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

Draft for 30-day Federal Register Notice

Standard Form 85 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 Non-Sensitive 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 U.S. Government conducts background investigations to
establish that applicants or incumbents either employed by the
Government or working for the Government under contract, are
suitable for the job. Information from this form is used primarily as the
basis for this investigation.
Giving us this information is voluntary. However, we will not be able
to complete your investigation, or complete it in a timely manner, if
you don't give us each item of information we request. This may
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.
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 and 3302 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 non-sensitive positions are conducted
to gather information to show whether you are reliable, trustworthy, of

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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
previously indicated on applications or other forms that you do not
want your current employer to be contacted.
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.
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

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date to the best of your ability and indicate this by writing "APPROX."
or "EST."
8. If you need additional space for explanations or continuations of
other items, 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 non-sensitive position is
the responsibility of the Federal agency that requested your
investigation. You may be provided the opportunity personally to
explain, refute, or clarify any information before a final decision is
made.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that
knowingly falsifying or concealing a material fact is a felony which
may result in fines 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.

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

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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.
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.

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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
Public burden reporting for this collection of information is estimated
to average 100 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?

Section 3. Place of Birth
In what city were you born?

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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 6a. 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"
Last Name:

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First Name:
Middle Name:

Section 6b. Father’s Full Name
If your father only has initials in his name, use them and enter (I/O) after the
initial(s). If he has no middle name, enter "NMN"
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:

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Work e-mail address:
Home Telephone Number (International, if applicable):
Work Telephone Number (International, if applicable):
Cell Telephone Number (International, if applicable):

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

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□ 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:

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:

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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

□ 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:

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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:
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:
Country of citizenship:

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

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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.

Section 11. Where you have lived
List the places where you have lived beginning with your present residence and
working back 5 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:

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

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
□ Friend
□ Landlord
□ Tenant
□ Business Associate

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□ 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 5 years. List college or university degrees and the dates they were
received. If you received your most recent degree or diploma more than 5 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.
Please enter the 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:
Date awarded (MM/YYYY)

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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
□ No
Section 13a. Employment Activities

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List all of your employment activities, including unemployment and selfemployment, beginning with the present (#1) and working back 5 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
What is your assigned duty station during this period?
Street Address of Duty Station

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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
Country

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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
Provide employer Telephone Number:

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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
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:
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
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

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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?
□ Yes
□ No
If you selected Code 7, answer the following:

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

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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 5 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.

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

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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

Specify the reason for quitting.

Have you quit any other job after being told you would be fired?
□ Yes

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□ 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
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

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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

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

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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)

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:

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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
□Merchant Marine

Were you discharged from U.S. military service, to include Reserves,
National Guard, or U.S. Merchant Marine?
□ Yes
□ No

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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 5 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
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.

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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.)

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)

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:

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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 17. 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 5 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:

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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
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 five years, have you ever been arrested for any other offense?
□ Yes
□ No
In the past 5 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

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

In the last five years, 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
Please explain.

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Are you currently awaiting sentencing for a criminal offense?
□ Yes
□ No
Please explain.

Section 18. Illegal Use of Drugs or Drug Activity
In the last 5 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 5 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)
□ 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)
□ Hallucinogens (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.

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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.

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?

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□ Yes
□ No
In the last year, 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:
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
In the last 5 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

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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 19. Use of Alcohol (Respond for the time frame of the last 5 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.

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

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□ 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:
State of counseling/treatment provider:
Telephone Number

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

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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

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.

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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 20. 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
□ 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

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Is there another investigation you would like to list?
□ Yes
□ No
Were you ever found unsuitable for Federal employment?
□ Yes
□ 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 21. Financial Record
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 a description of the type of federal debt(s) (e.g., federal income
tax, federal student loan)

Provide the reason(s) for your delinquency.

Enter the loan/account number involved:

Section 22, Association Record

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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,
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?
□ Yes
□ No
Have you ever knowingly engaged in any acts of terrorism? □ Yes
□ No
Have you ever advocated any acts of terrorism or activities designed to
overthrow the U.S. Government by force?
□ Yes
□ No
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?
□ Yes
□ No
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 the Constitution of any state of the United
States?
□ Yes
□ No
Have you ever knowingly engaged in activities designed to overthrow the U.S.
Government by force?
□ Yes
□ No
Continuation Space
Use the space below to continue answers to all items and any information
you would like to add. If more space is needed than is provided below, use
a blank sheet(s) of paper. Start each sheet with your name and Social
Security number. Before each answer, identify the number of the item.

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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 85 Revised July 2008 U.S. Office of Personnel
Management 5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS
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 or eligibility for
a non-sensitive 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

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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 suitability for a non-sensitive 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 85, and that it may be
disclosed by the Government only as authorized by law. Photocopies
of this authorization that show my signature are valid. This
authorization is valid for two (2) years from the date signed or upon
the termination of my affiliation with the Federal Government,
whichever is sooner.
Signature (Sign in ink)

Full name (Type or print legibly)

Date signed (mm/dd/yyyy)

Other names used

Date of birth

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Social Security Number

Current street address

Apt. #

City (Country)

State

ZIP Code

Home telephone number

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