INV 40, 41, 42, 43 Investigative Request for Information, Employment Data a

.II

II
GENERAL REQUEST FOR
INVESTIGATIVE INFORMATION

INV FORM 40 (Rev. 6i/14)
U.S. OFFICE OF PERSONNEL
MANAGEMENT (5 CFR 736)

U.S. GOVERNMENT USE ONLY

o

UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX 618

M

BOYERS. PA 16018{t618

R

IIS'RUCTIO S: W€ are invesligating lho porson identified below' Pleas. search your rccords, indicaling the.esults by
marking ono ot tle ovab on the rovelBo ol lhls torm. f any pertinent info,mallon is contained in your records, ploase send
a photooopy as an attachment to lhi3 fo.m. It a photocopy is not avalhblo, ropo.t the pertinent information in lhe
".gmarks" seclion, Please r€tuh O|e complgted lorm, with any attachmonb to th6 Otfic€ of Personnol Managgmenl at the

addrg$ shown above,

PRIVACY ACT I]{FORHATION: This investigative inquiry is in tull compll.nco with lh6 Privacy Act ol 1974 and oth€r laws
proiecting the civil rights of ihe peBon w€ are Investigating. The Intormalion you provide, including your ldentiv wilt be
disclos€d to the peason b€ing invegtigatod and other fod€ral agencies, at this po6on's request
CERTIFICATION: The person we arc invogtigating haa given written consont tor this investigative

consent on

file. It a copy is

inquiry We keep that
required in ord€r to complete lhis form, ploase indicate this r€quiroment in writlng on tho

Completion ot this form as soon as possible will help this person and the agency porform their duties in a morc
timely and etficient manner.
CASE NUMBER:

FUII-

I{A[E

CASE TYPE:

lTEl', NUMBERi

FIRSII,

OTHER NAMES USED

PI.ACE OF

BIfiIII
FOR YOUH NE@RD

PUaucBURDEN|NFoFMAnoN:l^bdd.lbfbbe'd.6lo.th6@l|eliddlhlfElio...pp|dfl..y5n'u.F€pd!*'Tnisir|ud6ljfldBi*i.9'l.iBlrcl
(rml3
dh'n9 rh. tom.
dh'ng
tom Yd nBv
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p.|:dd M;ae€mt,
dt dim.ro d.ny othd *pd., nis rdh, ir.tdE
our
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l"roms
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(3206.0165)'walin9ton,oc20415.79oo.DgoMBNunb'32o6.o155i.crFllyvalid'oPi|,myot.dh.1l'..i;io.l'JdYqedlo'un|lh
'€d,r@s
and

(i

1f}

u.s. covenlueNT pFrNING oFFrcE:2o1s-:oo-203/6361 r

221421-3

otfcd. papofo( Fed*6n ad

FOBM APPROVED: OMB:3206{t165

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iIARKING
INSTRUCTIONS
.

CORRECT MARK:

.
.

O

USE A NO. 2 PENCIL OR BLUE OR BLACK INK PEN ONLY
DO NOT USE PENS WITH INK THAT SOAKS THROUGH THE PAPER.
DO NOT MAKE ANY STRAY MARKS ON THIS SHEET.

INCORRECT MARKS:

x./

MARK THE OVAL CORRESPONDING TO THE RESULTS OF YOUR RECORD SEARCH
:
:
.
:

RECORD INFORMATION SHOWN BELOW

F

RECORD IS ATTACHED

:;

PREVIOUSLY FURNISHED (Explain in REMARKS section)
RECORD AT ANOTHER LOCATION (Enter address and ZIP

code in REMARKS section)

NO PERTINENT INFORMATION

h

OPM REVIEW
ABOVE INFORMATION VERIFIED

NOT LOCATED (Explain in REMARKS section)
NO RECORD

REMARKS

USE ONLY
ISSI,|ES/CHARACTERIZATION

RESULTS
AC ACCEPTABLE

rs tssuEs

AA ACCEPTABLE/ATTACHED

PI CONFIDENTIAMSSUES
RI RECORD INCONCLUSIVE

PA CONFIDENTIAUACCEPTABLE

Nt NO PERTINENT INFORMATION
NF NO RECORO
NL NOT LOCATED
UC UNABLE TO CONTACT

RF REFERREO
RB RECORD

FB FEE REOUIRED
RL RELEASE REQUIRED
SK SUBJECT UNKNOWN
NZ NOT AVAILABLE
ON DISCREPANT

IOABCOEN
2O A B C
3O A B C
4O A B C
5O A B C
6O A B C
7O A A C
8o A B C

O
O
D
O
D
O
O

E
E
E
E
E
E
E

N
N
N
N
N
N
N

9O
10 O
11 O
'12 o
13 O
14 o

A
A
a
a
A
A

B
B
a
B
I
B

C
C
C
c
C
C

D
D
O
o
O
O

E
E
E
E
E
E

N
N
N
N
N

N

T

-l

II
INVESTIGATIVE REOUEST FOR EMPLOYMENT
DATA ANO SUPERVISOR INFORMATION

INV FOBM 41 (Rev. 6/14)
U.S. OFFICE OF PERSONNEL
MANAGEMENT (5 CFR 736)
F

U.S. GOVERNMENT USE ONLY

UNITED STATES OFFICE OF PEBSONNEL MANAGEMENT
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX 618
BOYERS, PA 16018-0618

u

o
tll

T

o

INSTRUCTIO S: Your name has been provided by the person identified below to assist in completing a
background investigation to help us determine this person's suitability tor employment or security
clearance. To help us make this determination, we ask that you complete all items on the back of this form
and return the form in the enclosed envelope,
We send a separate inquiry to the personnel office and each supervisor shown on the person's application;
therefore please do not torward this for completion by someone else.
PRIVACY ACT INFORMATIOI: This investigative inquiry is in full compliance with lhe Privacy Act ol 1974 and other laws
protectlng ihe civil rights ol the person we are Investigating. The intormatlon you provide, including your identity, wlll be
disclosed to the person being investlEeted and other tederal agencies, at lhis peison's request. In compliance with Title 5
Code of Fed€.al Regulations, Part 736.102(c), if you have signiticant info.mation which you feel unable to lurnish without a

promise that your identity will be kepl contldential, please indicale this In writing on the reverse and only provide your
conlact information. Providing addilional intormation on this form will void your request for conlidentiality.
CERTIFICATIOI{: The person we are Investlgating has given writien consenl for this investigative inquiay. We keep
lhat consent on file. lf a copy is required in otder to complete this torm, please indicate this requiremenl in writing
on the reverse.

Completion of this form as soon as possible will help this pe6on and the agency perform their duties in a more
timely and efficient manner.
.ASE

N

UNlBEFI:

FULL NAiIE (LASI

CASE TYPE:

FIRSI,

IDDLE}

OATE OF BIRTH

PLACE OF

ITEM NU[,4BERI

SOCIAL SECURITY NUMBER

BIBIH

CLAIMED EMPLOYUENT
POSITtOl{

( l{l

L,

s

(n)vr:HNMENT pRrNrNG oFFrcE:2cj5-388

203/63616

221431-s

FORM APPROVEO: OMB:3206-0165

II

I

l-

MARKING
il{STRUCTtONS
.

CORRECT MARK:

.
.

a

USE A NO. 2 PENCIL OR BLUE OR BLACK INK PEN ONLY.
DO NOT USE PENS WITH INK THAT SOAKS THROUGH THE PAPER,
DO NOT MAKE ANY STMY MARKS ON THIS SHEET.

INCORRECT MARKS:

x,/

PLEASE COMPLETE THE ITEMS SHOWN BELOW
IS THE INFORMATIOT{ ON THE FROTIT OF THIS FORTT THE SATIE AS SHOW'I IN YOUR RECORDS?

1

A
2

YES

b

C

NO (Pl€ase explain in itern 6)

WE HAVE NO RECORD ON THIS PERSON

MARK OI{E OF THE FOLLOWITIG PERTAINING TO THIS PERSOI,I'S EMPLOYIIEI{T

A

SUAJECT CURRENTLY EMPLOYED

D

LEFTEMPLOYMENTVOLUNTARILY/EMPLOYMENT

C

HERE

d

LEFT EMPLOYMENT VOLUNTARILY/EMPLOYMENT
ENTIRELY FAVORABLE (Please explain in ilem 6)

ENTIBELY FAVORABLE

FIRED FOR UNFAVORABLE EMPLOYMENT OR
CONDUCT (Please explain in item 6)

SEPARATEO BECAUSE OF COMPANY CUTEACK IN
WORKFORCE OR CHANGE IN SKILL NEEDS

RESIGNEO AFTER INFORMEO OF POSSIBLE
FIRING (Please explain in item 6)

NOT

LEFT EMPLOYMENT BY MUTUAL AGREEI\,{ENT DUE
TO SPECIFIC PROBLEMS (Please explain in item 6)
IS THIS PERSOT{ ELIGIALE FOR REHIRE?

A
4

YES

D

FOR REASONS RELATING TO UNFAVORABLE
EMPLOYMENT (Please explain in ilem 6)

DO YOU HAVE ANY REASON TO OUESTION THIS PERSON'S HOI{ESTY OR TRUSTWORTHITIESS?

aNo
b
5

NO

NO - DUE TO COMPANY POLICY AND/OR
NOT RELATED TO UNFAVORABLE EMPLOYMENT

C
d

YES (Ptease expain in item 6)

I DO NOT KNOW THIS PERSON WELL ENOUGH TO RESPONO
I WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

DO YOU HAVE ANY ADVERSE INFORITATIOI{ ABOLTT THIS PERSON'S EMPLOYMEI{T, FESIOENCE OF ACTIVITIES CONCEBNING:
YES NO

A
b
C

YES

VIOLATIONS OF THE LAW
FINANCES

d
E

NO

YES NO

ABUSE oF

oRUGs

MENTAL OR EMOTIONAL

STABILITY

I
g

GENERAL aEHAVIOB OR CONDUCT
OTHER MATTERS

(lf YES to any ol these questions, pleas€ explain in item 6)

AAUSE OF ALCOHOL

IWISH TO DISCUSS THE ADVERSE INFORMATION I HAVE
IF ADDITIONAL INFORMATION IS PROVIOED BELOW. YOU MUST FILL IN THIS MARK

AOOITIONAL INFORMATION TYHICH YOU FEEL UAY HAVE A BEARING ON THIS PERSON'S SUITABILITY
FOR GOVEBNMENT EMPLOYMENT OR A SECUR]TY CLEARANCE, THIS SPACE MAY BE USED FOR
DEROGATORY AS WELL AS POSMVE INFORMANON, A CONFIDENNALITY REOUEST,
ANO/OR A COPY OF CONSENT REOUEST.

OO YOU RECOMMEI{D THIS PERSON FOR GOVER?{MENT SECURTTY CLEARANCE OR EMPLOYMENT?

A
b

C

YES

I DON'T KNOW THIS PERSON WELL ENOUGH TO MAKEA RECOMMENDATION

NO lPlease explain in ilem 6)

PRlt{T NAUEI

FOR OPT USE ONLY
RESULTS

ACCEPTABLE
ACCEPTAALSATTACHED

tS

rssuEs

PI

coNFrDElfnAUlSSU€S

COT.IFIDEN-I.IAUACCEF'TASLE

FI

RE@RO rr{CO CLUSNE

INFORMATION
NORECORO
NOTLOCATED
UNABLETOCONTACT
REFEFFED

FR FEE REOUIRED

NO PERNNEMT

NL
UC

RECORD

FL RELEASE REOUIRED
SX SUBJECT

UNKNOW{

NZ NOT AVAILABLE
DN DISCREPANT

10
20
30
40
50
60
7C)
80

ISSUES/CHARACTERIZATION
BCDEN
9o A b
acDEu
10 o ^ r
^
a BCOEN
11 o ^ 3
A
BCOEN
12. | ..
A
BCOEN
13 J A ll
a BCOEN
14.r.i.
A
BCDEN
a BCDEN
A

r

I

F

o
M

r
INVESTIGATIVE REOUEST FOR
PERSONAL INFORMATION

INV FORM 42 (Rev. 6/14)
U.S. OFFICE OF PERSONNEL
MANAGEMENT (5 CFR 736)

U.S. GOVERNMENT USE ONLY

UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
FEOERAL INVESTIGATIONS PROCESSING CENTER
PO BOX 618
aoYEBS, PA 16018-0618

INSTRUCTIONS: Your name has been provided by the person identilled below io assist in completing a background
investigation lo help us determlne ihls person's suitability for employment or securily clearance. To help us make this
determination, we ask that you complele all ilems on the back ot this torm 6nd return the form in the enclosad envelope.
You were llsted as:

PRIVACY ACT INFORMATIO : This investigative inquiry is in lull complisnce with the Privacy Act ot 1974 and other laws
prolecting lhe civll rights of the pe.son we ane investigating. The informatlon you provide, including your identity, witt be
dlsclosed io the person being investigated and other federal agencaes, ai this person's request. In compliance wlth Title 5
Code ol Federal Regulations, Part 736.102(c), if you have signiticanl intormation which you feel unable to furnish without a
promise thal your id,entity will be kept confidential, please indicate this in wdllng on the revers€ and only provide your contacl
intormalion. Providing additional info.mation on this torm will void your requ$t for confidentiality.
CERTIFICATIONT The person we are Investigating has given written consenl for this investigative inqulry. We keep that
consent on file. It a copy is required in order to complete this form, please Indlcate this requirement in writing on the reverse.

Completion of this torm as soon as possible will help this person and the agency perform their duties in a more
timely and efficient manner.
CASE NUMBER:

G{}

CASE TYPE:

u.s.eov:uueNTpFrNTrNG oFFrcE:2or5{ss-2oiy636rs

ITEM NUMBER:

221433-6

FOFM APPROVED: OMB:3206-0165

I
MARKING
INSTRUCTIONS
.
.
.

CORRECT MARK:

a

USE A NO. 2 PENCIL OR BLUE OR BLACK INK PEN ONLY
DO NOT USE PENS WITH INK THAT SOAKS THROUGH THE PAPER.
DO NOT MAKE ANY STRAY MARKS ON THIS SHEET.

INCORRECT MARKS:

r

PLEASE COMPLETE THE ITEMS SHOWN BELOW
1

HOW LONG HAVE YOU KNOWN THIS PERSON?
MONTHS

YEARS

A
2

A
b
3

NEIGHBOR

E
I

FRIEND
SPOUSE

C
d

DAILY
WEEKLY

I

KNOW THIS PERSON

@oN-r coMpL€rE orHe F rEMs)

SPOUSE
INSTRUCTOR
FORMER

9

RELAIIVE

h

OTHER

EXPLAIN N ITEM

E
I

MONTHLY
TWICE A YEAR

ONCE EVERY YEAR OR 2
ONCE IN 3 OR MOBE YEARS

I LAST ASSOCIATED WITH THIS PERSON:
O

C
d

TO 3 MONTHS AGO

3TO 12 MONTHS AGO

1

E

TO 3 YEARS AGO

[4ORE THAN 5 YEARS AGO

3 TO 5 YEABS AGO

DOES THE INFORMATION ON THE FRONT OF THIS FORM CONCERNING THIS PERSON APPEAR TO BE CORRECT?

a

YES

b

NO

ITAPPEARSTO BE INCORRECTOR

DO YOU HAVE ANY REASON TO OUESTION THIS PERSON'S

aNO
b YES

7

I DON

ON THE AVEBAGE, I ASSOCIATE(D} WITH THIS PERSON:

A
b
5

C
d

COWOBKER

A
b
4

b

MY ASSOCIATION WITH THIS PERSON IS/WAS AS A:

IN

C
d

EXPLAIN IN ITEI'

COM

P

LETE

,sHow coRREcr oR ADDrr oNAL DArA

rN

rrEM

HONESry OR TRUSTWORTHINESS?
I DO NOT KNOW THIS PERSON WELL ENOUGH TO BESPOND
I

WISH TO DISCUSS THE ADVERSE INFORMATION I HAVE

DO YOU HAVE ANY ADVERSE INFORMATION ABOUT THIS PERSON'S EMPLOYMENT, RESIDENCE OR ACTIVITIES CONCEBNING:
Y€S

NO

A
b
C

YES NO

YES NO

VIOLATIONS OF THE

LAW

FINANCES

DRUGS

d

ABUSE OF

E

MENTAL OR EMOTIONAL

STABILITY

]

GENERAL BEHAVIOR OR CONDUCT

S

OTHER MATTERS
(IF YES, PLEASE EXPLAIN IN ITEM 8)

ABUSE OF ALCOHOL
I

WISH TO DISCUSS IHE ADVERSE INFORMATION I HAVE

IF ADDITIONAL INFOBMATION IS PROVIDEO BELOW, YOU MUST FILL IN THIS MARK.

8

ADDITIONAL INFORMATION WHICH YOU FEEL MAY HAVE A BEARING ON THIS PERSON'S SUITABILITY FOR GOVERNMENT
EMPLOYMENT OB A SECURITY CLEARANCE. lHlS SPACE ilAY BE USEO FOR DEROGATOBY AS WELL AS POSITIVE
INFORMATION, A CONFIDENTIALITY REQUEST, AND/OR COPY OF CONSENT REOUEST.

9

OO YOU RECOMMEND THIS PERSON FOR GOVERNMENT SECURITY CLEARANCE OR EMPLOYMENT?

A
PRINT

C

YES

bNo

EXPLAIN IN ITEM

I DON'T KNOW THIS PERSON WELL ENOUGH TO MAKE

A RECOMMENDATION

NAI'E:

SIG ATURE:
YOUR TITLE:

ISSUES/CHARACTERIZATION

BESULIS
AC ACCEPTABLE

rs tssuEs

AA ACCEPTABLE/ATTACHED
PA CONFIDENTIAI,./ACCEPTABLE

P' CONFIOENTIAL/ISSUES
FI RECORD INCONCLUSIVE

NI NO PERTINENT INFORMATION

FR FEE FEQUIFIED

N8 NO RECORD
NL NOT LOCATED

8L RELF:ASE REOUIRED

IJC UNABLE TO CONTACT

SK SUBJECT UNKNOWN
NZ NOT AVAILAALE
DN DISCREPANT

FR RECORD

I o
2 o
3 O
4 o
5 o
6 O
7o
8O

A
A
A
a
a
A
A
A

B
B
B
B
B
B
e
B

C
C
C
c
c
C
c
C

D
O
O
D
D
D
D
D

E
E
E
E
E
E
E
E

N
N
N
N
N
iI
N
N

9O
10 O
11 O
12 O
13 O
14 O

A
A
A
A
A
A

S
S
B
B
B
B

C
C
C
C
C
C

D
D
O
O
O
D

E
E
E
E
E
E

N
N
N
N
N
N

rII

II
INVESTIGATIVE REQUEST FOR
EDUCATIONAL RECORD DATA

INV FORM 43 (Rev. 6fl4)
U.S. OFFICE OF PEBSONNEL
MANAGE ENT (5 CFR 736)

U.S. GOVERNiIENT USE ONLY

UNITED STATES OFFICE OF PERSONNEL IIANAGEMENT
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX 618
BOYERS. PA 16018-{'618

o
M

I STRUCTIONS: Your name has been provlded by the person ldentitied below to a$lst in completing
a background investlgatlon to help ua determlne this p€rson's suitability for employment or securlty
clearanca. To help us make this determlnatlon, we ask that you complete all items on the back of this
form and r€turn the form In the enclosed envelope.
AcT I FORHATIO ! Thl8 Inve€tigatlve Inqulry ls In tull cotnpliance wlth lhe Pdyacy Act ot 1974 and other l.ws
protoctlng th. clvll rlghlg ot ths ps6on we a.e inwltlgatlng. The inlormatlon you provide, includlng your idenrity, will be
diaclosod lo the person belng Invo8flgated and other iadgral agencles, at thb p6rson's requert.
PRIVACY

h!! glven wrttten coni€nt for thls Investlgatlvo Inquiry. \rye k€ep that
t€qulr€d ln ord€r to completo thls form, plear€ Indlcate lhis roquhom6nt In wrltlng on th€

CERTIFICATION: The peBon w€ are Invesllgatlng

consent on
rcv9lao.

flle. lf

a copy

l!

Completion of this torm a3 soon aa poaslbl€ will help this pet1Bon and the agency pertorm th€ir dutiea in a mot€
timely and etficient mannei
CASE NUMBER:

Hru-

l{ !E

CASE TYPE:

(LAST, FrRsf,

ITEM NUMBER:

nDDE)

OTHER AMES USEO

OATE OF

BIFfi

80cn|. aEcutsTY ]|U

Fogno

BER

REOUnNGD{I,E8n@T|ON

THAPENSO C{IIIED AITENDAI{CE AA FOU-oS

FRflorofin)l I rooro/YB

SCH@L ]{AMElrIDADORESS

DEOREE ATD DA?E (HO/YRI

|r8T CI.^I[ED

RESIOEIICE DI'flNG PERPO OF AITEIIOAI'CE

PUBUC BUBOEN INFOF ANON:

sdt6lunl.eth.|m.YoUmay$ndconmb6g.dhgdl6tnat6daiyo1h*sp.cl.o]lhb|m'ir|udinc&!g..n.6tcr*4daolml'ol
F-2!aol35).wshingion'Dc2o415'7900'IrEoMaNumbd320f]lr,5E4@nl|yvdd'oPMm.ynd6]hd!t5

GlG

u.s. coventrv eNT

eRTNTTNG

oFFrcE:2oi

5-3ss-2036i,619

?21434-4

FOBM APPROVED: OMA:320,6{165

II

Il-

IIARKING
INSTRUCNONS
.
.

CORRECT MARK:

a

.

USE A NO. 2 PENCIL OR BLUE OR BLACK INK PEN ONLY
OO NOT USE PENS WITH INK THAT SOAKS THROUGH THE PAPER.
OO NOT MAKE ANY STRAY MARKS ON THIS SHEET.

INCORRECT MARKS:

x/

PLEASE COMPLETE THE ITEMS SHOWN BELOW
TO THE BEST OF YOUR KNOWLEOGE. IS THE INFORMATION ON THE FRONT OF THIS FORM THE SAME AS SHOWN IN YOUR
RECOBDS?

A
2

b
C

YES

NO (Last discrepancies in REMARKS section)
WE HAVE NO RECORD ON THIS PERSON

DO YOUR RECORDS CONTAIN ANY ADVERSE INFORMATION RELEVANY TO THIS PERSON?

aNO

YES (Explain in REMARKS section)

REMARKS

PRINT IIAME:

$GNATURE:

DAYTIME TEI..EPHONE NUMBER

YOUR TITLE/ORGANTZANON:

(INCLUDE AREA COOEI

)

1:

ACCEPTABLE

rs tssuEs

; A ACCEFTABLE/ATTACHED

PI CONFIOET.ITIAL/ISSUES

fu

CONFIDENTIAUACCEPTAALE

RI RECORD INCONCLUSTVE

III

NO PEFNNENT INFORMANON

FR FEE REOUIRED

NO RECORD

F'. RELEASE REQUIRED

!i

NL NOT LOCATED

SK SUBJECT UNKNOWN

Ir'

NZ NOT AVAILABLE
OII DISCREPANT

:F

UNABLE TO CONTACT
RECORD

IOABCOEN
2a a a c
3O A B C
4C A B C
5o A B C
A I C
60
a
a c
70
A
s c
8o

o
O
O
O
O
o
D

E
E
E
E
E
€
E

N
N

N
N
N
N
N

9O
10 O
11 O
12o
13 o
14 o

A B C o
A B C D
A B C o
B c D
^
A I C o
a B c o

E
E
E
E
E
E

N
N
N
N
N
N

II

-II

INVESTIGATIVE REOUEST FOR
LAW ENFORCEMENT DATA

INV FORM 44 (Rev. 6/14)
U.S. OFFICE OF PERSONNEL
MANAGEMENT (5 CFR 736)
F
R

M

U,S. GOVERNMENT USE ONLY

UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
FEDERAL INVESTIGATIONS PROCESSING CENTER
PO BOX 618
BOYEFS, PA 16018-0618

INSTRUCTIONS! We aro conducling a background Invostlgatlon on th€ p€rson ldentllled below to detsrmlne thls pe6on's
ellgibilily lor federal employrnenl or accegg to claaaltled IntoJmaiion. To help make ihls delermlnatlon, we ask thot you
complete all itema on lho beck

ofthls form and J€lurn ths iorm

In the €ncloa€d onvelope.

PRIVACY ACT

|I{FORIIATIOI: This investlgallve Inquiry is in full compllance with lhe P.ivacy Act ot 1974 and other lews
prol€c-ting lho clvll rlghta ot lhe peraon rve ar! Inve3llgaling- The inlorm.tlon you provide, includlng your identity, will be
dlEclooed to the p€r8on b€ing investigated and othor t€de]al agencies, at lhlg p€fgon's request.
CERTIFICAYIO ! Th€ poraon we a.e Investlgatlng haE given w.inen conlsnl lor this investigatlve Inqulry. We keep that
cons€nt on flle. It a copy 13 required in order to complele lhis form, plgass Indicate this requiaenont In wdtlng on lh€
tevols0.

The U,S. Oftice ol PetSonnel llanagemenl's Fodoral Investigations Prcgran ig en authorizod law entorcemenl activity
rcquired by Stalute, Arsldential Executive Ord€r and Fodaral Regulalions to make thb invostigatlve Inqulry.
Request covered by the Securlty Claaranco Intormatlon Act (P.L. 9$169)
Request not covered by the Security Cl€arance Intormation Aci

Completion of thls toJm as soon as possible will help thl3 pelson and th€ agency pertorm their duties in a more
tlmely and efficient manner:
CASE

NUMBEB:

FULL NAXE

CASE

TYPE:

ITEM NUMBEB:

FtRST,

OTHER ATES USED

PLACE OF BIRTH
CURRENT RESIDET{CE

THIS PERSON CLAIMS THE

CBIMINAL HISTORY RECORD AT YOUF LOCA

LAW ENFORCEIIEIIT AUTHORITY OR O(ruRT

CLAIIIED BESIDEI{CE AT TIME OF OFFENSE

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