background and/or having granted you a security clearance eligibility/access.
	Provide the investigating agency:	□ U.S. Department of Defense □ U.S. Department of State □ U.S. Office of Personnel Management □ Federal Bureau of Investigation □ U.S. Department of Treasury (provide name of bureau) □ U.S. Department of Homeland Security □ Foreign government, (Provide name of government) □ I don’t know □ Other (Provide explanation)
	Explanation or name of government (Free Text)
	Date the investigation was completed. □ I don’t know					Date (Estimated)
	Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.					Name (Free Text)
	Provide the date clearance eligibility/access was granted. □ I don’t know					Date (Estimated)
	Provide the level of clearance eligibility/access granted.	□ None □ Confidential □ Secret □ Top Secret □ Sensitive Compartmented Information (SCI) □ Q □ L □ I don’t know □ Issued by foreign country □ Other (Provide explanation)
	Explanation (Free Text)
	Do you have another investigation to enter?		YES (Yes adds another entry)			NO (Required to validate)
Have you EVER had a security clearance eligibility/access authorization denied, suspended, or revoked? (Note: An administrative downgrade or administrative termination of a security clearance is not a revocation.)									YES	NO
Branch If Yes to Denied (Multiple Entries Allowed)	You responded ‘Yes’ to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked.
	Provide the date security clearance eligibility/access authorization was denied, suspended or revoked.						Date (Estimated)
	Provide the name of the agency that took the action.					Name (Free Text)
	Provide an explanation of the circumstances of the denial, suspension or revocation action.					Explanation (Free Text)
	Do you have another denied, revoked or suspended security clearance eligibility/access authorization to enter?				YES (Yes adds another entry)	NO (Required to validate)
Have you EVER been debarred from government employment?								YES		NO
Branch If Yes to Debarment (Multiple Entries Allowed)	You responded ‘Yes’ to having EVER been debarred from government employment.
	Provide the name of the government agency taking debarment action.					Agency name
	Provide the date the debarment occurred.					Date (Estimated)
	Provide an explanation of the circumstances of the debarment					Circumstances (Free text)
	Do you have another Government debarment to enter?			YES (Yes adds another entry)		NO (Required to validate)

Section 24 – Financial Record

In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?

YES

Branch

If Yes to Having Filed Bankruptcy

(Multiple Entries Allowed)

You responded ‘Yes’ to having filed a petition under any chapter of the bankruptcy code.

Select the applicable bankruptcy petition type:

□ Chapter 7 □ Chapter 11 □ Chapter 12 □ Chapter 13

Provide the bankruptcy court docket/account number.

Account Number (Free Text)

Provide the date bankruptcy was filed.

Date (Estimated)

Provide date of bankruptcy discharge. □ Not Applicable

Date (Estimated)

Provide the total amount (in U.S. dollars) involved in the bankruptcy. □ Estimated

Amount (Free Text)

Provide the name debt is recorded under.

Last

First

Middle

Suffix

Provide the name of the court involved.

Court Name (Free Text)

Provide the address of the court involved.

Street address and City

State and Zip Code or Country

Branch

If Chapter 13

Provide the name of the trustee for this bankruptcy.

Name (Free Text)

Provide the address of the trustee for this bankruptcy.

Street address and City

State and Zip Code or Country

Were you discharged of all debts claimed in the bankruptcy? Provide Explanation

Explanation (Free Text)

YES

In the last seven (7) years, have you filed any additional petitions under any chapter of the bankruptcy code?

YES

(Yes adds another entry)

(Required to validate)

In the last seven (7) years have you failed to meet financial obligations due to gambling?

YES

Branch

If Yes to Financial Problems Due to Gambling

(Multiple Entries Allowed)

You responded ‘Yes’ to in the last seven (7) years have you experienced financial problems due to gambling.

Provide the date range of your financial problems due to gambling.

From Date (Estimated)

To Date (Estimated/Present)

Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.

Amount (Free Text)

Provide a description of your financial problems due to gambling.

Description (Free Text)

If you have taken any action(s) to rectify your financial problems due to gambling, provide a description of your actions. If you have not taken any action(s) provide explanation.

Description (Free Text)

In the last seven (7) years have failed to meet other financial obligations due to gambling?

YES (Yes adds another entry)

NO (Required to validate)

In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance?

YES

Branch

If Yes to Failing to File/Pay Taxes

(Multiple Entries Allowed)

You responded ‘Yes’ to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.

Did you fail to file, pay as required, or both? □ File □ Pay □ Both

Provide the year you failed to file or pay your Federal, state or other taxes.

Provide the reason(s) for your failure to file or pay required taxes.

Reasons (Free Text)

Provide the Federal, state or other agency to which you failed to file or pay taxes.

Agency (Free Text)

Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.).

Tax Type (Free Text)

Provide the amount (in U.S. dollars) of the taxes. □ Estimated

Amount (Free Text)

Provide date satisfied. □ Not applicable

Date (Estimated)

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.

Description (Free Text)

Are there any other instances in the past seven (7) years where you failed to file or pay Federal, state or other taxes when required by law or ordinance?

YES

(Yes adds another entry)

(Required to validate)

In the past seven (7) years have you been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card provided by your employer?

YES

Branch

If Yes to Violation of Credit/Travel Card Terms

(Multiple Entries Allowed)

You responded ‘Yes’ to having been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card provided by your employer.

Provide the name of the agency or company.

Agency (Free Text)

Provide the address of the agency or company.

Street address and City

State and Zip Code or Country

Provide the reason(s) for the counseling, warning or disciplinary action.

Reasons (Free Text)

Provide the amount (in U.S. dollars) of violation. □ Estimated

Amount (Free Text)

Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any action(s) provide explanation.

Description (Free Text)

Are there any other instances in the past seven (7) years where you have been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card provided by your employer?

YES

(Yes adds another entry)

(Required to validate)

Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve an inability to meet financial obligations?

YES

Branch

If Yes to

Seeking Credit Counseling

(Multiple Entries Allowed)

You responded ‘Yes’ to currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve an inability to meet financial obligations.

Provide explanation (Free Text)

Provide the name of the credit counseling organization or resource.

Name (Free Text)

Provide the phone number of the credit counseling organization.

Number / Ext

Provide the location of the credit counseling organization.

City

State

As a result of this counseling provide a description of any action(s) you have taken to resolve your inability to meet financial obligations. If you have not taken any action(s) provide explanation.

Description (Free Text)

Are you currently utilizing, or seeking assistance from any other credit counseling service or other similar resource to resolve your inability to meet financial obligations?

YES (Yes adds another entry)

NO (Required to validate)

Other than previously listed, have any of the following happened to you? (You will be asked to provide details about each financial obligation that pertains to the items identified below).

• You are currently delinquent on alimony or child support payments.

• In the past seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

• In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

• You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

YES

Branch

If Yes to Having Financial Issues Involving Enforcement

(Multiple Entries Allowed)

You answered ‘Yes’ to having experienced one or more of the previously stated financial issues.

Provide the name of agency/organization/individual to which debt is/was owed

Name (Free Text)

Did/does this financial issue include any of the following: (Check all that apply)

□ You are currently delinquent on alimony or child support payments.

□ In the past seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

□ In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

□ You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

YES

Provide the associated loan / account number(s) involved

Loan / account number (Free Text)

Identify/describe the type of property involved (if any).

Property type (Free Text)

Provide the amount (in U.S. dollars) of the financial issue. □ Estimated

Amount (Free Text)

Provide the reason(s) for the financial issue.

Reasons (Free Text)

Provide the current status of the financial issue.

Status (Free Text)

Provide the date the financial issue began.

Date (Estimated)

Provide date the financial issue was resolved. □ Not resolved

Date (Estimated)

Provide the name of the court involved.

Court name (Free Text)

Provide the address of the court involved.

Street address and City

State and Zip Code or Country

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any provide explanation.

Description (Free Text)

Other than previously listed, are there any other instances of the following occurrences?

• You are currently delinquent on alimony or child support payments.

• You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

YES (Yes adds another entry)

NO (Required to validate)

Other than previously listed, have any of the following happened?

• In the past seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

• In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

• In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

• In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

• In the past seven (7) years, you were evicted for non-payment?

• In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason?

• In the past seven (7) years, you have been over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

• You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor)

YES

Branch

If Yes to Having Financial Issues Involving Routine Accounts

(Multiple Entries Allowed)

You answered ‘Yes’ to having experienced one or more of the previously stated financial issues.

Provide the name of agency/organization/individual to which debt is/was owed.

Did/does this financial issue include any of the following: (Check all that apply)

□ In the past seven (7) years you had your possessions or property voluntarily or involuntarily repossessed or foreclosed. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

□ In the past seven (7) years you defaulted on any type of loan. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

□ In the past seven (7) years you had bills or debts turned over to a collection agency. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

□ In the past seven (7) years you had an account or credit card suspended, charged off, or cancelled for failing to pay as agreed. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

□ In the past seven (7) years you were evicted for non-payment.

□ In the past seven (7) years you had wages, benefits, or assets garnished or attached for any reason.

□ In the past seven (7) years you were over 120 days delinquent on any debt not previously entered. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

□ You are currently over 120 days delinquent on any debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

YES

Provide the associated loan / account number(s) involved.

Loan / account number (Free Text)

Identify/describe the type of property involved (if any).

Property type (Free Text)

Provide the amount (in U.S. dollars) of the financial issue. □ Estimated

Amount (Free Text)

Provide the reason(s) for the financial issue.

Reasons (Free Text)

Provide the current status of the financial issue.

Status (Free Text)

Provide date the financial issue was resolved. □ Not resolved

Date (Estimated)

Provide the date the financial issue began.

Date (Estimated)

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.

Description (Free Text)

Other than previously listed, are there any other instances of the following occurrences?

□ Yes □ No

• In the past seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed. (include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

• In the past seven (7) years, you defaulted on any type of loan, (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

• In the past seven (7) years, you had bills or debts turned over to a collection agency. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

• In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

• In the past seven (7) years, you have been evicted for non-payment.

• In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason.

• In the past seven (7) years, you have been over 120 days delinquent on any debt not previously entered. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor).

• You are currently over 120 days delinquent on any debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor).

YES (Yes adds another entry)

NO (Required to validate)

Section 25 – Use of Information Technology Systems

We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal government. The following questions ask about your use of information technology systems. Information technology systems include all related computer hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage or protection of information.

In the last seven (7) years have you illegally or without proper authorization accessed or attempted to access any information technology system?

YES

Branch

If Yes to Unauthorized Access

(Multiple Entries Allowed)

You responded ‘Yes’ to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter into any information technology system.

Provide the date of the incident

Date (Estimated)

Provide a description of the nature of the incident or offense.

Description of incident (Free Text)

Provide the location where the incident took place.

Street address and City

State and Zip Code or Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Description (Free Text)

Are there any other incidents to report?

YES (Yes adds another entry)

NO (Required to validate)

In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or denied others access to information residing on an information technology system or attempted any of the above?

YES

Branch

If Yes to Manipulating Access

(Multiple Entries Allowed)

You responded ‘Yes’ to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or denied others access to information residing on an information technology system or attempted any of the above.

Provide the date of the incident

Date (Estimated)

Provide a description of the nature of the incident or offense.

Description of incident (Free Text)

Provide the location where the incident took place.

Street address and City

State and Zip Code or Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Description (Free Text)

Are there any other incidents to report?

YES (Yes adds another entry)

NO (Required to validate)

In the last seven (7) years have you introduced, removed, or used hardware, software, or media in connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or attempted any of the above?

YES

Branch

If Yes to Unlawful Use

(Multiple Entries Allowed)

You responded ‘Yes’ to having in the last seven (7) years introduced, removed, or used hardware, software, or media in connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or attempted any of the above.

Provide the date of the incident

Date (Estimated)

Provide a description of the nature of the incident or offense

Description (Free Text)

Provide the location where the incident took place.

Street address and City

State and Zip Code or Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Description (Free Text)

Are there any other incidents to report?

YES (Yes adds another entry)

NO (Required to validate)

Section 26 – Involvement in Non-Criminal Court Actions

In the last seven (7) years, have you been a defendant in any public record civil court action alleging fraud or intentional tortuous conduct?

YES

Branch

If Yes to Having Non Criminal Court Actions

(Multiple Entries Allowed)

You responded ‘Yes’ to having been a defendant in any public record civil court action alleging fraud or intentional tortious conduct in the last seven (7) years.

Provide the date of the civil action

Date (Estimated)

Provide the court name

Court name (Free Text)

Provide the address of the court

Street address and City

State and Zip Code or Country

Provide details of the nature of the action

Details (Free Text)

Provide a description of the results of the action

Results (Free Text)

Provide the name(s) of the principal parties involved in the court action.

Names (Free Text)

Are there any other civil court actions in the last seven (7) years to report?

YES

(Yes adds another entry)

(Required to validate)

Section 27 – Association Record

The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment, security, or credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or coercion or to affect the conduct of a government by mass destruction, assassination or kidnapping.

Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an awareness of the organization’s dedication to that end, or with the specific intent to further such activities?

YES

Branch

If Yes to Being a Member of a Terrorist Organization

(Multiple Entries Allowed)

You responded ‘Yes’ to being or EVER having been a member of an organization dedicated to terrorism, either with an awareness of the organization’s dedication to that end, or with the specific intent to further such activities.

Provide the full name of the organization.

Organization name (Free Text)

Provide the address/location of the organization.

Street address and City

State and Zip Code or Country

Provide the dates of your involvement with the organization.

From Date (Estimated)

To Date (Estimated/Present)

Provide all positions held in the organization, if any. □ No positions held

Positions (Free Text)

Provide all contributions made to the organization, if any. □ No contributions made

Contributions (Free Text)

Provide a description of the nature of and reasons for your involvement with the organization.

Involvement (Free Text)

Do you have any other instances of being a member of an organization dedicated to terrorism, either with an awareness of the organization’s dedication to that end, or with the specific intent to further such activities to report?

YES

(Yes adds another entry)

(Required to validate)

Have you EVER knowingly engaged in any acts of terrorism?

YES

Branch If Yes Engaging in Terrorism (Multiple Entries Allowed)

You responded ‘Yes’ to EVER having knowingly engaged in any acts of terrorism.

Describe the nature and reasons for the activity.

Nature and reasons (Free Text)

Provide the dates for any such activities

From Date (Estimated)

To Date (Estimated/Present)

Do you have any other instances of knowingly engaging in acts of terrorism to report?

YES

(Yes adds another entry)

(Required to validate)

Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force?

YES

Branch

If Yes to Advocating

(Multiple Entries Allowed)

You responded ‘Yes’ to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force.

Provide the reason(s) for advocating acts of terrorism.

Reasons (Free Text)

Provide the dates of advocating acts of terrorism

From Date (Estimated)

To Date (Estimated/Present)

Do you have any other instances of advocating acts of terrorism or activities designed to overthrow the U.S. Government by force to report?

YES (Yes adds another entry)

NO (Required to validate)

Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or with the specific intent to further such activities?

YES

Branch

If Yes to being Member of Organization Using Violence to Overthrow the U.S. Govt.

(Multiple Entries Allowed)

You responded ‘Yes’ to having EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or with the specific intent to further such activities.

Provide the full name of the organization.

Organization name (Free Text)

Provide the address/location of the organization.

Street address and City

State and Zip Code or Country

Provide the dates of your involvement with the organization

From Date (Estimated)

To Date (Estimated/Present)

Provide all positions held in the organization, if any. □ No positions held

Positions (Free Text)

Provide all contributions made to the organization, if any. □ No contributions made

Contributions (Free Text)

Provide a description of the nature of and reasons for your involvement with the organization.

Description (Free Text)

Do you have any other instances of being a member of an organization dedicated to the use of violence or force to overthrow the United States Government, which engaged in activities to that end with an awareness of the organization’s dedication to that end or with the specific intent to further such activities to report?

YES

(Yes adds another entry)

(Required to validate)

Have you EVER been a member of an organization that advocates or practices commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the United States with the specific intent to further such action?

YES

Branch

If Yes to Being a Member of Organization Using Violence

(Multiple Entries Allowed)

You responded ‘Yes’ to being or EVER having been a member of an organization that advocates or practices commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or that of any state of the U.S. with the specific intent to further such action.

Provide the full name of the organization.

Organization Name (Free Text)

Provide the address/location of the organization.

Street address and City

State and Zip Code or Country

Provide the dates of your involvement with the organization

From Date (Estimated)

To Date (Estimated/Present)

Provide all positions held in the organization, if any. □ No positions held

Positions (Free Text)

Provide all contributions (in U.S. dollars) made to the organization, if any. □ No contributions made

Contributions (Free Text)

Provide a description of the nature of and reasons for your involvement with the organization.

Involvement (Free Text)

Do you have any other instances of being a member of an organization that advocates or practices commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the United States with the specific intent to further such action to report?

YES

(Yes adds another entry)

(Required to validate)

Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?

YES

Branch If Yes to Activities to Overthrow

(Multiple Entries Allowed)

You responded ‘Yes’ to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.

Describe the nature and reasons for the activity.

Reasons (Free Text)

Provide the dates of such activities.

From Date (Estimated)

To Date Estimated/Present)

Do you have any other instances of having knowingly engaged in activities designed to overthrow the U.S. Government by force to report?

YES

(Yes adds another entry)

(Required to validate)

Have you EVER associated with anyone involved in activities to further terrorism?

YES

Branch If Yes to Having

Terrorism Association

Terrorism Association Detail

Provide Explanation

Explanation (Free Text)

After completing this form and any attachments, 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 the attached release(s).

Certification

My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I have carefully read the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information may have a negative effect on my, employment prospects, or job status, or my removal and debarment from Federal service.

Signature (Sign in ink)

Date (mm/dd/yyyy)

QUESTIONNAIRE FOR PUBLIC TRUST POSITIONS

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date it in ink.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation or reinvestigation to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection 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, criminal history record information, and financial and credit information. I authorize the Federal agency conducting my investigation to disclose the record of my background investigation to the requesting agency for the purpose of making a determination of suitability or eligibility for a public trust position.

I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and date of birth with information in SSA records and provide the results of the match) to the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy.

I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of information, a separate specific release may be needed, and I may be contacted for such releases at a later date.

I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of Investigation, the Department of Defense, Department of State, and any other authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment to, or retention in, a public trust position, in accordance with 5 U.S.C. 9101. I understand that I may request a copy of such records as may be available to me under the law.

I Authorize custodians of records and other 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 85P, and that it may be disclosed by the Government only as authorized by law.

I Authorize the information to be used to conduct officially sanctioned and approved suitability-related studies and analyses, which will be maintained in accordance with the Privacy Act.

Photocopies of this authorization with my signature are valid. This authorization is valid for five (5) years from the date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.

Signature (Sign in ink)

Full name (Type or print legibly)

Date signed (mm/dd/yyyy)

Other names used

Date of birth

Social Security Number

Current street address Apt. #

City (Country)

State

ZIP Code

Home telephone number

QUESTIONNAIRE FOR PUBLIC TRUST POSITIONS

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT

TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

Instructions for Completing this Release

This is a release for the investigator to ask your health practitioner(s) only the specific questions below concerning any mental health consultations of which the practitioner might be aware. Your signature will allow the practitioner(s) to answer only these questions. Should additional information be required from the health care practitioner, a separate specific release is needed, and you may be contacted for such a release at a later date.

If you are completing the SF 85P, this release will be required in the event information arises in an investigation that requires such further inquiry for resolution and only to resolve such issues.

If you are completing the SF 85P with the supplemental SF 85P-S, this release is required if you respond “yes” to the question regarding Your Medical Record.

Authorization

I am seeking assignment to or retention in a public trust position. As part of the investigation process, I hereby authorize the investigator, special agent, or duly accredited representative of the authorized Federal agency conducting my background investigation, to obtain the following information relating to my mental health consultations.

In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to the U.S. Office of Personnel Management. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. Further, I understand that this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

I understand the information disclosed pursuant to this release is for use by the Federal Government only for purposes provided in the Standard Form 85P and that it may be disclosed by the Government only as authorized by law, but will no longer be subject to the HIPAA privacy rule.

Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed or upon termination of my affiliation with the Federal Government, whichever is sooner.

Signature (Sign in ink)		Full name (Type or print legibly)			Date signed (mm/dd/yyyy)
Other names used				Date of birth	Social Security Number
Current street address Apt. #	City (Country)		State	ZIP Code	Home telephone number

For Use By Practitioner(s) Only

Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to perform a position of public trust?

__YES __NO

If so, describe the nature of the condition and the extent and duration of the impairment or treatment.

What is the prognosis?

Dates of treatment?

Signature (Sign in ink)

Practitioner name

Date signed (mm/dd/yyyy)

QUESTIONNAIRE FOR PUBLIC TRUST POSITIONS

UNITED STATES OF AMERICA

FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION

Disclosure

One or more reports from consumer reporting agencies may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, codified at 15 U.S.C. § 1681 et seq.

Purpose

Information provided by you on this form will be furnished to the consumer reporting agency in order to obtain information in connection with a background investigation to determine your (1) fitness for Federal employment, (2) clearance ability to perform contractual service for the Federal government, and/or (3) eligibility for a public trust position.

The information obtained may be disclosed to other Federal agencies for the above purposes in fulfillment of official responsibilities to the extent that such disclosure is permitted by law. Information from the consumer report will not be used in violation of any applicable Federal or state equal employment opportunity law or regulation.

Authorization

I hereby authorize the investigative agency conducting my background to obtain such reports from any consumer reporting agency for employment purposes described above.

Note: If you have a security freeze on your consumer or credit report file, then we may not be able to complete your investigation, which can adversely affect your eligibility for a public trust position. To avoid such delays, you may want to consider requesting that the consumer reporting agencies lift the freeze in these instances.

Your Social Security Number (SSN) is needed to identify your unique records. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397.

Print name

Social Security Number

Signature (Sign in ink)

Date (mm/dd/yyyy)

File Type	application/msword
File Title	Questionnaire for National Security Positions
Author	Loss, Lisa M
Last Modified By	DeMarion, Michele
File Modified	2012-08-15
File Created	2012-08-15

Guide

SF 85P Content Guide_revised for 30 Day Notice-FINAL DMS.DOC

SF 85P Questionnaire for Public Trust Positions and SF 85PS Supplemental Questionnaire for Selected Positions

Guide

OMB: 3206-0258

Questionnaire for Public Trust Positions

Questionnaire for Public Trust Positions

Purpose of this Form

Authority to Request this Information

The Investigative Process

Your Personal Interview

Instructions for Completing this Form (Electronic)

*****Instructions for Completing this Form (Paper Form Only) *****

Final Determination on Your Suitability

Penalties for Inaccurate or False Statements

Disclosure Information

Privacy Act Routine Uses

Public Burden Information (Electronic)

Public Burden Information

Instructions for Completing this Form (Paper Form Only)