Form PC-0005 Questionnaire for Peace Corps Volunteer Background Inves

O.M.B. No. 0420-0001
Expires 07/31/2017

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 5 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 t h S t r e e t NW, 2nd Floor, Washington, D.C. 20526. Do
not return the completed form to this address.

PC-0005 (Rev. 09/2015)

Instructions
Do not extend any response beyond the space provided w ithin each form field. If you are unable to complete a form field
using the space provided continue on a separate electronic document that can be saved in one of the follow ing electronic
formats: “.doc,” “.docx,” “.pdf.” At the top of each continuation sheet, type your name, social security number and the w ords
"Peace Corps BI Questionnaire Continuation." Be sure to indicate the number(s) of the questions to w hich you are
at the bottom of each continuation sheet in the follow ing format: “Signature:

responding. Sign (type legal name) and date
Date: MM/DD/YYYY”.

Item 1: Type 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 form
field and type (IO) after the initial for INITIAL ONLY. If you have no middle name, enter NMN in the f or m field under
"Middle".

Examples:
Normal Entry
Last

1. Applicant’s Name

First

Doe

Middle

John

Carr Sr.

Initials Only
Last

1. Applicant’s Name

First

Doe

Middle

A (IO)

C (IO)

No Middle Name
1. Applicant’s Name

Last

First

Middle

John

Doe

NMN

Item 2: Type your social security number (SSN).
Item 3: Type your date of birth in the follow ing format: MM/DD/YYYY. For example, December 5, 1948, should be typed:

12

05

1948

Item 4: Type other names you have used and the dates (month and year) the names w ere used, such as maiden names,
names by former marriages, aliases, nicknames, or former names changed legally or otherw ise. Print "NEE" before
maiden names.
Item 5: Type your place of birth. Enter the city/tow n and county. If you w ere not born in the U.S.A. or its territories, type
the name of the foreign country w here you w ere born. If you w ere born in the U.S.A. or its territories, fill in the box
marked "State" w ith 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
Delaw are . . . . .DE
Florida . . . . . . . .FL
Georgia . . . . . .GA

Haw aii . . . . . . . .HI
Idaho . . . . . . . . .ID
Illinois . . . . . . . . .IL
Indiana . . . . . . . .IN
Iow a . . . . . . . . . .IA
Kansas . . . . . . .KS
Kentucky . . . . . .KY
Louisiana . . . . .LA
Maine . . . . . . . .ME
Maryland . . . . . MD

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

American Samoa – AS District of Columbia – DC Guam – GU
Puerto Rico – PR Trust Territory – TT Virgin Islands – VI
Item 6: Click to reveal a “” in the appropriate box.

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

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

Northern Mariana Islands – CM

Item 7: Read the certification. Sign by typing your legal name and date using the follow ing format: MM/DD/YYYY. . Be sure to
sign and date all continuation sheets.

Once you have com pleted the form , save, and then upload it and any continuation sheet(s) through the Applicant Portal
via the follow ing instructions:
1. Go to the “Edit your profile” page
2. Click the “Attachments” tab
3. Brow se for and upload your attachment
4. *Select “SAC Questionnaire” as the “Category” for the attachment
5. Click “Save”
6. Once you are done uploading, click “Continue” *If you do not select a “Category” for an attachm ent, then the
attachm ent WILL NOT appear as part of your Talent Record

Questionnaire for Peace Corps Volunteer Background Investigation
(Peace Corps, Washington, D.C. 20526)
BI Use Only
Peace Corps
Form 0005

1. Applicant’s Name

Last

3. Date of Birth

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

First

1.

5. Place of Birth

2. Social Security Number

Middle

2.

City

County

State

Countr y

6. Sex
Female
Male

Office Use Only
Program Name/Tr ai ni ng

Initial:

Class Number/D es k

Changes, Comments

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

Signatur e