SF-85P (EQIP) SF-85P Template for the EQIP Screen

Draft for 30-day Federal Register Notice

Standard Form 85P Revised July 2008 U.S. Office of Personnel Management 5
CFR Parts 731, 732, and 736
Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111
Questionnaire for Public Trust Positions Follow instructions fully or we
cannot process your form. If you have any questions, contact the office
that gave you the form.
Purpose of this Form
The United States (U.S.) Government conducts background investigations and
reinvestigations to establish that applicants or incumbents either employed by the
Government or working for the Government under contract are suitable for the
job and are eligible for a public trust position.
Giving us 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 placement or employment
prospects. Any information that you provide is evaluated on the basis of its
recency, seriousness, relevance to the position and duties, and consistency with
all other information about you.
Withholding, misrepresenting, or falsifying information will have an impact on
your employment prospects, or job status, up to and including removal and
debarment from Federal Service.
Authority to Request this Information
Depending upon the purpose of your investigation, the United States
Government is authorized to ask for this information under Executive Order
10450; sections 3301, 3302, and 9101 of title 5, United States Code; and parts 2,
5, 731, and 736 of title 5, Code of Federal Regulations.
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.
The Investigative Process
Background investigations for public trust positions are conducted to gather
information to show whether you are reliable, trustworthy, of good conduct and
character, and loyal to the U.S. The information that you provide on this form
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, even if you have

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previously indicated on applications or other forms that you do not want your
current employer to be contacted.
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 helps to
complete your investigation faster. It is important that the interview be conducted
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 asked to bring identification with your picture on it,
such as a valid state driver's license. There are other documents you may be
asked to bring to verify your identity as well. These may include documentation of
any legal name change, Social Security card, passport, and/or your birth
certificate.
You may also be asked to bring documents about information you provided on
the 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
1. Follow the instructions given to you by the office that gave you this form and
any other clarifying instructions furnished by that office to assist you in
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 with "N/A" unless otherwise noted.
3 You must use the Location codes (abbreviations) listed below when you fill out
this form. Do not abbreviate the names of cities or foreign countries.
4. Whenever "City (Country)" is shown in an address block, also provide in that
block the name of the country when the address is outside the U.S.
5. The 5-digit postal Zip Codes are needed to speed the processing of your
investigation. Refer to an automated system approved by the U.S. Postal Service
to assist you with Zip Codes.

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6. For telephone numbers in the U.S., be sure to include the area code.
7. 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 find that you cannot report an exact date,
approximate or estimate the date to the best of your ability and indicate this by
writing "APPROX." or "EST."
8. If you need additional space for explanation or to list your residences,
employment/self-employment/unemployment, or education, you should use the
Continuation Space or a blank sheet(s) of paper. Each blank sheet of paper you
use must contain your name and SSN at the top of the page.
Final Determination on Your Suitability
Final determination on your suitability for a public trust position is the
responsibility of the Federal agency that requested your investigation. You will be
provided the opportunity personally to explain, refute, or clarify any information
before a final decision is made.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying
or concealing a material fact is a felony which may result in fines and/or up to 5
years of 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 give to us on this
form and to make your comments part of the record.
DISCLOSURE INFORMATION
The information you give to us is for the purpose of determining your suitability
for Federal and Federal contract employment; we will protect it from unauthorized
disclosure. The collection, maintenance, and disclosure of background
investigative information is governed by the Privacy Act. The agency 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 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 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

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1. To the Department of Justice when: (a) the agency or any component thereof;
or (b) any employee of the agency in his or her official capacity; or (c) any
employee of the agency in his or her individual capacity where the Department of
Justice has agreed to represent the employee; or (d) the United States
Government, is a party to litigation or has interest in such litigation, and by
careful review, the agency determines that the records are both relevant and
necessary to the litigation and the use of such records by the Department of
Justice is therefore deemed by the agency to be for a purpose that is compatible
with the purpose for which the agency collected the records.
2. To a court or adjudicative body in a proceeding when: (a) the agency or any
component thereof; or (b) any employee of the agency in his or her official
capacity; or (c) any employee of the agency in his or her individual capacity
where the Department of Justice has agreed to represent the employee; or (d)
the United States Government is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records are both
relevant and necessary to the litigation and the use of such records is therefore
deemed by the agency to be for a purpose that is compatible with the purpose for
which the agency collected the records.
3. When a record on its face, or in conjunction with other records, indicates a
violation or potential violation of law, whether civil, criminal, or regulatory in
nature, and whether arising by general statute, particular program statute,
regulation, rule, or order issued pursuant thereto, the relevant records may be
disclosed to the appropriate Federal, foreign, State, local, tribal, or other public
authority responsible for enforcing, investigating or prosecuting such violation or
charged with enforcing or implementing the statute, rule, regulation, or order.
4. To any source or potential source from which information is requested in the
course of an investigation concerning the hiring or retention of an employee or
other personnel action, or the issuing or retention of a security clearance,
contract, grant, license, or other benefit, to the extent necessary to identify the
individual, inform the source of the nature and purpose of the investigation, and
to identify the type of information requested.
5. To a Federal, State, local, foreign, tribal, or other public authority the fact that
this system of records contains information relevant to the retention of an
employee, or the retention of a security clearance, contract, license, grant, or
other benefit. The other agency or licensing organization may then make a
request supported by written consent of the individual for the entire record if it so
chooses. No disclosure will be made unless the information has been determined
to be sufficiently reliable to support a referral to another office within the agency
or to another Federal agency for criminal, civil, administrative, personnel, or
regulatory action.

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6. To contractors, grantees, experts, consultants, or volunteers when necessary
to perform a function or service related to this record for which they have been
engaged. Such recipients shall be required to comply with the Privacy Act of
1974, as amended.
7. To the news media or the general public, factual information the disclosure of
which would be in the public interest and which would not constitute an
unwarranted invasion of personal privacy.
8. To a Federal, State, or local agency, or other appropriate entities or
individuals, or through established liaison channels to selected foreign
governments, in order to enable an intelligence agency to carry out its
responsibilities under the National Security Act of 1947 as amended, the CIA Act
of 1949 as amended, Executive Order 12333 or any successor order, applicable
national security directives, or classified implementing procedures approved by
the Attorney General and promulgated pursuant to such statutes, orders or
directives.
9. To a Member of Congress or to a Congressional staff member in response to
an inquiry of the Congressional office made at the written request of the
constituent about whom the record is maintained.
10. To the National Archives and Records Administration for records
management inspections conducted under 44 U.S.C. 2904 and 2906.
11. To the Office of Management and Budget when necessary to the review of
private relief legislation.
LOCATION CODES
Alabama AL Alaska AK Arizona AZ Arkansas AR California CA Colorado CO
Connecticut CT Delaware DE District of Columbia DC Florida FL Georgia GA
American Samoa AS Federated States of Micronesia FM Hawaii HI Idaho ID
Illinois IL Indiana IN Iowa IA Kansas KS Kentucky KY Louisiana LA Maine ME
Maryland MD Guam GU Marshall Islands MH Massachusetts MA Michigan MI
Minnesota MN Mississippi MS Missouri MO Montana MT Nebraska NE Nevada
NV New Hampshire NH New Jersey NJ Northern Mariana Islands MP Puerto
Rico PR 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 Palau PW Virgin Islands of the U.S. VI South Dakota SD Tennessee
TN Texas TX Utah UT Vermont VT Virginia VA Washington WA West Virginia
WV Wisconsin WI Wyoming WY
PUBLIC BURDEN INFORMATION

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Public burden reporting for this collection of information is estimated to average
150 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, 3206-0005, is currently
valid. OPM may not collect this information, and you are not required to respond,
unless this number is displayed.

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PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE
QUESTIONS BELOW AFTER CAREFULLY READING THE FOREGOING
INSTRUCTIONS.
I have read the instructions and 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, up to and including my removal and debarment from Federal service.
□ Yes
□ No
Section 1. Full Name
If you have only initials in your name, use them and enter (I/O) after the initial(s).
If you have no middle name, enter "NMN." If you are a "Jr.," "Sr.," etc. enter this
in the box after your middle name.
Last Name:
First Name:
Middle Name:
Suffix (Jr., II, etc)

Section 2. Date of Birth
In what month were you born?
In what day were you born?
In what year were you born?

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Section 3. Place of Birth
In what city were you born?
In what county were you born?
In what state were you born?
In what country were you born? (if outside the U.S.) - If born in the U.S. enter N/A

Section 4. Social Security Number
Please enter your Social Security Number (if you have one):

Section 5. Other Names Used
Have you used any other names?
□ Yes
□ No
If yes, list other names used and the period of time you used them [for
example: your maiden name(s) by a former marriage, former name(s),
alias(es), or nickname(s). If the other name is your maiden name, put
"maiden" in front of it.
Name #1:
Please list the month/year name was used:

Do you have other names used to report?
□ Yes
□ No
Section 6. Mother's Maiden Name
If your mother only has initials in her name, use them and enter (I/O) after the
initial(s). If she has no middle name, enter "NMN."

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Last Name:
First Name:
Middle Name:

Section 7. Your Identifying Information
Height: (feet and inches, e.g. 5’ 10”)
Weight: (in pounds)
Hair Color:
Eye Color:
Sex:

Section 8. Your Contact Information
Home e-mail address:
Work e-mail address:
Home Telephone Number (International, if applicable):
Work Telephone Number (International, if applicable):
Cell phone Number (International, if applicable):

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Section 9. Citizenship
a. Mark the appropriate selection to describe your citizenship status:
□ I am a U.S. citizen or national by birth in the U.S. or U.S.
territory/commonwealth.
□ I am a US citizen or national by birth, born to US parents in a foreign
country.
Document Type:
Document number for US citizen born abroad:
Date of issuance MM/YYYY:
Place of issuance (city/country):
Name in which document was issued:
Last Name, First Name, Middle Initial

I was born on a U.S. military installation:
□ Yes
□ No
If Yes, provide the name of the installation
Location of military installation (city/country)

□ I am a US citizen by adoption (pursuant to Public Law 106-395).
Date and place of entry in US –MM/YYYY:

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Country(ies) of prior citizenship:

Document type:
Document number:
Date of issuance MM/YYYY:
Place of issuance (city/country):

□ I am a naturalized U.S. citizen.
Date and place of entry in US –MM/YYYY:

Country(ies) of prior citizenship:

Document type:
Document number:
Date of issuance MM/YYYY:
Place of issuance issued (city and court):
Name in which certificate was issued:
Last Name, First Name, Middle Initial

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□ I am not a U.S. citizen.
Are you a legal permanent resident of the US?
□ Yes
□ No
If no, please explain your residence status:

If yes, answer the following:
Date and place of entry in US –DD/MM/YYYY:
]
Alien Registration Number:
Name in which your Alien Registration Number was issued:
Last Name, First Name, Middle Initial

Type of documentation issued:
Date documentation issued DD/MM/YYYY:
Expiration date of visa DD/MM/YYYY:

b. Do you possess a US Passport (current or most recent passport)?
□ Yes
□ No
If yes, answer the following:
US Passport number:
Date Issued DD/MM/YYYY:
Name in which passport was first issued:

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Last Name, First Name, Middle Initial
Expiration date of passport DD/MM/YYYY:

Section 10. Dual/Multiple Citizenship Information
Do you now hold or have you EVER held dual/multiple citizenship?
□ Yes
□ No
If yes, answer the following:
Non-US Country(ies) of citizenship:

During what period of time did you hold citizenship with this/these non-US
country(ies)? From (MM/YYYY to MM/YYYY/Present)

What is the reason that you hold, or held, non-US citizenship?

Have you ever exercised the rights or privileges of a foreign country after
obtaining U.S. citizenship (e.g. voting in a foreign election; use of a foreign
passport)?
□ Yes
□ No
If yes, provide explanation.

Have you renounced or attempted to renounce your citizenship with
this/these non-US country(ies)?
□ Yes
□ No
If yes, provide explanation.

If no, would you be willing to renounce your non-US citizenship, if
necessary, as a condition of access?

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□ Yes
□ No
If no, provide explanation.

Have you ever been issued a passport (or foreign identity card for travel)
by a country other than the US?
□ Yes
□ No
If yes, answer the following:
Country in which passport (or identity card) was issued
Date and place issued DD/MM/YYYY
Name in which passport (or foreign identity card) was issued: Last
Name, First Name, Middle Initial
Passport Number
Expiration Date? DD/MM/YYYY

Have you ever used this passport (or identity card) for travel?
□ Yes
□ No
If yes, list the countries to which you traveled on this
passport (or identity card) and the dates (MM/YYYY)
involved with each.

Would you be willing to relinquish your foreign passport with this
foreign country as a condition of access?
□ Yes
□ No
If no, provide explanation.

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Do you have any other foreign passports to report?
□ Yes
□ No
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.
For the First residence:
Date of residence - MM/YYYY to present

Is this address in the United States?
□ Yes
□ No
Enter the street address (including apt. #)
City
State
Zip Code

Do you:
□ Own this residence
□ Rent or lease this residence
□ Other (Provide explanation)

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Is this residence military housing?
□ Yes
□ No
Provide the name of a neighbor or other person who knows you at this address Last Name, First Name, Middle Initial

Date of Last Contact (MM/YYYY)

Is this person's current address in the United States?
□ Yes
□ No
Information regarding the person who knows you at this address
Enter the street, address (including apt. #)
City
State
Zip Code
Enter evening phone number for this person:
Enter daytime phone number for this person:
Enter cell phone number for this person (if unknown, enter 'Unk'):
Enter e-mail address for this person (if unknown, enter 'Unk'):

Provide your relationship to this person
□ Neighbor

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□ Friend
□ Landlord
□ Tenant
□ Business Associate
□ Other (Provide explanation)

Do you have an additional residence to enter?
□ Yes
□ No
Section 12. Where You Went to School
List all schools you have attended, beginning with the most recent (#1) working
back 7 years. List college or university degrees and the dates they were
received. If you received your most recent degree or diploma more than 7 years
ago, list it below no matter when you received it. In the Code block, show the
most appropriate code to describe your school.
1 - High School
2 - College/University/Military College
3 - Vocational/Technical/Trade School
4 - Correspondence/Distance/Extension/Online School
For schools you attended in the last 3 years, list a person who knew you at
school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago.
Dates of attendance - MM/YYYY to MM/YYYY

Code:

Name of School

Did you receive a degree/diploma?
□ Yes
□ No
If yes, identify type of degree/diploma received:

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Date awarded (MM/YYYY)

Street address of school (for Code 4 schools, provide the address where the
records are maintained):
City (Country)
State
Zip Code

Name of person who knows/knew you at school (for Code 4 schools, list
someone who knew you while you received this education):
Email address:
Current address (include apt.#)
City (Country)
State
Zip Code
Telephone Number

Other schools attended?
□ Yes

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□ No
Section 13a. Employment Activities
Employment activities include employment, self-employment, military duty,
and unemployment. List all of your employment activities, beginning with the
present (#1) 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.
Employment Activity Information
Provide dates for the FIRST employment activity period. (MM/YYYY to Present)

What is your most recent position title during this employment activity period?

Provide the reason for leaving the employment activity. (If the employment
activity period listed is your current employment, answer “None.”)

Please select employment activity code
□ 1 - Active military duty station
□ 2 - National Guard/Reserve
□ 3 - USPHS Commissioned Corps
□ 4 - Other Federal Employment
□ 5 - State Government (Non-Federal employment)
□ 6 - Self-employment
□ 7 - Unemployment
□ 8 - Federal Contractor
□ 9 - Non-government employment (excluding self-employment)
□ 10-Other (Provide explanation)
If you selected Code 1, 2, or 3, answer the following:
What is your most recent rank during this period?

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

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What is your assigned duty station during this period?
Street Address of Duty Station
City
State
Country
Telephone Number

Do you have an APO/FPO address at this location?
□ Yes
□ No
If yes, list the APO/FPO address, including zip code.

List the name of your supervisor. (Last name, First name)
Email address of your supervisor.
List the rank of your supervisor.
List the physical work location of your supervisor.
Street Address
City
State

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Country
Provide supervisor's Telephone Number:

Does your supervisor have an APO/FPO address at this location?
□ Yes
□ No
If yes, list the APO/FPO address, including zip code.

Do you have another employment to list?
□ Yes
□ No

If you selected Code 4, 5, 8, 9, or 10, answer the following:
What is your most recent position title during this period?

Select the employment status for this position:
□ Full time
□ Part-time
What is the name of your employer during this period?
What is the address of this employer?
Street Address
City
State
Country

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Provide employer Telephone Number:

Is your physical work address different than your employer’s address?
□ Yes
□ No
If yes, list the work address where you are physically located.
(Include Street Address, City, State (if US), Country)
List telephone number for this address

Do you have an APO/FPO address for your location?
□ Yes
□ No
If yes, list the APO/FPO address, including zip code.

List the name of your supervisor. (Last name, First Name)
Email address of your supervisor.
List the position title of your supervisor.
List the physical work location of your supervisor (Include Street Address,
City, State (if US), Country)
Provide the telephone number for this supervisor.

Does your supervisor have an APO/FPO address at this location?
□ Yes
□ No

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If yes, list the APO/FPO address, including zip code.

Do you have another employment to list?
□ Yes
□ No
If you selected Code 6, answer the following:
What is your most recent position title during this period?

Select the employment status for this position:
□ Full time
□ Part-time
What is the name of your employment during this period?

What is the address of this employment?
Street Address
City
State
Country
Zip Code
Provide employment Telephone Number:

Is your physical work address different than your emploment address?
□ Yes
□ No

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If yes, list the work address where you are physically located.
(Include Street Address, City, State (if US), Country)
List telephone number for this address

Do you have an APO/FPO address for your location?
□ Yes
□ No
If yes, list the APO/FPO address, including zip code.

List the name of someone who can verify your self-employment (Last
name, First name)

List the address of this verifier.
Street Address
City
State
Country
List the telephone number for this person.

Does the verifier have an APO/FPO address?
□ Yes
□ No
If yes, list the APO/FPO address, including zip code.

Do you have another employment to list?

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□ Yes
□ No
If you selected Code 6, answer the following:
List the name of someone who can verify your unemployment activities
and means of support. (Last name, First name)

List the address of this verifier.
Street Address
City
State
Country
Zip Code
List the telephone number for this person.

Does the verifier have an APO/FPO address?
□ Yes
□ No
If yes, list the APO/FPO address, including zip code.

Do you have another employment to list?
□ Yes
□ No
Section 13b. Former Federal Service, excluding military service NOT
indicated previously (list if applicable)

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Enter dates of Federal Service - MM/YYYY to MM/YYYY

List Agency

Street Address
City
State
Country
Zip Code

List Position Title

Section 13c. Employment Record
Has any of the following happened to you in the last 7 years? (If Yes, begin with
the most recent occurrence and go backward, providing date fired, quit, or left,
and other information requested)
Fired from a job?
□ Yes
□ No
If yes, answer the following:
Enter the month/year you were fired. - MM/YYYY

Enter the name of the employer from which you were fired.

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Enter the street address, city and state of the employer where you were
fired.
Street Address
City
State

Specify the reason for being fired.

Were you fired from any other job?
□ Yes
□ No
Quit a job after being told you would be fired?
□ Yes
□ No
If yes, answer the following:
Enter the month/year when you quit your job - MM/YYYY

Enter the name of the employer from which you quit.

Enter the street address, city and state of the employer where you quit.
Street Address
City
State

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Specify the reason for quitting.

Have you quit any other job after being told you would be fired?
□ Yes
□ No
Have you left a job by mutual agreement following charges or allegations of
misconduct?
□ Yes
□ No
If yes, answer the following:
Enter the month/year that you left a job - MM/YYYY

Enter the name of the employer from which you left.

Enter the address, city, and state of the employer which you left.
Street Address
City
State

Specify the allegations of misconduct.

Have you left any other job by mutual agreement following charges or
allegation of misconduct?
□ Yes
□ No

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Left a job by mutual agreement following notice of unsatisfactory performance?
□ Yes
□ No
If yes, answer the following:
Enter the month/year for the time you left a job MM/YYYY

Enter the name of the employer from which you left.

Enter the street address, city, and state of the employer which you left.
Street Address
City
State
Specify the reason(s) for unsatisfactory performance.

Have you left any other job following notice of unsatisfactory
performance?
□ Yes
□ No
Received a written warning, been officially reprimanded, suspended, or
disciplined for misconduct in the workplace, to include violation of a security
policy?
□ Yes
□ No
If yes, answer the following:
Enter the month/year you were warned, reprimanded, suspended or
disciplined - MM/YYYY

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Enter the name of the employer where you were warned, reprimanded,
suspended or disciplined.

Enter the street address, city, and state of the employer where you were
warned, reprimanded, suspended or disciplined.
Street Address
City
State
Specify the reason(s) for being warned, reprimanded, suspended or
disciplined.

Did you receive a written warning, official reprimand, been suspended or
disciplined for misconduct at any other employer?
□ Yes
□ No
Section 14. Selective Service Record
Were you born a male after December 31, 1959?
□ Yes
□ No
If yes, have you registered with the Selective Service System (SSS)?
□ Yes
□ No
If no, provide explanation.

If yes, provide registration number. (The Selective Service website,
www.sss.gov, can help provide the registration number for persons
who have registered)

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Section 15. Military History
Have you EVER served in the U.S. Military or the U.S. Merchant Marine?
□ Yes
□ No
If yes, answer the following:
In which branch of service did you serve? Please check all that apply and
indicate your start and end date with each service (MM/YYYY to
MM/YYYY)
□Army
□Army National Guard
□Army Reserve
□Navy
□Navy Reserve
□Air Force
□Air Force Reserve
□Air National Guard
□Marine Corps
□Coast Guard
□Coast Guard Reserve

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□Merchant Marine

Were you discharged from U.S. military service, to include Reserves,
National Guard, or U.S. Merchant Marine?
□ Yes
□ No
If yes, answer the following:
Select the type of discharge you received
□Honorable
□Dishonorable
□Other than Honorable
□General (Under honorable conditions)
□Bad Conduct
□Other (provide explanation)
From what branch of service were you discharged?
□Army
□Army National Guard
□Army Reserve
□Navy
□Navy Reserve
□Air Force
□Air Force Reserve
□Air National Guard
□Marine Corps
□Coast Guard
□Coast Guard Reserve
□Merchant Marine
Enter the date of discharge listed above - MM/YYYY

Enter the reason(s) for the above discharge except for “Honorable.”

In the last 7 years, have you been subject to court martial or other
disciplinary procedure under the Uniform Code of Military Justice?
(Including all Article 15’s, Captain’s mast, and Article 135 Court of Inquiry).
□ Yes
□ No

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If yes, answer the following:
Enter the date(s) of the court martial or other disciplinary procedure
- MM/YYYY

Describe the UCMJ offense(s) for which you were charged.

Enter 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.)

Describe the outcome of the court martial or other military
procedure under the UCMJ (guilty, not guilty, Article 15, fine,
reduction in rank, imprisonment, etc.)

Have you EVER served in a non-US country’s military, security forces, merchant
marine, militia, other defense forces or other government position?
□ Yes
□ No
If yes, answer the following:
During your service, which organizations were you serving
under: (Check all that apply)
□Military (Specify Army, Navy, Air Force, Marines, etc)
□Intelligence Service
□Diplomatic Service
□Security Forces
□Merchant Marine
□Militia
□Other Defense Forces (Please Specify)
□Other Government Agency (Please Specify)
□None
Period of service: From To

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Name of Country

Highest position/rank held

List the division/department/office in which you served

Describe the circumstances of your association with the organization
checked

Do you maintain contact with current or former associates, colleagues,
acquaintances from your service in one or more of the above
organizations?
□ Yes
□ No
If yes, provide full name, address (if known), official title, length of
association, and frequency of contact for each former associate,
colleague or acquaintance with whom you maintain contact.

Section 16. People Who Know you Well
List 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 the workplace, school, or
neighborhoods and whose combined association with you covers at least the last
5 years. Do not list your spouse, former spouse (s), other relatives, or anyone
listed elsewhere on this form.
Reference Name #1 (Last Name, First Name)

Rank/title (If applicable)

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Dates Known (From MM/YYYY to MM/YYYY)

Relationship to you: (Check all that apply)
□ Neighbor
□ Friend
□ Work Associate
□ Schoolmate
□ Other (provide explanation)
Enter evening phone number for this person:
Enter daytime phone number for this person:
Enter cell phone number for this person:
Enter e-mail address (if known) for this person:

Please provide home or work address for this reference.
Street Address
City (Country)
State
Zip Code

List another person who knew you well?
□ Yes
□ No
Section 17a. Marital Status

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Mark one box to show your current marital status and provide information
about your spouse or cohabitant. If there is not a middle name, enter
“NMN.”
Current Marital Status
□ Never married
□ Married
□Separated
□Annulled
□Divorced
□Widowed
If you answered “Never married,” proceed to Section 18.
If you answered “Married” or “Separated,” provide the following information:
Complete the following about your current spouse only. If your current
spouse was born outside of the U.S., provide citizenship information.
Last name

First name
Middle name

Date of Birth (DD/MM/YYYY)
Place of birth (include country if outside the U.S.)

Social Security Number

Maiden name

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Other names used (specify other names, names by other marriages, etc.
and show dates used for each name)
Last name, First Name, Middle name /Dates

Country(ies) of citizenship

Date married (DD/MM/YYYY)
Place married (City, include Country if outside the U.S.)
State
Zip code

Current address of your spouse, if different than your current address
(Street, City, include Country if outside the U.S.)
State
Zip code
Telephone number
Email address

Was your spouse born in the United States?
□ Yes
□ No

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If yes, indicate one type of documentation that he or she possesses
and the document numbers.
□ FS 240 or 545
□ DS 1350
□ Citizenship certificate
□ U.S. Passport (current or most recent)
□ Alien registration
□ Naturalization certificate
□ Other (please explain)
Document number

If separated, date of separation (MM/DD/YYYY)

If legally separated, where is the record located?
City (Country)
State
Zip code

If you answered “Widowed,” “Divorced,” or “Annulled” provide the following
information:
Complete the following about your former spouse.

Last name
First name
Middle name

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Date of birth (MM/DD/YYYY)
Place of birth (include Country if outside the U.S.)
Country(ies) of citizenship

Date married(DD/MM/YYYY)
Place married (City, include Country if outside the U.S.)
State

Date Divorced, Annulled or Widowed (MM/DD/YYYY)

If divorced/annulled, where is the record located?
City (Country)
State
Zip code

If divorced/annulled, provide last known address of former spouse (Street,
City, include Country if outside the U.S.)
State

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Zip code
Telephone number

Do you have another former spouse to report?
□ Yes
□ No
Section 17 b. Cohabitant
A cohabitant is a person with whom you share bonds of affection, obligation, or
other commitment as in a spouse-like relationship, 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, with whom you
share bonds of affection, obligation , or other commitment, as opposed to a
person with whom you live for reasons of convenience (a roommate)?
□ Yes
□ No
If yes, provide the following information:
Last name
First name
Middle name

Date of Birth (DD/MM/YYYY)
Place of birth (include Country if outside the U.S.)

Social Security Number

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Other names used (specifically maiden names, names by other marriages,
etc., and show dates used for each name)

Country(ies) of citizenship

Date cohabitation began

Was the cohabitant born in the United States?
□ Yes
□ No
If yes, indicate one type of documentation that he or she possesses
and the document numbers.
□ FS 240 or 545
□ DS 1350
□ Citizenship certificate
□ U.S. Passport (current or most recent)
□ Alien registration
□ Naturalization certificate
□ Other (please explain)
Document number

Section 18. Relatives
For each of your relatives listed below check all that apply and provide all
requested information whether or not they are living or deceased:
□Mother
□Father
□Stepmother
□Stepfather
□Foster parent
□Child (including adopted/foster)
□Stepchild

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□Brother
□Sister
□Stepbrother
□Stepsister
□Half-brother
□Half-sister
□Father-in-law
□Mother-in-law
□Guardian
For each person checked, provide the following information:
Full name (Last Name, First Name, Middle Name)

Date of birth MM/YYYY

Place of Birth
City
State
Country

Was this person born in the US?
□ Yes
□ No
If yes, Is this person deceased?
□ Yes
□ No
If no, your relative's current address (street, city)
State

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Country

If no, Is this person deceased?
□ Yes
□ No
If no, Is this person a U.S. citizen?
□ Yes
□ No
If yes, indicate one type of documentation that he or she possesses
and provide the document number below:
□ FS 240 or 545
□ DS 1350
□ U.S. Citizenship certificate
□ U.S. Naturalization certificate
□ U.S. Passport
□ Other (please explain)
Document Number

If no, list country of citizenship

Indicate type of documentation he or she possesses to support
U.S. residence:
□ Alien Registration
□ Visa
□ Other (Explain
Document Number

Do you have another relative to list?
□ Yes
□ No

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Section 19. Foreign Activities: Foreign Contacts
Do you have, or have you had, close and continuing contact with a foreign
national (i.e., a person who is not a citizen or national of the US) within the last 7
years with whom you or your spouse, or your cohabitant are bound by affection,
common interests, and/or obligation? Include associates, as well as relatives, not
already listed previously.
□ Yes
□ No
If yes, answer the following:
Last name, First name, Middle name (if known) of foreign contact

Provide other names, nicknames, as appropriate

Country of citizenship

Date and place of birth (if known)

Current address (if known)
Street Address and City
Country

Name and address of current employer (if known)

Approximate date first met - MM/YYYY

Approximate date of last contact - MM/YYYY

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Methods of contact (check all that apply)
□ In person
□ Telephone
□ Electronic (e.g. e-mail, chat room)
□ Written correspondence
□ Approximate frequency of contact
□ Daily
□ Weekly
□ Monthly
□ Quarterly
□ Annually
□ Other (provide explanation)

Nature of relationship (check all that apply)
□ Professional
□ Personal
□ Other (provide explanation)

Is this foreign national affiliated with a foreign government, military,
security, defense industry, or intelligence service?
□ Yes
□ No
□ Don't know
If yes, describe the organization with which this foreign national is
affiliated.

Section 20a. Foreign Activities: Foreign Financial Interests
In the last 7 years, have you, your spouse or children ever had any foreign
financial interests (include stocks, personal property, investments, bank
accounts, ownership of corporate entities) in which you (and/or your
spouse/children) have/had direct control or direct ownership? (Exclude US-based
fund managers and accounts.)
□ Yes
□ No
If yes, answer the following:

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Specify: (check all that apply)
□ Yourself
□ Spouse
□ Children
Type of financial interest

Date acquired - DD/MM/YYYY
How acquired (purchase, gift, etc.)
Cost in US dollars at time of acquisition
Current value in US dollars

Are there any co-owners?
□ Yes
□ No
If yes, provide the name, address, citizenship, and relationship of
the co-owner(s).

Do you have any other foreign financial interests (as described above) to
report?
In the last 7 years, have you (and/or your spouse or children) ever had any
foreign financial interests that someone controlled on your behalf?
□ Yes
□ No
If yes, answer the following:
Specify: (check all that apply)
□ Yourself
□ Spouse
□ Children
Type of financial interest

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Who controls it on your behalf (last name, first name, relationship)

Date acquired - DD/MM/YYYY

How acquired (purchase, gift, etc.)

Cost in US dollars at time of acquisition

Current value in US dollars

Are there any co-owners?
□ Yes
□ No
If yes, please provide the name, address, citizenship, and
relationship of the co-owner(s).

Do you have any other foreign financial interests (as described above) to
report?
□ Yes
□ No
Have you (and/or your spouse or children) owned in the last 7 years, or do you
expect to inherit, real estate in a foreign country?
□ Yes
□ No
If yes, answer the following:
Specify: (check all that apply)
□ Yourself

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□ Spouse
□ Children
Type of real estate property (home, business, etc.)

Location/address of property (City, Country)
Date acquired - DD/MM/YYYY
Date sold (if appropriate) MM/YYYY
How acquired (purchase, gift, etc.)
Cost in US dollars at time of acquisition
Current value in US dollars

Are there any co-owners?
□ Yes
□ No
If yes, provide the name, address, citizenship, and relationship of
the co-owner(s).

Do you own, or expect to inherit, any other real estate in a foreign country
(as described above)?
□ Yes
□ No
If you currently have dual/multiple citizenship, have you (and/or your spouse or
children) ever received, or are eligible to receive in the future any educational,
medical, retirement, social welfare, or other such benefit from a foreign country
since you became a US citizen?
□ Yes
□ No

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If yes, answer the following:
Specify: (check all that apply)
□ Yourself
□ Spouse
□ Children
Type of benefit

Dates benefits received or will become eligible MM/YYYY
The value of any benefit you now receive, have received or anticipate
receiving (total one-time payment, annual, monthly, weekly, etc.) in US
dollars
Reason

Does any immediate family member (other than your spouse or children) receive
educational, medical, retirement, social welfare, or other such benefit from a
foreign country?
□ Yes
□ No
If yes, answer the following:
Provide the name of the immediate family member and their relationship
to you.

Describe the nature, frequency and amount of the benefits received by
this immediate family member.

Do you provide financial support for any foreign national?
□ Yes
□ No
If yes, answer the following:
Provide the name(s) of the foreign national(s) you support financially.

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Provide the address (street, city, country) of the individual(s) listed above.

Explain the nature or your relationship with the individual(s) listed above.

Provide the amount and frequency of all financial support provided.

Section 20b. Foreign Activities: Foreign Business, Professional Activities,
and Foreign Government Contacts
(Based on information readily available or known to you without having to
independently query immediate family members) Respond for the time frame of
the last 7 years, unless otherwise noted.
Have you provided advice or support to anyone associated with a foreign
business or other foreign organization that you have not previously listed as a
former employer? (Answer “No” if your advice or support was authorized
pursuant to official US Government business.)
□ Yes
□ No
If yes, answer the following:
Describe advice/support provided.

Name of foreign national and/or organization(s) to which advice or support
was provided

Country of foreign national or organization

Date(s) involved From MM/YYYY To MM/YYYY

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Describe what compensation, if any, was provided for your service.

Have you or any member of your immediate family been asked to provide advice
or serve as a consultant, even informally, by any foreign government official or
agency? (Answer “No” if your advice or support was authorized pursuant to
official US Government business.)
□ Yes
□ No
If yes, answer the following:
Provide the name of the requesting person/organization and country.

Date of the request MM/YYYY

What are the circumstances of the request, including the City where the
request was made?

Country where the request was made.

Has any foreign national offered you a job, asked you to work as a consultant, or
consider employment with them?
□ Yes
□ No
If yes, answer the following:
Provide the name of the person who made the offer (last/first/middle).

Describe the position offered.

When did this occur? - MM/YYYY

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Where did this occur?
City
Country

Did you accept the offer?
□ Yes
□ No
Provide explanation.

Have you been involved in any other type of business venture with a foreign
national not described above (own, co-own, serve as business consultant,
provide financial support, etc.)?
□ Yes
□ No
If yes, answer the following:
Provide full name of this person. (Last Name, First Name)

Provide the full address of this person. (Street address, city, country)

Provide citizenship of this person.

Provide description of business venture.

What is your relationship to this person?

Length of time (years) you have been involved in the business venture.

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Describe nature of your association with the business venture. Include
position held, product or service provided, and your financial investment, if
applicable.

Describe the compensation you received for your service.

Have you attended or participated in any conferences, trade shows, seminars, or
meetings outside the US? (Do not include those you attended or participated in
on official business for the
U.S. government)
□ Yes
□ No
If yes, answer the following:
Name and description of event

Name of sponsoring organization

City
Country
Dates - MM/YYYY

Purpose

Was there any subsequent contact with any foreign nationals as a result of
the event?
□ Yes

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□ No
If yes, provide explanation.

Have you or any member of your immediate family had any contact with a foreign
government, its establishment (embassy, consulate, agency, military service,
etc.) or its representatives, whether inside or outside the US? (Answer No if the
contact was for routine visa applications and border crossings related to either
official U.S. Government travel or foreign travel on a US passport listed in
Question 20)
□ Yes
□ No
If yes, answer the following:
Provide the name(s) of those persons involved in the contact.

Location (City/State/Country) and date (MM/YYYY) of contact

Foreign government and type of establishment involved

Foreign representatives involved in contact

Purpose/circumstances of contact

Was there any subsequent contact initiated by you, your family member,
or a representative of the foreign organization?
□ Yes
□ No
If yes, answer the following:
Purpose of subsequent contact

Date and purpose of most recent contact

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Plans for future contact

Have you sponsored any foreign citizen to come to the U.S. as a student, for
work, or for permanent residence?
□ Yes
□ No
If yes, answer the following:
Full Name (Last Name, First Name)
Date of birth (if known) (MM/YYYY)
Place of birth (City/Country)
Current Address (Include street address, city, state and country)
Country of citizenship

Name and address of organization through which sponsorship was
arranged, if applicable.

Dates of stay in US - From MM/YYYY To MM/YYYY

Address while residing in the U.S.

Purpose of stay in the US

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Purpose of your sponsorship

Section 20c. Foreign Activities: Foreign Countries You Have Visited
Respond for the time frame of the last 7 years (Do not list trips that ONLY
involved travel on official U.S. Government business, but you must include any
personal trips made in conjunction with the official US Government travel)
Have you traveled outside the U.S. in the last seven years?
□ Yes
□ No
If yes, answer the following:
List the most recent country visited.

List dates of travel beginning with the most recent and working backwards
(From MM/YYYY To MM/YYYY)

List the total number of days involved in the visit.
□ 1-5
□ 6-10
□ 11-20
□ 21-30
□ >30
List the purpose of the travel to this country (Check all that apply)
□ Business/professional
□ Volunteer activities
□ Education
□ Tourism
□ Trade shows
□ Visit family or friends
□ Other
While traveling to, in, or from this country, were you: (check all that apply)
Questioned, searched, or otherwise detained (other than for normal
customs requirements) by the local customs or security service officials
when entering or leaving a country?
Involved in any encounter with the police?

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In contact with any person known or suspected of being involved or
associated with foreign intelligence, terrorist, security, or military
organizations?
Provide explanation for each instance checked.

Have you traveled to any other foreign countries?
□ Yes
□ No
Section 21. Mental and Emotional Health
Mental and/or emotional health counseling in and of itself is not a reason for an
adverse suitability determination.
In the last 7 years, have you consulted with a health care professional regarding
an emotional or mental health condition or were you hospitalized for such a
condition? Answer “No” if the counseling was for any of the following reasons
and was not court-ordered:
- strictly marital, family, grief not related to violence by you; or
- strictly related to adjustments from service in a military combat environment.
□ Yes
□ No
If yes, answer the following:
Name of counselor or treatment provider:

Street address of counseling/ treatment provider:
City
State
Telephone Number

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Name of agency/organization where counseling/treatment was provided:

Is the address the same as above?
□ Yes
□ No
Please provide the street address, city, state, and zip code.

Date counseling or treatment began? - MM/YYYY

Date counseling or treatment ended? - MM/YYYY

Were you admitted as an inpatient to the agency/organization where
counseling/treatment was provided?
□ Yes
□ No
If yes, was the admission voluntary or involuntary?
□ Voluntary
□ Involuntary
Provide explanation.

Has a court or administrative agency ever declared you mentally
incompetent?
□ Yes
□ No
If yes, answer the following:
Which court or administrative agency declared you mentally
incompetent?
Provide the name and address.

When did this occur? - MM/YYYY

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Was this matter appealed to a higher court?
□ Yes
□ No
Provide the name and address of the court.

What was the final disposition?

In the last 7 years, have you consulted with another health care
professional regarding an emotional or mental health condition or were
you hospitalized for such a condition?
□ Yes
□ No
Section 22. Police Record
For this item 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.
In the past 7 years, have you been arrested by any police officer, sheriff, marshal
or any other type of law enforcement official?
□ Yes
□ No
If yes, answer the following:
Were you charged with a felony or misdemeanor in the jurisdiction in
which the arrest occurred?
□ Yes
□ No
Describe the specific nature of the offense(s)/charge(s) for which you were
arrested.

Enter the month and year you were arrested? - MM/YYYY

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Enter the city/county where the arrest took place.
Select the state where the arrest took place.
Enter the Country where the arrest took place (if outside the US).
What is the name of the law enforcement agency that arrested you?

Did any of the charges related to this arrest involve firearms or
explosives?
□ Yes
□ No
Did any of the charges related to this arrest involve alcohol or drugs?
□ Yes
□ No
What was the disposition of this offense?

In the last 7 years, have you been arrested for any other offense?
□ Yes
□ No
Have you ever been convicted in any court of the United States of a crime for
which you were sentenced to imprisonment for a term exceeding one year?
□ Yes
□ No
If yes, answer the following:
Provide the name and address (street, city, state) of the court which
convicted you.

Provide the date(s) of your conviction. - MM/YYYY

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Were you imprisoned as a result of that sentence for more than one year?
□ Yes
□ No
If yes, provide the length of the sentence that you served. From
MM/YYYY to MM/YYYY

Do you have any other convictions to report?
□ Yes
□ No
Are you now or have you been on probation or parole?
□ Yes
□ No
If yes, provide explanation.

In the past 7 years have you been issued a summons, citation, or ticket to appear
in court in a criminal proceeding against you? (Answer NO if you were fined less
than $300 for a traffic offense that did not involve alcohol or drugs)
□ Yes
□ No
If yes, answer the following:
Enter the month and year of the offense? - MM/YYYY

Enter the city where the offense took place.
Select the state where the offense took place.
What is the name of the law enforcement agency that cited you?

Did the offense involve firearms or explosives?
□ Yes
□ No
Did the offense involve alcohol or drugs?

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□ Yes
□ No
Describe the specific nature of the offense/charge for which you were
cited and the disposition.

Are there any other offenses for which you have been cited, ticketed, or
issued a summons or notice to appear before a court by any police officer,
sheriff or any other type of law enforcement officer? (Answer NO if you
were fined less than $300 for a traffic offense that did not involve alcohol
or drugs)
□ Yes
□ No
Are you on trial or awaiting a trial on criminal charges?
□ Yes
□ No
If yes, provide explanation.

Are you currently awaiting sentencing for a criminal offense?
□ Yes
□ No
If yes, provide explanation
.
Section 23. Illegal Use of Drugs or Drug Activity
In the last 7 years, have you illegally used any controlled substances? Use of a
controlled substance includes injecting, snorting, inhaling, swallowing,
experimenting with or otherwise consuming any controlled substance.
□ Yes
□ No
In the last seven years, have you illegally used any controlled substances listed
below? Use of a controlled substance includes injecting, snorting, inhaling,
swallowing, experimenting with or otherwise consuming any controlled
substance. (Check all that apply)

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□ Cocaine, crack cocaine
□ THC (marijuana, hashish, etc)
□ Ketamine
□ Narcotics (opium, morphine, codeine, heroin, etc)
□ Stimulants (amphetamines, speed, crystal methamphetamine, Ecstasy, etc.)
□ Depressants (barbiturates, methaqualone, tranquilizers, etc)
□ Hallucinogenic (LSD, PCP, etc)
□ Steroids
□ Inhalants (toluene, amyl nitrate, etc)
□ Other
If yes, answer the following for each marked box:
Estimate the month and year of first use. - MM/YYYY

Estimate the month and year of most recent use. - MM/YYYY

Estimate the number of times you have used this drug.

Do you intend on using this drug in the future?
□ Yes
□ No
Provide explanation.

Have you been ordered, advised, or asked to seek counseling or treatment as a
result of your use of drugs?
□ Yes
□ No
If yes, answer the following:
Provide the name of the first treatment provider (Last Name, First Name)
Provide the address for this person (street address, city, state).
Provide a phone number for the treatment provider.

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Beginning date of treatment - MM/YYYY
Ending date of treatment - MM/YYYY

Reason for treatment

Did you successfully complete the treatment?
□ Yes
□ No
If no, provide explanation

Do you have another treatment provider to enter?
□ Yes
□ No
In the last seven years, have you been involved in the purchase, manufacture,
cultivation, trafficking, production, transfer, shipping, receiving, handling or sale
of any controlled substance?
□ Yes
□ No
Please check all the drugs that apply.
□ Cocaine, crack cocaine
□ THC (marijuana, hashish, etc)
□ Ketamine
□ Narcotics (opium ,morphine, codeine, heroin, etc),
□ Stimulants (amphetamines, speed, crystal methamphetamine, Ecstasy,
ketamine, etc.),
□ Depressants (barbiturates, methaqualone, tranquilizers, etc),
□ Hallucinogenics (LSD, PCP, etc),
□ Steroids
□ Inhalants (toluene, amyl nitrate, etc),
□ Other
If yes, answer the following for each marked box:

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For the first drug selected, provide the following information
Estimate the month and year of first involvement? - MM/YYYY
Estimate the month and year of most recent involvement? - MM/YYYY

Why did you engage in the activity?

Do you intend to engage in this activity in the future?
□ Yes
□ No
Have you EVER illegally used or otherwise been involved with a controlled
substance while possessing a security clearance?
□ Yes
□ No
If yes, answer the following:
Describe your involvement.

Provide the dates of involvement or use (From MM/YYYY To MM/YYYY)
Estimate the number of times you used and/or were involved with this
drug while possessing a security clearance:

Have you EVER illegally used or otherwise been involved with a 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?
□ Yes
□ No
If yes, answer the following:
Describe the drugs used and your involvement.

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Provide the dates of involvement or use. (From MM/YYYY To MM/YYYY)
Estimate the number of times you used and/or were involved this drug
while employed in this capacity:

In the last seven years have you intentionally engaged in the misuse of
prescription drugs (to include giving or selling prescription drugs to someone
else), regardless of whether or not the drugs were prescribed for you or someone
else?
□ Yes
□ No
If yes, answer the following:
Provide the names of the prescription drug(s) that you misused.

List the dates involved in the above. - MM/YYYY

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

Section 24. Use of Alcohol (Respond for the time frame of the last 7 years)
Has your use of alcohol had a negative impact on your work performance, your
professional or personal relationships, or your finances, or resulted in
intervention by law enforcement/public safety personnel?
□ Yes
□ No
If yes, answer the following.
Provide the month/year when this negative impact occurred. - MM/YYYY

Explain the circumstances and the negative impact.

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Has the use of alcohol had other negative impacts on your work
performance, your professional or personal relationships, or your finances,
or resulted intervention by law enforcement/public safety personnel?
□ Yes
□ No
Have you been ordered, advised, or asked to seek counseling or treatment as a
result of your use of alcohol?
□ Yes
□ No
If yes, answer the following:
Who ordered, advised, or asked you to seek counseling or treatment?
□ Employer, military commander, or employee assistance program
□ Medical professional
□ Mental health professional
□ Court official / judge
□ Spouse or Cohabitant
□ Other family member (e.g. Parent or legal guardian)
□ Friend or acquaintance
Did you in fact receive counseling or treatment?
□ Yes
□ No
If no, provide explanation.

If yes, answer the following:
Date counseling or treatment began - MM/YYYY
Date counseling or treatment ended - MM/YYYY

Name of individual counselor or treatment provider:

Street address of counseling/treatment provider:
City of counseling/treatment provider:

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State of counseling/treatment provider:
Telephone Number

Did you successfully complete the treatment program?
□ Yes
□ No
If no, provide explanation.

Have you received counseling or treatment as a result of your use of alcohol in
addition to what you listed above?
□ Yes
□ No
If yes, answer the following:
Name of individual counselor or treatment provider:

Street address of counseling/ treatment provider:
City of counseling/treatment provider:
State of counseling/treatment provider:

Name of agency/organization where counseling/treatment was provided:

Address of agency/organization where counseling/treatment was
provided:
□ Same as above
□ Other (Please include street address, city, state

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Date counseling or treatment began - MM/YYYY
Date counseling or treatment ended - MM/YYYY

Did you successfully complete your counseling or treatment?
□ Yes
□ No
If no, provide explanation.

Did you receive alcohol-related counseling or treatment another time?
□ Yes
□ No
Have you sought assistance for alcohol abuse a recognized alcohol support
group like Alcoholics Anonymous?
□ Yes
□ No
If yes, are you still participating in the support group?
□ Yes
□ No
If no, provide explanation.

Section 25. Investigations and Clearance Record
Has the US Government (or a foreign government) ever investigated your
background? (Begin with the most recent and work backwards)
□ Yes
□ No
If yes, answer the following:
Investigating agency:
□ Defense Department
□ U.S. Department of State
□ U.S. Office of Personnel Management
□ Federal Bureau of Investigation
□ Treasury Department

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□ Department of Homeland Security
□ Foreign Government, Provide Name of Government
□ Unknown
□ Other (Explain)
Date the investigation was completed (if known) - MM/YYYY

Name of agency that issued the clearance/access if different from the
investigating agency

Is there another investigation you would like to list?
□ Yes
□ No
In the last 7 years, have you had a clearance or access authorization denied,
suspended, or revoked? (Note: An administrative downgrade or termination of a
security clearance is not a revocation)
□ Yes
□ No
If yes, answer the following:
Date clearance or access authorization was denied, suspended or
revoked? -MM/YYYY

Provide the name of the agency or activity that took the action?

Provide the address of the agency or activity that took the action?

Explain the circumstances of the denial, suspension or revocation action?

Were you ever found unsuitable for Federal employment?
□ Yes

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□ No
If yes, provide details of the action taken, including the agency taking the
action, the reasons for the action, and,any debarment, including all
relevant dates.

Section 26. Financial Record
For the following, answer for the last 7 years, unless otherwise specified in the
question. Disclose all financial obligations, including those for which you are a
cosigner or guarantor.
Have you filed a petition under any chapter of the bankruptcy code?
□ Yes
□ No
If yes, answer the following:
Check all that apply to the bankruptcy petition:
□ Chapter 7
□ Chapter 11
□ Chapter 13
Provide the name and address of the court involved in handling your
bankruptcy

Were you discharged of all debts claimed in the bankruptcy?
□ Yes
□ No
Provide explanation.

Did you have any other bankruptcy?
□ Yes
□ No
Have you had any possessions or property voluntarily or involuntarily
repossessed or foreclosed?
□ Yes
□ No
If yes, answer the following:

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Identify/describe the type of property or possessions that were
repossessed or foreclosed.

Provide the date(s) you had any possessions or property repossessed or
foreclosed - MM/YYYY

Provide the reason(s) for the repossession or foreclosure.

Have you failed to pay Federal, state, or other taxes or to file a tax return, when
required by law or ordinance?
□ Yes
□ No
If yes, answer the following:
Provide the year(s) you failed to file your Federal, state or other tax
return(s) - YYYY

Provide the reason(s) for your failure to file required tax returns.

Identify the Federal, state or other agency where you failed to file a tax
return

Have you had a lien placed against your property for failing to pay taxes or other
debts?
□ Yes
□ No
If yes, answer the following:
Provide the date(s) you had any liens placed against your property MM/YYYY

Provide the reason(s) for the lien(s)

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Have you had a judgment entered against you?
□ Yes
□ No
If yes, answer the following:
Provide the date(s) you had a judgment entered against you - MM/YYYY

Provide the reason(s) for the judgment.
Provide the name of the lender or court that had a judgment entered
against you.

Have you defaulted on any type of loan?
□ Yes
□ No
If yes, answer the following:
Provide the name of the lender who held the loan

Provide the date(s) you defaulted on any type of loan MM/YYYY
Provide the reason(s) for the default.

Have you had bills or debts turned over to a collection agency?
□ Yes
□ No
If yes, answer the following:
Provide the name of the collection agency.

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Provide the date(s) you had bills or debts turned over to a collection
agency - MM/YYYY

Provide the reason(s) that the bill or debt(s) was turned over to a
collection agency.

Have you had any account or credit card suspended, charged off, or cancelled
for failing to pay as agreed?
□ Yes
□ No
If yes, answer the following:
Provide the name and address of the credit company that suspended,
charged off, or cancelled for failing to pay as agreed?

Provide the date(s) your account or credit card was suspended, charged
off or cancelled - MM/YYYY

Have you been evicted for non-payment of financial obligations?
□ Yes
□ No
If yes, answer the following:
Provide the name and address of the individual, company or agency that
evicted you.

Provide the date(s) you were evicted - MM/YYYY

Provide the reason(s) for the eviction.

Have you been delinquent on court imposed alimony or child support payments?
□ Yes
□ No

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If yes, answer the following:
Provide the name and address of the court or agency.

Provide the date(s) of your delinquency - MM/YYYY

Have you had your wages, benefits, or assets garnished or attached for any
reason?
□ Yes
□ No
If yes, answer the following:
Provide the name and address of the court or agency that had your
wages, benefits, or assets garnished or attached for any reason.

Provide the reason(s) for the garnishment(s).

Have you been counseled, warned, or disciplined for violating terms of
agreement for a travel or credit card provided by your employer?
□ Yes
□ No
If yes, answer the following:
Provide the name and address of the company or agency that counseled,
warned, or disciplined for violating terms of agreement for a travel or credit
card provide by your employer.

Provide the date(s) of your counseling, warning, or disciplinary action MM/YYYY

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

Have you been over 120 days delinquent on any debt(s)?

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□ Yes
□ No
If yes, answer the following:
Enter the loan/account number involved:

Provide the date(s) of your delinquency - MM/YYYY
Provide the reason(s) for the delinquency.

Are you currently over 120 days delinquent on any debt(s)?
If yes, answer the following:
Enter the loan/account number involved:

Provide the date(s) of your delinquency - MM/YYYY

Provide the reason(s) for the delinquency.

Are you currently involved with a credit counseling service?
□ Yes
□ No
If yes, answer the following:
Provide name and address of counseling service

Provide date(s) that you received counseling from this service - MM/YYYY

Have you experienced financial problems due to gambling?
□ Yes
□ No

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If yes, answer the following:
Provide the date(s) of your financial problems - MM/YYYY

Estimate the amount of gambling losses incurred.

Describe the reason(s) for the financial problems.

Are you currently delinquent on any Federal debt?
□ Yes
□ No
If yes, answer the following:
Provide the date(s) of your delinquency - MM/YYYY

Provide the reason(s) for your delinquency.

Enter the loan/account number involved:

Section 27, Use of Information Technology Systems
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.
a. In the last 7 years, have you illegally or without proper authorization entered
into any information technology system?
□ Yes
□ No
If yes, answer the following:
List the date of the incident(s)
MM/YYYY

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Describe the nature of the incident or offense

Provide the location where the incident took place.
Street address
City
State

Describe the action (administrative, criminal or other) taken as a result of
this incident, if any.

Are there any other incidents to report?
□ Yes
□ No
b. In the last 7 years, have you illegally or without authorization, modified,
destroyed, manipulated, or denied others access to information residing on an
information technology system?
□ Yes
□ No
If yes, answer the following:
List the date(s) of the incident(s)
MM/YYYY

Describe the nature of the incident or offense

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Provide the location where the incident took place.
Street address
City
State

Describe the action (administrative, criminal or other) taken as a result of
this incident, if any.

Are there any other incidents to report?
c. In the last 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?
□ Yes
□ No
If yes, answer the following:
List the date(s) of the incident(s)
MM/YYYY
Describe the nature of the incident or offense
Provide the location where the incident took place.
Street address
City
State
Describe the action (administrative, criminal or other) taken as a result of
this incident, if any.
Are there any other incidents to report?
Section 28, Involvement in Non-Criminal Court Actions

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In the last 6 years, have you been a party to any public record civil court action(s)
not listed elsewhere on this form?
□ Yes
□ No
If yes, answer the following:
Provide the date of the civil action
MM/YYYY

Provide the name and address of the court involved in the civil action
Court Name
Street Address
City
State

Provide details of the nature of the action(s)

Describe the results of the action(s)

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

Are there any other civil court actions to report?
□ Yes
□ No
Section 29, 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 or credentialing decision. For the purpose of this question,

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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.
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
□ No
If yes, answer the following:
Provide the full name of the organization.

Provide the address/location of the organization.
Street Address
City
State
Country

Provide the dates of your involvement with the organization - From
MM/YYYY To MM/YYYY

List all positions held in the organization, if any.

List all contributions made to the organization, if any.

Describe the nature of and reasons for your involvement with the
organization.

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Have you ever knowingly engaged in any acts of terrorism?
□ Yes
□ No
If yes, answer the following:
Provide the reasons for such activities.

Provide the dates for any such activities - MM/YYYY

Have you ever advocated any acts of terrorism or activities designed to
overthrow the U.S. Government by force?
□ Yes
□ No
If yes, answer the following:
Provide the reasons for such activities.

Provide the dates of such activities - MM/YYYY

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, either with an awareness of the organization’s
dedication to that end or with the specific intent to further such activities?
□ Yes
□ No
If yes, answer the following:
Provide the full name of the organization.

Provide the address/location of the organization.
Street Address

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City
State
Country

Provide the dates of your involvement with the organization - From
MM/YYYY To MM/YYYY

List all positions held in the organization, if any.
List all contributions made to the organization, if any.

Describe the nature of and reasons for your involvement with the
organization.

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
□ No
If yes, answer the following:
Provide the full name of the organization.

Provide the address/location of the organization.
Street Address

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City
State
Country

Provide the dates of your involvement with the organization - From
MM/YYYY To MM/YYYY

List all positions held in the organization, if any.

List all contributions made to the organization, if any.

Describe the nature of and reasons for your involvement with the
organization.

Have you ever knowingly engaged in activities designed to overthrow the U.S.
Government by force?
□ Yes
□ No
If yes, answer the following:
Provide the reasons for such activities.

Provide the dates of such activities - MM/YYYY

Have you ever held political office or voted in the election of a foreign country?
□ Yes

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□ No
If yes, answer the following:
Identify the position held, if any.

Provide the date(s) you held political office or voted in a foreign election From MM/YYYY To: MM/YYYY

Provide the name(s) of the country involved.

Provide the reason(s) for these activities and include current eligibility to
hold political office or vote in a foreign election.

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, up to and including my removal and
debarment from Federal service.
Signature

Date (mm/dd/yyyy)

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Standard Form 85P
Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736
Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111
UNITED STATES OF AMERICA
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, 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 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 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, separate specific releases 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, the 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
position. 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 also understand that
the information may be used to conduct officially sanctioned and approved personnel
related research and studies, and will be maintained in accordance with the Privacy Act.
Photocopies of this authorization that show my signature are valid. This authorization
shall remain in effect so long as I remain in a Public Trust position.

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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

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Authorization for Release of Medical Information Pursuant to the Health
Insurance Portability and Accountability Act (HIPAA)
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)
If you answered "Yes" to Question 23, carefully read this authorization to release
information about you, then sign and date it in ink.
Instructions for Completing this Release
This is a release for the investigator to ask your health practitioner(s) the
questions below concerning your mental health consultations. Your signature will
allow the practitioner(s) to answer only these questions.
Authorization
I am seeking assignment to or retention in a national security position. As part of
the clearance 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)

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Date signed (mm/dd/yyyy)
Other names used
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 or reliability?
__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)

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Fair Credit Reporting Disclosure And Authorization
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
to perform contractual service for the Federal government, and/or (3) eligibility for
a sensitive position or access to classified information.
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 U.S. Office of Personnel Management 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 position of public trust. 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)

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