Form PFPA Form 1409 PFPA Form 1409 Character Reference Questionnaire

PENTAGON FORCE PROTECTION AGENCY

OMB No. xxxx-xxxx
OMB approval expires
XXXXX XX XXXX

CHARACTER REFERENCE QUESTIONNAIRE
The public reporting burden for this collection of information, xxxx-xxxx, is estimated to average 10 minutes per response, including the 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 burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected].
Respondents should be aware that not withstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if
it does not display a current valid OMB control number.

Privacy Act Notice
Pentagon Force Protection Agency will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or
5 U.S. Code 552a for routine uses (i.e., information verifying an applicant’s character may be disclosed to a prospective Agency that require information obtained in the
completion of this form to help in the determination as to the individual’s fitness for federal employment in the field of law enforcement) as identified in the system of
records notice at OPM/GOVT-5 system of records at http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article- View/Article/570737/opmgovt-5/. Your
obligation to respond is voluntary, but failure to provide requested information could impede processing.

1. Applicant
a. Name:

b. Also Known As:

2. Reference
a. Name:

b. Address:

c. Telephone Number:

3. Please answer all questions and provide additional information as requested
a. Are you related to the applicant?
Yes
No
If yes please explain:
b. How many years have you known the applicant?
c. What is your occupation?
d. In what context (s) supervisor, colleague, friend, etc.) have you known the applicant?
5. Please answer all questions to the best of your knowledge
a. Do you question the applicant’s honesty, trustworthiness, diligence, reliability, or character?

Yes

No

b. Has the applicant been discharged or asked to resign from employment?

Yes

No

c. Has the applicant engaged in fraudulent or deceitful conduct?

Yes

No

d. Has the applicant been disciplined or subject to charges or complaints?

Yes

No

e. Has the applicant misused or abused prescription drugs or alcohol?

Yes

No

f. Has the applicant used illegal drugs?

Yes

No

g. Based on your knowledge of this person, would you recommend them for employment with
the Pentagon Force Protection Agency?

Yes

No

h. Are there any issues other than those listed above that you believe may be relevant to our
investigation?

Yes

No

5. Please explain any “Yes” answers in questions 5 through 12

PFPA FORM 1409, April 2018

FOR OFFICIAL USE ONLY-PRIVACY SENSITIVE

Any misuse or unauthorized disclosure can result in both civil and criminal penalties.

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