Form PC-0005 Questionnaire for Peace Corps Volunteer Background Inves

O.M.B. No. 0420-0001

_{Expires xx/xx/xxxx}

Questionnaire for Peace Corps Volunteer Background Investigation

Privacy Act Statement: The Peace Corps, an agency of the U.S. government, is required by the Privacy Act of 1974 (5 U.S.C. §552a) to advise you of the following information regarding this form.

This information is being collected pursuant to the Peace Corps Act, 22 U.S.C. §§ 2504(a), 2519. It will be used to determine whether you are qualified, eligible and suitable to be a Peace Corps Volunteer and whether your assignment to the Peace Corps would be consistent with the national interest. It will be used by the Peace Corps or a contractor to conduct a Background Investigation (BI), which may include a check of records at the Office of Personnel Management, the Federal Bureau of Investigation, the Defense Security Service and other agencies which might have pertinent records relating to your activities. Signature on the form provides your consent for such a check.

The information may be used and disclosed for the routine uses described in the Privacy Act, 5 U.S.C. §552a, and the Peace Corps’ published Routine Uses for PC-17 (Volunteer Records), summarized in Peace Corps' System of Records. (Peace Corps System of Records link)   

Your Social Security Number (SSN) is needed to ensure that records are accurate, since other people may have the same name and birthdate. Completion of this form, including your SSN, is voluntary, but without it, the Peace Corps will be unable to process your application.

Paperwork Reduction Act Burden Statement:  Public reporting burden for this information collection is estimated to average 1-2 minutes. This includes the time for reviewing instructions and completing the information. This is a voluntary information collection. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: the FOIA Officer, Peace Corps, 1111 20^th Street NW, 2^nd Floor, Washington, D.C. 20526. Do not return the completed form to this address.

Instructions

All responses must be printed in black ink. The completed form will be photocopied, and clarity is essential. If the form is not clearly written, it will have to be resubmitted, and this may delay your placement. Print all responses with care. Make corrections neatly. Do not extend any response beyond the edge of the space provided within the answer box.

If you need more space for an answer, continue on a separate sheet of paper, the same size as this page (8.5" x 11"). At the top of each continuation sheet, print your name, social security number and the words "Peace Corps BI Questionnaire Continuation." Be sure to indicate the number(s) of the questions to which you are responding. Sign and date each continuation sheet. Attach three (3) copies of each continuation sheet behind the last page of the questionnaire.

Item 1: Print your full name in the following order – LAST, FIRST, MIDDLE, if you are a "Sr.", "Jr.", "III", etc., skip one space after your middle name and enter the appropriate designation. If you have initials only, enter each initial in the appropriate block and print (IO) after the initial for INITIAL ONLY. If you have no middle name, enter NMN in the block under "Middle".

Examples:

Normal Entry

1. Applicant’s Name

Doe

Last

First

John

Middle

_{Carr Sr.}

Initials Only

1. Applicant’s Name

Doe

Last

First

Middle

_{A (IO) C (IO)}

No Middle Name

1. Applicant’s Name

_Doe

Last

First

John

Middle

NMN

Item 2: Print your social security number (SSN).

_{Item 3: Print your date of birth (DOB) using numbers, for example, December 5, 1948, should be printed:}

¹² 05 48

Item 4: Print other names you have used and the dates (month and year) the names were used, such as maiden names, names by former marriages, aliases, nicknames, or former names changed legally or otherwise. Print "NEE" before maiden names.

Item 5: Print your place of birth. Enter the city/town and county. If you were not born in the U.S.A. or its territories, print the name of the foreign country where you were born. If you were born in the U.S.A. or its territories, fill in the box marked "State" with the appropriate abbreviation from the list below:

_{Coding for States, District of Columbia, and U.S. territories (Item 5)}

Alabama . . . . . .AL Alaska . . . . . . . .AK Arkansas . . . . .AR Arizona . . . . . .AZ California . . . . .CA Colorado . . . . .CO Connecticut . . .CT Delaware . . . . .DE Florida . . . . . . . .FL Georgia . . . . . .GA

Hawaii . . . . . . . .HI Idaho . . . . . . . . .ID Illinois . . . . . . . . .IL Indiana . . . . . . . .IN Iowa . . . . . . . . . .IA Kansas . . . . . . .KS Kentucky . . . . . .KY Louisiana . . . . .LA Maine . . . . . . . .ME Maryland . . . . . MD

Massachusetts .MA Michigan . . . . . .MI Minnesota . . . .MN Mississippi . . . .MS Missouri . . . . . .MO Montana . . . . . .MT Nebraska . . . . .NE Nevada . . . . . . .NV New Hampshire NH New Jersey . . . .NJ

New Mexico . . .NM New York . . . . . .NY North Carolina .NC North Dakota . .ND Ohio . . . . . . . . .OH Oklahoma . . . . .OK Oregon . . . . . . .OR Pennsylvania . . .PA Rhode Island . . .RI South Carolina .SC

South Dakota . .SD Tennessee . . . .TN Texas . . . . . . . . .TX Utah . . . . . . . . . UT Vermont . . . . . . .VT Virginia . . . . . . .VA Washington . . .WA West Virginia . .WV Wisconsin . . . . .WI Wyoming . . . . .WY

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

Item 6: Print an X in the appropriate box.

Item 7: Read the certification. Sign and date page 1 (Peace Corps copy). Be sure to sign and date all continuation sheets.

When you have completed all items, including signature and date, carefully detach the last copy (Applicant’s Copy) and return pages 1 through 3 to the Peace Corps. Keep "Applicant’s Copy" for your records.

Questionnaire for Peace Corps Volunteer Background Investigation

(Peace Corps, Washington, D.C. 20526)

RESPONSES MUST BE IN BLACK INK - SEE INSTRUCTIONS

_{BI Use Only}

Peace Corps

_{Form 0005}

1. Applicant’s Name

Last

^First Middle

_{2. Social Security Number}

_{3. Date of Birth}

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

5. Place of Birth

^{City County} State ^Country

_{Office Use Only}

6. Sex

Female

Male

Program Name/Training Class Number/Desk

_{Changes, Comments}

Initial:

_Date:

_7.

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

I authorize this information to be provided to an investigator or other duly authorized representative of the Peace Corps for the purpose of undertaking a background investigation. I also authorize such investigator or representative to obtain information from the Office of Personnel Management, the Federal Bureau of Investigation, the Defense Security Service or any other relevant agency relating to my qualifications, eligibility or suitability for Peace Corps service or whether assignment to the Peace Corps would be consistent with the national interest.

_{CERTIFICATION}

Date

_Signature

_MARGINALS

pt 1 — PEACE CORPS COPY pt 3 — APPLICANT FOLDER

pt 2 — BI FILE pt 4 — APPLICANT COPY

PC-0005 (Rev. 4/2014)