PC-1336 Intelligence Background Questionnaire

See the Privacy Act Statement and Burden Notice at the end of this form.

OMB No. 0420-0551
This form is pending renewal

PEACE CORPS INTELLIGENCE BACKGROUND QUESTIONNAIRE
The following information is required by Peace Corps Manual Section (MS) 611 Eligibility for Peace Corps
Employment or Volunteer Service of Applicants with Intelligence Backgrounds. If you have any questions, please
contact the Peace Corps Office of the General Counsel at 1275 First St., N.E. | Washington, D.C. | 20526
or (202) 692-2150.
Eligibility for Employment by the Peace Corps, MS 611
• Permanent Ineligibility - Persons formerly employed by the Central Intelligence Agency shall be permanently
ineligible for employment by the Peace Corps.
• Ineligibility for a Minimum of Ten Years - Any person who had been employed by an agency or division of an
agency, other than the Central Intelligence Agency, a substantial part of whose mission has been determined by
the Peace Corps General Counsel to include intelligence activities, shall be ineligible for employment for a period of
ten (10) years from the last date of employment by such agency.
• Ineligibility for a Period in Excess of Ten Years - Individuals may be ineligible for employment for a period in excess
of ten (10) years where the General Counsel determines that their background or work history with regard to
intelligence activities warrants such actions.
• Related Work - Applicants for employment whose background or work history discloses a substantial connection
with an intelligence activity or related work other than through employment shall be ineligible to serve as employees
of the Peace Corps for a period of time ordinarily not to exceed ten (10) years from the date of their last connection
with the agency or activity. For the purpose of this provision, family relationship to an employee of an intelligence
agency may be considered a disqualifying connection.
Have you ever been employed by an intelligence organization or otherwise engaged in or been connected with
intelligence-related activities?
Yes ____

No ____

If yes, please explain below by providing the dates, nature of connection, and other details.

Attention
I have completed this statement with the knowledge and understanding that all items contained herein may be
subject to investigation and verification prescribed by law or regulation.
I have read the paragraph relating to eligibility for a position as an employee, expert, consultant, or personal services
contractor with the Peace Corps. I understand that a false answer or false information may be grounds for not
employing me or for dismissing me after I have been hired, and may be punishable by fine or imprisonment (U.S.
Code, Title 18, Section 1001).
Certification
I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and belief,
and are made in good faith.
__________________________ ___________
Applicant's Signature
Date

PC-1336 (Rev. Sep 2022)

___________________________ ___________
Appointee's Signature
Date

See the Privacy Act Statement and Burden Notice at the end of this form.

PC-1336 (Rev. Sep 2022)

OMB No. 0420-0551
This form is pending renewal

See the Privacy Act Statement and Burden Notice at the end of this form.

OMB No. 0420-0551
This form is pending renewal

Privacy Act Statement
The Peace Corps, an agency of the federal government, is required by the Privacy Act of 1974, 5 U.S.C. 552a (The Privacy Act) to
advise you of the following information regarding this form. The Peace Corps follows the requirements of the Privacy Act which
protects personal identifiable information that the agency maintains and uses in its systems of records.
Authority: The Peace Corps Act, 22 U.S. Code § 2501 - Congressional declaration of purpose; and MS 611 Eligibility for Peace
Corps Employment or Volunteer Service of Applicants with Intelligence Backgrounds.
Purpose: The purpose of this form is to determine your eligibility for hire for a position at the Peace Corps.
Routine Uses: Use of the information collected based on this form is restricted to the purposes cited in this privacy statement or
unless the disclosure is otherwise permitted under the provisions of the Privacy Act of 1974, and the agency’s privacy policy. The
information you provide may be used for the routine uses described in the Privacy Act, and the Peace Corps' published General
System of Records Notices PC-8 Legal Files – Staff, Volunteers, and Applicants; and PC-28, Applications for Employment.
Disclosure: The information you provide is voluntary. However, failure to provide complete information and to submit this form
may slow down the hiring process, and will eventually disqualify you from being hired for a Peace Corps position. The agency is
committed to ensuring that any personal information it receives is safeguarded against unauthorized disclosure.
Paperwork Reduction Act Notice (Burden Statement)
Public reporting burden for this information collection is estimated to average 5 minutes per response, including the time for
reviewing instructions and completing the information. You do not have to supply this information unless this collection displays a
currently valid OMB control number. Send comments on the accuracy of this burden estimate and/or recommendations for
reducing it to the Privacy Officer, Peace Corps, 1275 First Street, NE, Washington, DC 20526.

PC-1336 (Rev. Sep 2022)