Form PC Form 0005 PC Form 0005 Peace Corps National Agency Check (NAC) Questionnaire fo

Peace Corps
Form 0005

Form approved
O.M.B. No. 0420-0001
Expires 03/31/2012

National Agency Check Questionnaire
for Peace Corps Volunteer Background Investigation

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

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

Burden Statement:
Public reporting burden for this collection of information is estimated to average 15 minutes per response. This estimate includes the time for reviewing instructions and completing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace
Corps, 1111 20th Street, NW, Washington, DC 20526 ATTN: PRA (0420- -0001). Do not return the completed form to this address.

read instructions on back of this page

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

Examples:
Normal Entry
1. Applicant’s Name

Last

First

DOE

Middle

JOHN

CARR Sr.

Initials Only
Last

1. Applicant’s Name

First

DOE

Middle

A (IO)

C (IO)

No Middle Name
1. Applicant’s Name

Last

First

Middle

JOHN

DOE

NMN

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

12

05

48

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

Coding for States, District of Columbia, and U.S. Territories (Item5)
Alabama . . . . . .AL
Alaska . . . . . . . .AK
Arkansas . . . . .AR
Arizona . . . . . .AZ
California . . . . .CA
Colorado . . . . .CO
Connecticut . . .CT
Delaware . . . . .DE
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

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

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

Northern Mariana Islands – CM

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

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

OPM Use Only

Peace Corps
Form 5

1. Applicant’s Name

Last

First

3. Date of Birth

4. Other (Full) Name(s) Used and Dates Used

5. Place of Birth

City

2. Social Security Number

Middle

County

State

Country

Office Use Only
Program Name/Training Class Number/Desk

Initial:

7.

Changes, Comments

Date:

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

CERTIFICATION
Date

Signature

- MARGINALS -

pt 1 — OPM COPY
pt 2 — NAC FILE
pt 3 — APPLICANT FOLDER
pt 4 — APPLICANT COPY

6. Sex
Female
Male