For Reference Only
All questions on this form must be answered completely and truthfully in order for the United States (U.S.) Government to make trust determinations described below on a complete record.
AUTHORITY TO REQUEST THIS INFORMATION
Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under
- Executive Orders 9397, as amended, 10577 and 10865, 12333, and 12968, 13467, 13488, as amended; and
- Sections 3301, 3302, 7301, 9101, and 11001 of title 5, United States Code (U.S.C.);
- Sections 272b, 290a, and 2519 of title 22, U.S.C.;
- Section 1537 of title 31, U.S.C.;
- Sections 1874, 2165 and 2201 of title 42, U.S.C.;
- Section 803 of chapter 23 of title 50, U.S.C.;
- Section 20132 of title 51, U.S.C.;
- Section 925 of Public Law 115-91;
- Parts 2, 5, 6, 731, 736, and 1400 of title 5, Code of Federal Regulations (C.F.R.);
- and, Homeland Security Presidential Directive-12 (HSPD-12).
PURPOSE OF THIS FORM
This personnel vetting form will be used by the U.S. Government in conducting a personnel vetting investigation on you if you are under consideration for placement or retention in a low risk, public trust, or national security position as defined in 5 C.F.R. Part 731 and 5 C.F.R. Part 1400, as well as if you require eligibility for access to classified information under Executive Order 12968, as amended. If you are an individual performing work for, or on behalf of, the U.S. Government under a contract, this form may also be used by agencies in determining whether you are deemed fit to perform the duties and whether you are eligible for logical or physical access, when the duties you perform as a contractor are equivalent to the duties performed by an employee in a low risk position, a public trust position or when the nature of the work to be performed is sensitive and could bring about an adverse effect on national security.
This form may also be used for making ongoing trust determinations associated with your suitability or fitness for Federal employment, fitness for contract employment, eligibility for access to classified information or to hold a sensitive position, or eligibility for physical and logical access to federally controlled facilities or information systems. Your responses to this form may be compared with your responses to previously completed personnel vetting forms or other employment documents.
Providing this information is voluntary. However, if you do not provide each item of requested information, we will not be able to complete your investigation, which may adversely affect your eligibility for the U.S. Government related position you hold or for which you are being considered. It is imperative that the information provided be true and accurate, to the best of your knowledge. Any information that you provide is evaluated based on its recency, seriousness, relevance to the position and duties, and consistency with all other information about you.
Withholding, misrepresenting, or falsifying information may negatively affect your employment prospects and job status, and the potential consequences include, but are not limited to, removal, debarment from Federal service, loss of eligibility for access to classified information, loss of eligibility to hold a sensitive position, loss of eligibility for physical or logical access to federally controlled facilities or information systems, or prosecution. If you are a current civilian employee of the federal government: failure to answer any questions completely and truthfully could result in an adverse personnel action against you, including loss of employment; with respect to the Psychological and Emotional Health Sections, Section 12-Drug Activity, Section 13-Marijuana and Cannabis - Derivative Use, Section 16-Information Technology Systems, and Section 18-Associations however, neither your truthful responses nor information derived from those responses will be used as evidence against you in a subsequent criminal proceeding.
Investigations conducted based on information provided on this form may be selected for anonymous studies and analyses in support of evaluating and improving the effectiveness and efficiency of the investigative and adjudicative methodologies. Investigations reviewed and all study results released to the public will delete personal identifiers such as name, Social Security Number, and date and place of birth.
INSTRUCTIONS FOR COMPLETING THIS FORM
To avoid delays or possibly discontinuation of the personnel vetting process you must follow instructions completely in completing this form. If you have any questions, contact the office that requested you complete this form.
The office requesting you to complete this form will keep you informed as your application moves through the personnel vetting investigation process, as appropriate. To facilitate your investigation, should any information you provided change, please contact the requesting office with the additional information.
The accuracy of the information on this form must be certified by you and by your electronic signature. If you are asked to submit a hard copy, paper form, you must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.
You will need to have on hand some or all of the following documents and items of information, to include but not limited to, state issued driver’s license, U.S. passport (and passport card if you have one and foreign passport, if applicable), naturalization documentation, Social Security Number, contact information for current and former employers, educational institutions attended, locations of military assignments, and details regarding criminal history records. Contact information required will be in the form of phone numbers, email addresses and/or physical address. If you are undergoing investigation for a position of public trust or a national security sensitive position, you will need to provide details regarding foreign contacts, dates and locations of foreign travel, and details regarding certain financial delinquencies. Please make sure you have all relevant information on hand to facilitate completion of the form.
All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box, unless otherwise noted.
Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the “Country” dropdown feature.
When entering a U.S. address or location, select the state or territory from the "States" dropdown list that will be provided. For locations outside of the U.S. and its territories, select the country in the "Country" dropdown list and leave the "State" field blank.
The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes such as one located on www.usps.com.
For telephone numbers in the U.S., ensure that the area code is included.
All dates provided in this form must be in month/day/year or month/year format. Use the Dropdown lists to select the month and day. The year should be entered as a four-character number (i.e., 1978 or 2001.), or selected from a Dropdown list. If you are unable to report an exact date, approximate or estimate the date to the best of your ability, and indicate this by checking the "Est." box.
For military service members, do not list military services as one entry. List each military duty station as separate entries. Be sure to include the physical address, to include if you were stationed or deployed overseas. Reserve/National Guard Service must be listed. Avoid using acronyms/abbreviations.
THE INVESTIGATIVE PROCESS
Personnel vetting investigations are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and loyal to the United States. The information that you provide on this personnel vetting form may be confirmed during the investigation and may be used for identification purposes throughout the vetting process. The investigation may extend beyond the time covered by this form, when necessary to resolve issues. Your current employer may be contacted as part of the investigation, even if you may have previously indicated on applications or other forms that you do not want your current employer to be contacted.
Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397.
In addition to the questions on this form, inquiries may also be made about your adherence to security requirements, your honesty and integrity, vulnerability to exploitation or coercion, falsification, misrepresentation, and any other behavior, activities, or associations that will allow for evaluation of your conduct, integrity, judgment, loyalty, and reliability.
If you are undergoing a personnel vetting investigation for a sensitive position, federal agency records checks may be conducted on your spouse or legally recognized civil union/domestic partner, cohabitant(s), and immediate family members. Your spouse/partner/cohabitant or family member is not the subject of the investigation. Any relevant information obtained will be included in your personnel vetting record only; there will not be a separate record created on your spouse/partner/cohabitant or family member.
After a favorable trust determination has been made, you may be subject to continuous vetting. Continuous vetting means reviewing the background of an individual at any time to determine whether that individual continues to meet applicable requirements.
YOUR INDIVIDUAL INTERVIEW
Some personnel vetting investigations will include an individual interview with you as a routine part of the personnel vetting process. The investigator may ask you to explain your answers to any question on this form. The interview provides you the opportunity to update, clarify, and explain information on your form, which often assists in completing your investigation. It is imperative that the interview be conducted as soon as possible after you are contacted. Postponements will delay the processing of your personnel vetting investigation and declining to be interviewed may result in your investigation being delayed or canceled.
If you are interviewed, you will be required to provide photo identification, such as a valid state driver's license. You may be required to provide other documents to assist with your investigation such as passport or other identification document, as instructed by the investigator. You may also be asked about matters requiring specific attention as relevant to the type of background investigation required for your position.
TRUST DETERMINATION
A trust determination will be made by the office that requested your personnel vetting investigation. Depending on the nature of the position for which you are being investigated, the trust determination may include your suitability or fitness for employment or to perform work on behalf of the U.S. Government, your eligibility to occupy a national security position or eligibility for access to classified information, and/or your eligibility for a personal identity credential permitting access to federal facilities or information systems.
The U.S. Government does not discriminate on the basis of prohibited categories, including but not limited to race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, or genetic information when making a trust determination.
PENALTIES FOR INACCURATE OR FALSE STATEMENTS
The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a felony which may result in fines and/or up to five (5) years imprisonment. In addition, Federal agencies generally fire, do not grant a security clearance, disqualify, and/or debar individuals who have materially and deliberately falsified these forms, and this remains a part of your vetting record for future placements. Your prospects of placement or security clearance are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any information you provide on this form and to make your comments part of the record.
DISCLOSURE INFORMATION
The information you provide is for the purpose of investigating you for a suitability, fitness, national security, and/or credentialing trust determination.
This information will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of Federal personnel vetting investigative information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. The information you provide on this form, and information collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C. 552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register. You will not receive prior notice of such disclosures under a routine use. The office that gave you this form can provide you with its routine uses.
The Defense Counterintelligence and Security Agency, the U.S. Government’s primary investigative service provider, has published its routine uses in the Federal Register at the following address:
PUBLIC BURDEN INFORMATION
Public burden reporting for this collection of information is estimated to average 150 minutes per response for individuals completing all parts of this form, including 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 any other aspect of this collection of information, including suggestions for reducing this burden, to U.S. Office of Personnel Management (OPM), Attn: SuitEA, 1900 E Street, N.W., Washington, DC 20415. The OMB clearance number, 3206-[final number to be inserted upon issuance], is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the penalties for inaccurate or false statement (in accordance with U.S. Criminal Code, title 18, section 1001), denial or revocation of a security clearance or eligibility to occupy a national security sensitive position, and/or removal and debarment from Federal Service. |
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[] Yes |
[] No |
The purpose of this section is to collect information from you that helps us verify your identity. We ask for your name, date of birth, place of birth, Social Security Number, and contact information. This helps make sure we only collect information that pertains to you.
This section asks for information regarding your full legal name. Your full legal name is usually the name you have on your most recently issued, unexpired government-issued picture identification. This is the name that identifies you for legal, administrative, and other official purposes, such as social security, census, taxes, and other official transactions or records.
• If your name is one alpha character or a string of alpha characters (such as "Z" or "T.J.", where "T." and "J." are not initials for names), check the "Letter(s) Only" box.
• If you do not have a middle name, check the "No Middle Name" box.
• If you are a "Jr.," "Sr.," "II," "III", "IV," etc. enter this under Suffix.
• If you have a hyphenated name, put the entire hyphenated name in the applicable block (for example, if your last name is "Smith-Jones", put "Smith-Jones" in the "Last Name" block.)
• If you have two last names that are not hyphenated (such as Smith Jones), please enter them as separate word in the “Last Name” block.
• If you only have one name, put it in the "Last Name" block.
What is your full name?
Last Name |
[ Text ] |
[] Letter(s) Only |
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First Name |
[ Text ] |
[] Letter(s) Only |
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Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
Suffix
If you wish to provide, indicate your pronouns. (he/him, she/her, or they/them) |
[ Dropdown ]
[Text]
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This section asks for information regarding your date of birth. If you do not know your date of birth, put the date of birth you have been using on official documents, check the 'Estimated' box, and provide an explanation.
What is your date of birth? |
[ mm/dd/yyyy] |
[] Estimated |
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Please explain. |
[ Text ] |
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This section asks for information regarding your place of birth. The United States (U.S.) is defined as the 50 U.S. states, the District of Columbia, and the U.S. territories.
Were you born in the U.S.? |
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[] Yes |
[] No |
Where were you born?
City |
[ Text ] |
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County Or County Equivalent |
[ Text ] |
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State or Territory |
[ Dropdown ] |
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Where were you born?
City |
[ Text ] |
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Country |
[ Dropdown ] |
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This section asks for information regarding your U.S. Social Security Number.
What is your U.S. Social Security Number? |
[ Number ] |
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[] Not Applicable |
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Please explain. |
[ Text ] |
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Additional name(s) you provide are used to check for records about you. Having your additional names will assist investigators using your correct name and identifiers while conducting interviews or record checks for various activities and timeframes related to your background.
• You must include the name on your birth certificate.
•If your name is one alpha character or a string of alpha characters (such as "Z" or "T.J.", where "T." and "J." are not initials for names), check the "Letter(s) Only" box.
• If you do not have a middle name, check the "No Middle Name" box.
• If you are a "Jr.," "Sr.," "II," "III", "IV," etc. enter this under Suffix.
• If you have a hyphenated name, put the entire hyphenated name in the applicable block (for example, if your last name is "Smith-Jones", put "Smith-Jones" in the "Last Name" block.)
• If you only have one name, put it in the "Last Name" block.
• For nicknames and aliases, put them in the "First Name" block and leave the "Last Name" and "Middle Name" blocks blank.
• Make sure the dates you provide for legal name changes (such as due to a marriage, civil union, or partnership; divorce, dissolution of, or annulment; or any other legal name changes) are the same as the dates on the applicable legal documents.
Have you ever used a different name? |
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[] Yes |
[] No |
What is the other name?
Last Name |
[ Text ] |
[] Letter(s) Only |
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First Name |
[ Text ] |
[] Letter(s) Only |
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Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
Suffix |
[ DROPDOWN ] |
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[] None |
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Please explain. |
[ Text ] |
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When did you use this name?
From |
[ mm/yyyy ] |
[] Estimated |
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To |
[ mm/yyyy] |
[] Estimated |
[] Present |
Do you have another name to report? |
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[] Yes |
[] No |
The following contact information is requested in the event we have additional questions for you. If we do, you will receive a call or contact by email. It is recommended for privacy and efficiency you provide a phone number and email address unique to you. Additional phone numbers and email addresses provide more opportunities to contact you when needed. This could minimize any unnecessary delays of your personnel vetting investigation.
What is your phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] Cell [] Home []Work |
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What is your email address? (You may list more than one.) |
[ Address + Type ] |
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This section asks for information regarding your U.S. passport, if you have one. This information is one way we verify citizenship for U.S. citizens and travel to non-U.S. countries. If you have a U.S. passport book, passport card, or both, answer the questions for the most recently issued book or card you have. If you cannot find or you do not have access to your most recently issued passport book or card, answer the questions using the most recently issued one you have. For more information on U.S. passports, go to the U.S. State Department web site -- https://travel.state.gov/passport.
Have you ever had a U.S. passport book? |
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[] Yes |
[] No |
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[] I Don't Know |
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Please explain. |
[ Text ] |
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What is the passport number on your passport book? |
[ Text ] |
[] Unable to obtain passport.
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Please explain [Text] |
What name is used on your passport book?
Last Name |
[ Text ] |
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First Name |
[ Text ] |
[] Letter(s) Only |
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Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
Suffix |
[ Dropdown ] |
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What is the issue date on your passport book? |
[ mm/dd/yyyy] |
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What is the expiration date on your passport book? |
[ mm/dd/yyyy] |
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Is this your most recently issued passport book? |
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[] Yes
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[] No
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Please explain. [ Text ] [1] Branch Auto Populate Another Active U.S. Passport to Report
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Have you ever had a U.S. passport card? |
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[] Yes |
[] No |
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[] I Don't Know |
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Please explain. |
[ Text ] |
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What is the passport number on your passport card? |
[ Text ] |
[] Unable to obtain passport card. |
Please explain [Text] |
What name is used on your passport card?
Last Name |
[ Text ] |
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First Name |
[ Text ] |
[] Letter(s) Only |
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Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
Suffix |
[ Dropdown ] |
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What is the issue date on your passport card? |
[ mm/dd/yyyy] |
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What is the expiration date on your passport card? |
[ mm/dd/yyyy] |
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Is this your most recently issued passport card? |
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[] Yes |
[] No |
Please explain. |
[ Text ] |
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This section asks for information regarding your citizenship. The information helps us verify U.S. citizenship -- an eligibility requirement for most federal, military, and national security positions and/or those performing work for or on behalf of government to include employment authorization for non-U.S. citizens. If you are not a U.S. citizen, we use the requested information to verify you are authorized to work for or on behalf of the Federal Government. The United States (U.S.) is defined as the 50 U.S. states, the District of Columbia, and the U.S. territories.
What is your citizenship status? |
[ Dropdown ] |
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What document do you have proving you are a U.S. citizen born abroad? |
[ Dropdown ] |
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What is the title of the form? |
[ Text ] |
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What is the serial number on your document? (This is typically the number in the top right-hand corner of your document (it is often in red ink).) |
[ Text ] |
[] Not Applicable (Text) |
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What is the issue date of your document? |
[ mm/dd/yyyy] |
[] Estimated |
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Was your document issued in the U.S.? |
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[] Yes |
[] No |
Where was it issued?
City |
[ Text ] |
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Country |
[ Text ] |
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What is your name on this document?
Last Name |
[ Text ] |
[] Letter(s) Only |
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First Name |
[ Text ] |
[] Letter(s) Only |
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Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
Suffix |
[ Dropdown ] |
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Were you born on an overseas U.S. military installation? |
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[] Yes |
[] No |
What is the name of the overseas U.S. military installation? |
[ Text ] |
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What is your U.S. Alien Registration Number?
• You can find your Alien Registration Number on your Certificate of Naturalization (N-550 or N-570). It is a 7- to 9-digit number typically listed as the "USCIS Registration No.", "INS Registration No.", "CIS Registration No." It is not the "No." (short for number) in the top right-hand corner often seen in red ink.
• You can also find your Alien Registration Number on your Permanent Resident Card/Resident Alien Card (Form I-551). It is a 7- to 9-digit number typically listed as the "A#", "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV), it is the "Registration Number". |
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[ Text ] |
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What is your Naturalization Certificate Number or Naturalization Number? This is the "No." (short for number) in the top right-hand corner of your Certificate of Naturalization (N-550 or N-570) (it is often in red ink). |
[ Text ] |
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What is the issue date of your Certificate of Naturalization? |
[ mm/dd/yyyy] |
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What is your name on your Certificate of Naturalization?
Last Name |
[ Text ] |
[] Letter(s) Only |
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First Name |
[ Text ] |
[] Letter(s) Only |
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Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
Suffix |
[ DROPDOWN ] |
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What is your U.S. Alien Registration Number?
• If you have a Certificate of Citizenship (Form N-560 or Form N-561), your Alien Registration Number is the 7- to 9-digit number typically listed as the "USCIS Registration No.", "CIS Registration No.", or "INS Registration No.".
• If you do not have a Certificate of Citizenship, you can find your Alien Registration Number on your Permanent Resident Card/Resident Alien Card (Form I-551). It is a 7- to 9-digit number typically listed as the "A#", "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV), it is the "Registration Number". |
[ Text ] |
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What is your Permanent Resident Card or Resident Alien Card number (Form I-551)? |
[ Text ] |
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What is your Citizenship Certificate Number or Citizenship Number? This is the "No." (short for number) in the top right-hand corner of your Certificate of Citizenship (Form N-560 or Form N-561) It is often in red ink. |
[ Text ] |
[] Not Applicable (Text) |
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What is your name on your Certificate of Citizenship?
Last Name |
[ Text ] |
[] Letter(s) Only |
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First Name |
[ Text ] |
[] Letter(s) Only |
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Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
Suffix |
[ Dropdown ] |
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What is the issue date of your Certificate of Citizenship? |
[ mm/dd/yyyy] |
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What is your residence status? |
[ Dropdown ] |
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Please explain. |
[ Text ] |
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When did you enter the U.S.? (This is the date you entered the U.S. on your current visa.) |
[ mm/dd/yyyy] |
[] Estimated |
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Where did you enter the U.S.?
City |
[ Text ] |
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State or Territory |
[ Dropdown ] |
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Provide country(ies) of citizenship
(Select all that apply.)
Country |
[ Dropdown ] |
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What is your Alien Registration Number?
• You can find your Alien Registration Number on your Permanent Resident Card/Resident Alien Card (Form I-551) or on your Employment Authorization Card (Form I-766), as applicable. Your Alien Registration Number may be listed as the "A#", "A" number, "INS A#", "Alien Number", or "USCIS#". On the Machine Readable Immigrant Visa (MRIV) Form I-551, it is the "Registration Number".) |
[ Text ] |
[] Not Applicable (Text) |
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When does your Employment Authorization Card (Form I-766) expire? |
[ mm/dd/yyyy] |
[] Not Applicable (Text) |
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What document do you have verifying your legal residency? |
[ Dropdown ] |
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What is the title of the form? |
[ Text ] |
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What is the document number?
• For the Form I-94, list the 11-digit number labeled either "Admission Number", "Departure Number", "Admission Record (I-94) Number", or "I-94#". Or, you may have an "Admission Stamp" in your unexpired foreign passport. If this is the case, also list your passport number and the country that issued the passport.
• For the U.S. Visa Card (nonimmigrant visa) -- the visa number, also called a visa foil number, is a red number that is generally printed on the bottom right corner of newer visa documents. In most cases, the U.S. visa number contains eight numeric characters. In some cases, the number contains one letter followed by seven numeric characters.
• For the Form I-20, list the "SEVIS ID" number near the top left or top right corner of the document (depending on the document version). All SEVIS ID numbers start with the letter N. If you also have an "Admission Number" on your Form I-20 document, list this number as well (this is your Form I-94 number).
• For the Form DS-2019, list the number on the top right-hand side of the page in the box above the barcode. This is the SEVIS number. All SEVIS ID numbers start with the letter N. |
[ Text ] |
[] Not Applicable (Text) |
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What is the issue date of your document? |
[ mm/dd/yyyy] |
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What is the expiration date of your document? |
[ mm/dd/yyyy] |
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What is your name on this document?
Last Name |
[ Text ] |
[] Letter(s) Only |
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First Name |
[ Text ] |
[] Letter(s) Only |
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Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
Suffix |
[ Dropdown ] |
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This section asks for information regarding any additional citizenships you currently hold or have previously held that you did not list above. These citizenships could be held at the same time as another citizenship (that is, simultaneously as in dual or multiple citizenships) or sequentially (one at a time).
Have you ever been a citizen of another country? (Answer "Yes" if you currently hold or have previously held a citizenship with a country you did not list in Section 3. Otherwise, answer "No".) |
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[] Yes |
[] No |
Provide country(ies) of citizenship.(Select all that apply.) |
[ Dropdown ] |
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How did you become a citizen of this country? (For example, by birth, applied for, or through your parents) |
[ Text ] |
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When were you a citizen of this country?
From |
[ mm/dd/yyyy] |
[] Estimated |
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To
Were you ever issued a passport by this country?
Is the passport still active? |
[ mm/dd/yyyy] |
[] Estimated
[ ] Yes [ ] No
[ ] Yes [ ] No
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[] Present
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This section asks for information regarding where you have lived for the past five years. Only report information prior to your 18th birthday if necessary to report a minimum of 2 years of information.
• Start with your current address and work back.
• You must account for all periods of time without breaks: however, you do not need to account for temporary addresses of fewer than 90 days -- such as vacations, conferences, or military training or temporary duty stations of fewer than 90 days.
• List temporary addresses -- those where you were away from your home address for a period of time 90 days or more (for example, extended travel, school, military training, military deployments). It does not matter if you intended to return to your home address or move to a new home address. You may or may not have changed your mailing address from your home address to the temporary address.
• List your home addresses -- those where you physically resided.
• Do not list a Post Office box.
• List all addresses even if you split your time between one or more addresses.
Do you currently live in the U.S.? |
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[] Yes |
[] No |
What is the address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
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City |
[ Text ] |
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State or Territory |
[ Dropdown ] |
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ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is the residence located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
|
|
When did you start living here? |
[ mm/yyyy] |
[] Estimated |
|
When did you stop living here? |
[ mm/yyyy] |
[] Estimated |
[] Present |
Is this a temporary address over 90 days? |
|
[] Yes |
[] No |
What is or was the purpose of your temporary living situation? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another address to report? (Only report information prior to your 18th birthday if necessary to report a minimum of 2 years of information.)
|
|
[] Yes |
[] No |
Is your next address in the U.S.? |
|
[] Yes |
[] No
|
This section asks for information regarding schools you have attended in the past five years and whether you received a degree or diploma. (Only report information prior to your 18th birthday if necessary to report a minimum of 2 years of information.) This question includes all types of schools -- both in-person and distance learning. Distance learning includes by correspondence, extension (such as foreign exchange program sponsored by a college or university), online, and other similar distance learning education. For assistance determining school addresses refer to http://ope.ed.gov/accreditation/search.aspx.
If your attendance was not consecutive, please report each period of attendance separately. If the institution is no longer in business please check “[] School no longer in business” box. However, please provide the address where it was located and all pertinent information asked below to the best of your ability.
Have you attended any schools in the past five years? (Only report information prior to your 18th birthday if necessary to report a minimum of 2 years of information.)
|
|
[] Yes |
[] No |
What is the name of the school? (Do not use abbreviations or acronyms.)
[ ]School no longer in business |
[ Text ] |
|
|
What type of school is this? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Which best describes your learning experience at this type of school? |
[ Dropdown ] |
|
|
When did you attend this school?
From |
[ mm/yyyy] |
[] Estimated |
|
To |
[ mm/yyyy] |
[] Estimated |
[] Present |
Is this school in the U.S.? (For distance-learning schools use the address where your school records are kept.) |
|
[] Yes |
[] No |
What is this school's address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this school located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Did you receive a degree or diploma from this school? |
|
[] Yes |
[] No |
What type of degree or diploma did you receive? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When were you awarded this degree or diploma? |
[ mm/yyyy ] |
[] Estimated
|
|
[1] Branch Auto Populate for Education in the Last Five Years. Education Experience of “In-Person” or “Combination” at Different Physical Location Question.
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Is or was the physical location different than [] Yes [] No the school address entered above, such as at another campus or other location?
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||
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||
[2] Branch Auto Populate for Affirmative Answer Education in the Last Five Years. Education Experience of “In-Person” or “Combination” at Different Physical Location. Education Location in U.S. Question.
[3] Branch Auto Populate for Education in the Last Five Years. Education Experience of “In-Person” or “Combination” at Different Physical Location in the U.S. DetailsWhat is or was your school address?
[4] Branch Auto Populate for Education in the Last Five Years. Education Experience of “In-Person” or “Combination” at Different Physical Location in U.S. Military Installation Question.
[3] Branch Auto Populate for Education in the Last Five Years. Education Experience of “In-Person” or “Combination” at Different Physical Location. School Address Not in U.S. Details.Where is or was your school located?
Please provide physical address [Text] (not mailing address).
[4] Branch Auto Populate for Education in the Last Five Years. Education Experience of “In-Person” or “Combination” at Different Physical Location. School Address in Foreign U.S. Military Installation.
Do you have another instance to report where the [] Yes [] No physical location you attended school is different than the school address entered above (such as at another campus or other location.)
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List a counselor, instructor, student, or other person who knew you at this school. For distance learning list someone who knew you received this education. Do not list your spouse; partner from a civil union, domestic partnership, or common law marriage; person you are in a committed, spouse-like relationship with; or other relatives. ("committed, spouse-like relationship" is defined as a relationship between two people who are not in a legally-recognized marriage, union, or domestic partnership, present themselves as a couple, and live together continuously.)
Last Name |
[ Text ] |
|
|
First Name |
[ Text ] |
|
|
Middle Name |
[ Text ] |
[] I Don't Know |
|
Suffix |
[ Dropdown ] |
|
|
What is your relationship with this individual? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What is their phone number? (You may list more than one.) |
[Country Code |Number|Extension|Type] |
[] [Day/Night/Both] |
[ ] Don’t Know |
What is their email address? (You may list more than one.) |
[ Address + Type ] |
[ ] I Don’t Know |
|
Do they currently live or work in the U.S.? |
|
[] Yes |
[] No |
What is the address? |
|
[] I Don't Know |
|
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of the U.S. military installation? |
[ Text ] |
[] I Don't Know |
|
What is the location? |
|
[] I Don't Know |
|
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] I Don't Know |
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
Do you have another school to report? (Only report information prior to your 18th birthday if necessary to report a minimum of 2 years of information.) |
|
[] Yes |
[] No |
Did you receive another degree or diploma over five years ago? |
|
[] Yes |
[] No |
What is the name of the school that awarded you this degree or diploma? (Do not use abbreviations or acronyms.) |
[ Text ] |
|
|
What type of school is this? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
|
Which best describes your learning experience at this school? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When did you attend this school?
From (Month/Year) |
[ mm/yyyy ] |
|
|
To (Month/Year) |
[ mm/yyyy ] |
|
|
Is this school in the U.S.? (For distance-learning schools use the address where your school records are kept.) |
|
[] Yes |
[] No |
What is this school's address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this school located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Text ] |
|
|
What type of degree or diploma did you receive? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When were you awarded this degree or diploma? |
[ mm/yyyy ] |
[] Estimated |
|
Do you have another degree or diploma to report? (You must report all degrees and diplomas you have received; however, you do not need to report a High School diploma if you have achieved a higher degree.)
|
|
[] Yes |
[] No |
This section asks questions regarding your employment activities for the past five years. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history. (Start with your current employment activity and work back.) You must list all periods of employment, whether they are full-time or part-time, as well as periods of unemployment and self-employment without any breaks. Include paid and unpaid internships or fellowships, but do not include volunteer work. For military and uniformed service, list each duty station you were assigned to as a separate employment activity.
What type of employment activity do you have to report? |
[ Dropdown ] |
|
|
Which branch of service are you or were you in? |
[ Dropdown ] |
|
|
What is the name of the duty station you are or were assigned to? |
[ Text ] |
|
|
When were you assigned here?
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Is this duty station in the U.S.? |
|
[] Yes |
[] No |
What is the address for this duty station?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this duty station located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
|
|
|
|
What unit or organization are you or were you assigned to? |
[ Text ] |
|
|
When were you assigned to this unit or organization? (These dates may or may not match the dates you were assigned to the duty station above -- it depends on whether or not you were assigned to more than one unit or organization while assigned to this duty station.)
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
What is the phone number of your unit or organization? |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
|
What is or was your duty status while assigned to this unit or organization? |
[ Dropdown ] |
|
|
What is or was your duty or job title while assigned to this unit or organization? |
[ Text ] |
|
|
Do you have another unit or organization you were assigned to while at this duty station? (Answer "Yes" if the assignments were consecutive (back-to-back). Answer "No" if you left this duty station and there was a time gap before returning to this duty station.) |
|
[] Yes |
[] No |
Who is or was your most recent supervisor?
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
Suffix |
[ Dropdown ] |
|
|
What is or was this supervisor's duty or job title? |
[ Text ] |
[] I Don't Know |
|
What is this supervisor's phone number? |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is this supervisor's email address? |
[ Address + Type ] |
[] I Don't Know |
|
What unit or organization is this supervisor currently assigned to? |
[ Text ] |
[] I Don't Know |
|
Does this supervisor currently work in the U.S.? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is this supervisor's current work address? |
|
[] I Don't Know |
|
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation? |
[ Text ] |
[] I Don't Know |
|
Where does this supervisor currently work? |
|
[] I Don't Know |
|
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] I Don't Know |
|
|
|
[] Not Applicable |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
[] I Don't Know |
|
Did you receive any disciplinary actions while assigned to this duty station? |
|
[] Yes |
[] No |
Which disciplinary action did you receive? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
Military |
Why did you receive this disciplinary action? (Include a description of the offense for which you received this disciplinary action, when the offense occurred, and any other important details.) |
[ Text ] |
|
|
When did you receive this disciplinary action? |
[ mm/yyyy ] |
[] Estimated |
|
Who gave you this disciplinary action? |
|
[] I Don't Know |
|
Rank |
[ Text ] |
|
|
Last Name |
[ Text ] |
|
|
First Name |
[ Text ] |
|
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
What were the consequences of this disciplinary action? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
You indicated you were court-martialed in the past five years. You will be asked for information regarding your court-martial in Section 9, U.S. Military or U.S. Uniformed Service.
Do you have another disciplinary action while assigned to this duty station to report? |
|
[] Yes |
[] No |
Do you have another employment activity to report? (Do not list employments before your 18th birthday unless to provide a minimum of 2 years employment history)
|
|
[] Yes |
[] No |
Who is or was your employer? (Do not use abbreviations, unless the name of this employment includes abbreviations.) |
[ Text ] |
|
|
When did you work for this employer?
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Is this employer still in business? |
|
[] Yes |
[] No [] I Don’t Know |
What is this employer's phone number? |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
|
Is this employer's current address in the U.S.? |
|
[] Yes |
[] No |
What is this employer's address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is this employer currently located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
|
|
Is or was your work address different than this employer’s address? (Your work address is where you physically work or worked.) |
|
[] Yes |
[] No |
Is or was your work address in the U.S.? (Your work address is where you physically work or worked.) |
|
[] Yes |
|
|
[] No |
What is or was your work address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is or was your work located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
|
|
What is or was your job title? |
[ Text ] |
|
|
Is this an internship? Were you full-time or part-time? |
[ ] Yes |
[ ] No [] Full time |
[] Part time |
Who is or was your most recent supervisor?
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
What is or was this supervisor's job title? |
[ Text ] |
[] I Don't Know |
|
What is your supervisor's phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is your supervisor's email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Does this supervisor currently work in the U.S.? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is this supervisor's current work address? |
|
[] I Don't Know |
|
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation? |
[ Text ] |
[] I Don't Know |
|
Where does this supervisor currently work? |
|
[] I Don't Know |
|
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] I Don't Know |
|
|
|
[] Not Applicable |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
[] I Don't Know |
|
Did you receive any disciplinary actions during this employment? (Examples of disciplinary actions include written warnings, official reprimands, official counseling, demotions, and suspensions) |
|
[] Yes |
[] No |
Which disciplinary action did you receive? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Why did you receive this disciplinary action? (Include a description of the offense for which you received this disciplinary action, when the offense occurred, and any other important details.) |
[ Text ] |
|
|
When did you receive this disciplinary action? |
[ mm/yyyy ] |
[] Estimated |
|
Please explain. |
[ Text ] |
|
|
Who gave you this disciplinary action? |
|
[] I Don't Know |
|
Last Name
First Name |
[ Text ] |
|
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
What is their phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is their email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Do you have another disciplinary action during this employment to report? |
|
[] Yes |
[] No |
Were you fired from this job? |
|
[] Yes |
[] No |
When were you fired?
Why were you fired? |
[mm/yyyy]
[ Text ] |
[ ] Estimated |
[ ] I Don’t Know |
Were you fired in writing? |
|
[] Yes |
[] No |
Were you fired in person? |
|
[] Yes |
[] No |
Who fired you (in writing or in person)?
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
What is this person's phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is this person's email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Did you quit this job after being told you would be fired? |
|
[] Yes |
[] No |
Why were you going to be fired? |
[ Text ] |
|
|
Were you notified in writing that you were going to be fired? |
|
[] Yes |
[] No |
Were you notified in person that you were going to be fired? |
|
[] Yes |
[] No |
Who told you that you were going to be fired (in writing or in person)?
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
What is this person's phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is this person's email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Did you leave this job after receiving allegations or a notice of misconduct? |
|
[] Yes |
[] No |
Provide a description of the misconduct. What was the alleged or actual misconduct? (Include a description of the misconduct, when the misconduct occurred, and any other important details.) |
[ Text ] |
|
|
Were you made aware or notified, in writing, of this alleged or actual misconduct? |
|
[] Yes |
[] No |
Were you made aware or notified, in person, of this alleged or actual misconduct? |
|
[] Yes |
[] No |
Who notified you of the alleged or actual misconduct in writing or in person?
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
What is this person's phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is this person's email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Did you leave this job after receiving allegations or a notice of unsatisfactory performance? |
|
[] Yes |
[] No |
Provide a description of the unsatisfactory performance. What was the alleged or actual unsatisfactory performance? (Include a description of the unsatisfactory performance, when the unsatisfactory performance occurred, and any other important details.) |
[ Text ] |
|
|
Were you made aware or notified, in writing, of unsatisfactory performance? |
|
[] Yes |
[] No |
Were you made aware or notified, in person, of unsatisfactory performance? |
|
[] Yes |
[] No |
Who notified you of the unsatisfactory performance?
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
What is this person's phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is this person's email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Did you leave this job pending the outcome of any investigation, review, or inquiry into your performance, conduct, or behavior? |
|
[] Yes |
[] No |
Provide a description of the reason for the investigation, review, or inquiry. Why was your performance, conduct, or behavior being investigated, reviewed, or looked into? |
[ Text ] |
|
|
Were you made aware or notified, in writing, of an investigation, review, or inquiry into your performance, conduct, or behavior? |
|
[] Yes |
[] No |
Were you made aware or notified, in person, of an investigation, review, or inquiry into your performance, conduct, or behavior? |
|
[] Yes |
[] No |
Who notified you of an investigation, review, or inquiry into your performance, conduct, or behavior?
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
What is this person's phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is this person's email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Why did you leave this job? |
[ Text ] |
|
|
Did you work for this employer for another period during the past five years? (Do not list employments before your 18th birthday unless to provide a minimum of 2 years employment history) |
|
[] Yes |
[] No |
When did you work for this employer?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present
|
Do you have another employment activity to report? (Do not list employments before your 18th birthday unless to provide a minimum of 2 years employment history) |
|
[] Yes |
[] No |
Is or was there a company associated with this self-employment?
|
|
[] Yes |
[] No |
[2] Branch Auto Populate for Employment Type Self. Affirmative Response for Company. Names |
|||
What is or was the name of your company? (Do [Text]
not use abbreviations, unless the name includes
abbreviations.)
Is your company still in business? [] Yeas [] No
[2] Branch Auto Populate for Employment Type Self. Company or No Company. Dates and Details |
When were you self-employed?
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy ] |
[] Estimated |
[] Present |
|
|
|
|
What is or was your job title? |
[ Text ] |
|
|
Were you self-employed full time or part time? |
|
[] Full time |
[] Part time |
What is or was your company's phone number? |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
|
What is or was your company's email address? |
[ Text ] |
[] Not Applicable (Text) |
|
What is or was your company's web address? |
[ Text ] |
[] Not Applicable (Text) |
|
Is or was your company's address the same as your current home address? |
|
[] Yes |
[] No |
Is or was your company based in the U.S.? |
|
[] Yes |
[] No |
What is or was your company's address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation? |
[ Text ] |
|
|
Where is or was your company located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
|
|
Is or was your work address different than your company's address? |
|
[] Yes |
[] No |
Is or was your work location in the U.S.? |
|
[] Yes |
[] No |
What is or was your work address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation? |
[ Text ] |
|
|
Where is or was your work address?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
What is or was your job title? |
[ Text ] |
|
|
Who can verify your self-employment?
(Unless there is no one else who can verify this self-employment, please do not list yourself, your spouse; partner from a civil union, domestic partnership, or common law marriage; person you are in a committed, spouse-like relationship with; or any relative as a verifier.)
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
What is their phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is their email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Does this person currently live or work in the U.S.? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is their current address? |
|
[] I Don't Know |
|
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation? |
[ Text ] |
[] I Don't Know |
|
Where are they currently located? |
|
[] I Don't Know |
|
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] I Don't Know |
|
|
|
[] Not Applicable |
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] I Don't Know |
|
Do you have another self-employment activity to report? (Do not list employments before your 18th birthday unless to provide a minimum of 2 years employment history) |
|
[] Yes |
[] No |
When were you unemployed?
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Who can verify your activities while unemployed and your means of support during that time?
(Unless there is no one else who can verify the unemployment, please do not list yourself, your spouse; partner from a civil union, domestic partnership, or common law marriage; person you are in a committed, spouse-like relationship with; or any relative as a verifier.)
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
What is their phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is their email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Does this person currently live or work in the U.S.? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is their current address? |
|
[] I Don't Know |
|
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation? |
[ Text ] |
[] I Don't Know |
|
Where are they currently located? |
|
[] I Don't Know |
|
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] I Don't Know |
|
|
|
[] Not Applicable |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
[] I Don't Know |
|
Do you have another unemployment activity to report? (Do not list employments before your 18th birthday unless to provide a minimum of 2 years employment history) |
|
[] Yes |
[] No |
This section asks for information regarding former Federal civilian employment that is outside of the past five years and not reported in section 7. Do not repeat employment that occurred in the past five years that you reported in section 7. This information is requested to determine the reason you left the former federal employment and whether you had any conduct issues or any disciplinary actions. This section does not apply to military service.
Other than employment listed in section 7, have you worked for the U.S. Federal Government outside of the past five years? |
|
[] Yes |
[] No |
When did you work for this federal agency?
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy ] |
[] Estimated |
|
What federal agency did you work for? |
[ Dropdown ] |
|
|
Did you receive any disciplinary actions during this employment? (Examples of disciplinary actions include terminations, written warnings, official reprimands, official counseling, and suspensions) |
|
[] Yes |
[] No |
Which disciplinary action did you receive? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Why did you receive this disciplinary action? (Include a description of the offense for which you received this disciplinary action, when the offense occurred, and any other important details.) |
[ Text ] |
|
|
When did you receive this disciplinary action? |
[ mm/dd/yyyy ] |
[] Estimated |
|
Who gave you this disciplinary action? |
[ Text ] |
|
|
Last Name |
[ Text ] |
|
|
First Name |
[ Text ] |
|
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
Do you have another disciplinary action for this period of federal employment to report ? |
|
[] Yes |
[] No |
Why did you leave this Federal employment? |
[ Text ] |
|
|
Do you have another period of federal employment with this federal agency to report? |
|
[] Yes |
[] No |
Do you have another period of federal employment to report? |
|
[] Yes |
[] No |
*** End Of Branch *** |
|||
This section asks questions regarding your U.S. military or U.S. uniformed service, as applicable. The military service you listed in the employment section, if any, was based on each duty station you were assigned to in the past five years. This section requests each period of military service in which you currently serve or for which you received a DD-214, Certificate of Release or Discharge. Do not break out separate enlistment periods unless you received a DD-214. List all periods of service even if you listed them in Section 7 - Employment Activities.
Have you ever served in the U.S. military or a U.S. uniformed service? |
|
[] Yes |
[] No |
When did you serve? (Start with your most recent period of service and work back.)
From |
[ mm/dd/yyyy] |
[] Estimated |
|
To |
[ mm/dd/yyyy] |
[] Estimated |
[] Present |
Which branch of service are you or were you in? |
[ Dropdown ] |
|
|
Which state or territory do you or did you [ Dropdown ] serve in the National Guard?
[1] Branch Auto Populate Employment Type as U.S. Military. Rank Details.
|
|
|
|
What is or was your duty status? |
[ Dropdown ]
|
|
|
|
Please explain. |
[ Text ] |
|
|
What type of discharge or separation did you receive? |
[ Dropdown ] |
|
|
Why were you discharged or separated? |
[ Text ] |
|
|
Did you receive any disciplinary actions for this period of service? |
|
[] Yes |
[] No |
Which disciplinary action did you receive? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When did you receive this disciplinary action? |
[ mm/yyyy ] |
[] Estimated |
|
Did you report this disciplinary action in section seven (7), Employment Activities? |
|
[] Yes |
[] No |
Why did you receive this disciplinary action? (Include a description of the offense for which you received this disciplinary action, when the offense occurred, and any other important details.) |
[ Text ] |
|
|
Who gave you this disciplinary action? |
|
[] I Don't Know |
|
What type of court-martial did you have? |
[ Dropdown ] |
|
|
Did this court-martial take place in the U.S.? |
|
[] Yes |
[] No |
Where did this court-martial take place?
City |
[ Text ] |
|
|
County Or County Equivalent |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
What is the name of the U.S. military installation? |
[ Text ] |
|
|
Where did this court-martial take place?
City |
[ Text ] |
|
|
Country |
[ Text ] |
|
|
What is the APO or FPO ZIP Code? |
[ Text ] |
|
|
What is the name of the U.S. military installation? |
[ Text ] |
|
|
What is the date of the offense for which you were court-martialed? |
[ mm/yyyy ] |
[] Estimated |
|
Did this offense occur in the U.S.? |
|
[] Yes |
[] No |
Where did it occur?
City |
[ Text ] |
|
|
County or County Equivalent |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation? |
[ Text ] |
|
|
Where did it occur?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
Was domestic violence involved? For this section, "domestic violence" is a crime of violence (such as battery or assault) against your parents or guardians; child; dependent; current or former spouse; current or former partner from a civil union, domestic partnership, or common law marriage; person you are in a committed, spouse-like relationship with; or, someone with whom you share a child in common. This includes crimes that meet this definition even if the term “domestic violence” is not specifically used in the criminal charges or conviction.
|
|
[] Yes |
[] No |
Were firearms involved? |
|
[] Yes |
[] No |
Were explosives involved? |
|
[] Yes |
[] No |
Were drugs involved? |
|
[] Yes |
[] No |
Was alcohol involved? |
|
[] Yes |
[] No |
What were the circumstances surrounding this offense? (Include what happened, why you were charged, who was involved, and any other important details.) |
[ Text ] |
|
|
What were your charges under the Uniform Code of Military Justice (UCMJ) for this offense? (Input one charge at a time. There will be an opportunity to input multiple entries.) |
[ Text ] |
|
|
What was the outcome for this charge? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What were the consequences of this disciplinary action? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another charge for this offense to report? |
|
[] Yes |
[] No |
Do you have another disciplinary action for this period of service to report? |
|
[] Yes |
[] No |
Do you have another period of service to report? |
|
[] Yes |
[] No |
This section asks for information regarding people who know you well (such as associates, friends, or peers) and are aware of your activities outside of your neighborhood, school, or workplace. Examples of outside activities include free time, recreational, or social. Please provide three people who you have known collectively for the past five years or longer and who preferably live in the U.S. Do not list your spouse; partner from a civil union, domestic partnership, or common law marriage; person you are in a committed, spouse-like relationship with; relatives; or anyone you've listed previously on this questionnaire.
List an associate, friend, peer, or other person who knows you well and is aware of your activities outside of your neighborhood, school, or workplace.
What is their name?
Last Name |
[ Text ] |
|
|
First Name |
[ Text ] |
|
|
Middle Name |
[ Text ] |
[] I Don't Know |
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
When did you meet this individual? |
[ mm/yyyy] |
[] Estimated |
|
When was your last contact with this individual? |
[ mm/yyyy ] |
[] Estimated |
|
How often do you have contact with this individual? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What is your current relationship with this individual? |
[ Text ] |
|
|
What is their phone number? |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
|
What is their email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Do they currently live or work in the U.S.? |
|
[] Yes |
[] No
|
What is their address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of this U.S. military installation? |
[ Text ] |
[] I Don't Know |
|
Where are they located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] I Don't Know |
|
What is the name of the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] I Don't Know |
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
Do you have another individual who knows you well to report? (You must list three people who you have known collectively for the past five years.) |
|
[] Yes |
[] No |
This section asks for information regarding your encounters with law enforcement and court systems, specifically any arrests, charges, convictions, or sentences you have had, as applicable.
• Report applicable incidents (such as arrests, charges, etc.) that occurred in the U.S. or in a foreign country. Foreign country means any geographic location not within the 50 U.S. states, District of Columbia, and U.S. territories.
• Report charges filed in federal, state, local, tribal, or non-U.S. courts, as applicable.
• Report information even if your record was expunged, sealed, or otherwise stricken from the court record. However, do not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607.
• Do not report crimes you listed in Section 9 (those you were charged with under the Uniform Code of Military Justice (UCMJ)).
• Omit any violation of law committed before your 18th birthday if finally decided in juvenile court or appealed from juvenile court to a higher court and dismissed.
For this section:
For 11.1.A This question asks for information regarding what are typically low-level civil or traffic violations or offenses (such as, jay walking, or running a red light) in which you have received a written notice from a law enforcement officer or other authorized official to appear in court or to pay a fine. These written notices include citations, summons, or tickets. This question differs from the next in that 11.1.B refers to offenses that rise to a higher level, such as misdemeanors, felonies, or their equivalents.
Have you received a citation, summons, ticket, or other similar written notice to appear in court or pay a fine in the past five years? (Answer “No” if it was for a traffic violation where the fine was under $1,000 and the offense did not involve alcohol or drugs.) |
|
[] Yes |
[] No |
For 11.1.B This question asks for information regarding offenses where you received a document listing criminal charges and to appear in criminal court. These documents are typically for offenses such as misdemeanors, felonies, or their equivalents. The written documents could include citations, summons, tickets, complaints, arrest warrants, or indictments.
Were you charged with, convicted of, or sentenced for a crime in the past five years? |
|
[] Yes |
[] No |
Have you been on probation in the past five years? (Answer "Yes" even if your probation was part of a criminal sentence for a crime in which you were found guilty) |
|
[] Yes |
[] No |
Have you been on parole or supervised release in the past five years? |
|
[] Yes |
[] No |
What is the date of the offense? |
[ mm/dd/yyyy] |
[] Estimated |
|
Did this offense occur in the U.S.? |
|
[] Yes |
[] No |
Where did it occur?
City |
[ Text ] |
|
|
County or County Equivalent |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where did it occur?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Domestic violence -- is a crime of violence (such as battery or assault) against your parents or guardians; child; dependent; current or former spouse; current or former partner from a civil union, domestic partnership, or common law marriage; person you are in a committed, spouse-like relationship with; or, someone with whom you share a child in common. This includes crimes that meet this definition even if the term “domestic violence” is not specifically used in the criminal charge or conviction. |
|||
Was domestic violence involved? |
|
[] Yes |
[] No |
Were firearms involved? |
|
[] Yes |
[] No |
Were explosives involved? |
|
[] Yes |
[] No |
Were drugs involved? |
|
[] Yes |
[] No |
Was alcohol involved? |
|
[] Yes |
[] No |
Why were you charged, cited, summoned, or ticketed? (Describe the offense to include what happened, who was involved, what the motivation was, and any other details. If domestic violence, firearms, explosives, drugs, or alcohol were involved in the offense, please explain.) |
[ Text ] |
|
|
What is the name of the law enforcement agency involved? (Do not use acronyms.) |
[ Text ] |
|
|
Is this law enforcement agency in the U.S.? |
|
[] Yes |
[] No |
What is the address for this law enforcement agency?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this law enforcement agency located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Were you arrested for this offense? |
|
[] Yes |
[] No |
Did the same law enforcement agency you listed above arrest you? |
|
[] Yes |
[] No |
What is the name of the law enforcement agency that arrested you? (Do not use acronyms.) |
[ Text ] |
|
|
Is this law enforcement agency in the U.S.? |
|
[] Yes |
[] No |
What is the address for this law enforcement agency?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this law enforcement agency located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Did you go to court or are you waiting to go to court? |
|
[] Yes |
[] No |
Did you pay a fine? |
|
[] Yes |
[] No |
How much was this fine? |
[ Text ] |
|
|
Did you pay this fine in full? |
|
[] Yes |
[] No |
When did you pay this fine in full? |
[ mm/yyyy ] |
[] Estimated |
|
Please explain. |
[ Text ] |
|
|
Please explain. |
[ Text ] |
|
|
What is the name of the court you appeared in or are to appear in? (Do not use acronyms.) |
[ Text ] |
|
|
Is this court in the U.S.? |
|
[] Yes |
[] No |
What is this court's address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this court located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
What is or was your charge? (If there is more than one charge for this offense, input one charge at a time. There will be an opportunity to input multiple entries.) |
[ Text ] |
|
|
What type of charge is this? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What was the outcome for this charge? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What were the specific court requirements you had to complete before this charge was dismissed or disposed of? (Select all that apply.) |
[ Dropdown ] |
|
|
When is your court date? |
[ mm/yyyy ] |
[] Estimated |
|
Please explain. |
[ Text ] |
|
|
Were you sentenced? |
|
[] Yes |
[] No |
When is your sentencing? |
[ mm/yyyy ] |
[] Estimated |
|
What was your sentence? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Were you sentenced to imprisonment? |
|
[] Yes |
[] No |
When were you incarcerated?
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy ] |
[] Estimated |
|
What is the name of the facility in which you were incarcerated? (Do not use acronyms.) |
[ Text ] |
|
|
Is this facility in the U.S.? |
|
[] Yes |
[] No |
What is the address of this facility?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this facility located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Were you granted parole or supervised release? |
|
[] Yes |
[] No |
What are or were the dates of your parole or supervised release?
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy ] |
[] Estimated |
|
Were you given probation? |
|
[] Yes |
[] No |
What are or were the dates of your probation?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
Do you have another charge for this offense to report? |
|
[] Yes |
[] No |
Is your case closed? |
|
[] Yes |
[] No |
When was your case closed? |
[ mm/yyyy ] |
[] Estimated |
|
|
Please explain. |
|
[] Yes |
[] No |
Were you arrested for a crime in the past five years but not charged? |
|
[] Yes |
[] No |
When were you arrested? |
[ mm/yyyy ] |
[] Estimated |
|
|
What is the name of the law enforcement agency that arrested you? (Do not use acronyms.) |
[ Text ] |
|
|
Is this law enforcement agency in the U.S.? |
|
[] Yes |
[] No |
What is the address for this law enforcement agency?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this law enforcement agency located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Why were you arrested? (Describe the circumstances that led to your arrest.) |
[ Text ] |
|
|
What is the date of the offense for which you were arrested? |
[ mm/yyyy ] |
[] Estimated |
|
Did this offense occur in the U.S.? |
|
[] Yes |
[] No |
Where did it occur?
County or County Equivalent |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where did it occur?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Was domestic violence involved? |
|
[] Yes |
[] No |
Were firearms involved? |
|
[] Yes |
[] No |
Were explosives involved? |
|
[] Yes |
[] No |
Were drugs involved? |
|
[] Yes |
[] No |
Was alcohol involved? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
What was the official reason you weren't charged? |
[ Text ] |
|
|
Do you have another instance in which you were arrested for a crime in the past five years but not charged to report? |
|
[] Yes |
[] No |
Is there currently a domestic violence, restraining, protective, stay-away, no-contact, anti-harassment order, or similar order issued against you? |
|
[] Yes |
[] No |
When was this order issued? |
[ mm/yyyy ] |
[] Estimated |
|
Is the court that issued this order in the U.S.? |
|
[] Yes |
[] No |
What is this court's address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Where is this court located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Who is the protected party in the order? (List all if more than one party.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What is the expiration date of the order? |
[ mm/yyyy ] |
[] Estimated |
|
Why was this order issued against you? (Describe the circumstances that led to this order being issued.) |
[ Text ] |
|
|
This section asks for information regarding your use of illegal drugs or misuse of controlled substances (excluding marijuana or cannabis derivatives, which are discussed in the next section) or prescription drugs as applicable. Questions focus on the type of illegal drugs, controlled substances, or prescription drugs; the frequency of your use; the circumstances surrounding your use; the impacts on your personal and professional activities; and any actions you've taken to overcome any drug-related concerns, as applicable. Your truthful responses and any information derived from your responses will not be used as evidence against you in a subsequent criminal proceeding. This applies whether or not you are employed by the Federal government.
For this section:
• A controlled substance is as defined in 21 U.S.C. 802.
• A prescription drug (also referred to as prescription medication or prescription medicine) is a pharmaceutical drug that legally requires a medical prescription to be dispensed.
• An illegal drug is a drug or substance which a person is forbidden by law to own, possess, distribute, or use.
• Use of a drug or controlled substance includes injecting, snorting, smoking, inhaling, swallowing, experimenting with, or otherwise consuming any drug or controlled substance.
• Report your use of an illegal drug or your misuse of a controlled substance or prescription drug whether or not you were arrested, charged, or convicted of breaking any laws.
• Report drugs or controlled substances (excluding marijuana or cannabis derivatives, which are discussed in the next section) that are illegal under federal law, even if legal under state or foreign (non-U.S.) laws.
Have you used an illegal drug or misused a controlled substance (excluding marijuana or cannabis derivatives) in the past five years or since the age of 16 (if you are under 21)? |
|
[] Yes |
[] No |
What type of illegal drug did you use or controlled substance did you misuse? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When was the first time you used this illegal drug or misused this controlled substance? |
[ mm/yyyy ] |
[] Estimated |
|
When was the last time you used this illegal drug or misused this controlled substance? |
[ mm/yyyy ] |
[] Estimated |
|
How many times did you use this illegal drug or misuse this controlled substance? |
[ Text ] |
|
|
What were the circumstances surrounding your use of this illegal drug or misuse of this controlled substance? |
[ Text ] |
|
|
Did you use this illegal drug or misuse this controlled substance while in a national security position? (A national security position is defined as any position in a department or agency, where the occupant of which could bring about, by virtue of the nature position, a material adverse effect on the national security regardless of whether the occupant has access to classified information and regardless of whether the occupant is an employee, military service member, or contractor.)
|
|
[] Yes |
[] No |
Please explain. (Include when and how many times you used this illegal drug or misused this controlled substance while in a national security position) |
[ Text ] |
|
|
Did you use this illegal drug or misuse this controlled substance while employed in a criminal justice or public safety position? ("While employed" does not necessarily mean your use was "on the clock" or "on duty".) |
|
[] Yes |
[] No |
|
|
What criminal justice or public safety position were you in? |
[ Dropdown ] |
|
|
Please explain. (Include when and how many times you used this illegal drug or misused this controlled substance while employed in a criminal justice or public safety position.) |
[ Text ] |
|
|
Do you intend to use this illegal drug or misuse this controlled substance in the future? |
|
[] Yes |
[] No |
Why? |
[ Text ] |
|
|
Why? |
[ Text ] |
|
|
Do you have another instance of using an illegal drug or misusing a controlled substance (excluding marijuana or cannabis derivatives) in the past five years or since the age of 16 (if you are under 21) to report? |
|
[] Yes |
[] No |
Have you intentionally misused drugs prescribed for you or someone else in the past five years or since the age of 16 (if you are under 21)? ("Intentionally" means you deliberately misused prescription drugs as opposed to accidently.) (Misuse of drugs includes the misuse of prescription and non-prescription drugs that may cause physical or mental impairment or that are deliberately used in a manner inconsistent with their intended purpose.) |
|
[] Yes |
[] No |
What prescription drug did you intentionally misuse? (List one at a time. There will be an opportunity to input multiple entries.) |
[ Text ] |
|
|
When was the first time you intentionally misused this prescription drug? |
[ mm/yyyy ] |
[] Estimated |
|
When was the last time you intentionally misused this prescription drug? |
[ mm/yyyy ] |
[] Estimated |
|
How many times did you intentionally misuse this prescription drug? |
[ Text ] |
|
|
What were the circumstances surrounding your intentional misuse of prescription drugs? |
[ Text ] |
|
|
Did you intentionally misuse this prescription drug while in a national security position? |
|
[] Yes |
[] No |
Please explain. (Include when and how many times you intentionally misused this prescription drug while in a national security position.) |
[ Text ] |
|
|
Did you intentionally misuse this prescription drug while employed in a criminal justice or public safety position? ("While employed" does not necessarily mean your use was "on the clock" or "on duty".) |
|
[] Yes |
[] No |
What criminal justice or public safety position were you in? |
[ Text ] |
|
|
Please explain. (Include when and how many times you intentionally misused this prescription drug while employed in a criminal justice or public safety position.) |
[ Text ] |
|
|
Do you intend to misuse this or any other prescription drugs in the future? |
|
[] Yes |
[] No |
Why? |
[ Text ] |
|
|
Why? |
|
[ Text ] |
|
|
Do you have another instance of intentionally misusing prescription drugs in the past five years or since the age of 16 (if you are under 21) to report? ("Intentionally" means you deliberately misused prescription drugs as opposed to accidently.) |
|
[] Yes |
[] No |
Has your use of an illegal drug or misuse of a controlled substance (excluding marijuana or cannabis derivatives) or prescription drug negatively impacted your life in the past five years or since the age of 16 (if you are under 21)? (For example, have you experienced poor work or school performance; professional or personal relationship problems; or, financial, legal, or health issues.) |
|
[] Yes |
[] No |
How has your use of an illegal drug or misuse of a controlled substance (excluding marijuana or cannabis derivatives) or prescription drug negatively affected your life? |
[ Text ] |
|
|
When was your life negatively affected?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Have you illegally possessed, purchased, manufactured, cultivated, trafficked, produced, transferred, shipped, received, handled, or sold any drug or controlled substance (excluding marijuana or cannabis derivatives) in the past five years or since the age of 16 (if you are under 21)? |
|
[] Yes |
[] No |
What type of drug or controlled substance did you illegally possess, purchase, manufacture, cultivate, traffic, produce, transfer, ship, receive, handle, or sell? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When was the first time you illegally possessed, purchased, manufactured, cultivated, trafficked, produced, transferred, shipped, received, handled, or sold this drug or controlled substance? |
[ mm/yyyy ] |
[] Estimated |
|
When was the last time you illegally possessed, purchased, manufactured, cultivated, trafficked, produced, transferred, shipped, received, handled, or sold this drug or controlled substance? |
[ mm/yyyy ] |
[] Estimated |
|
How many times did you illegally possess, purchase, manufacture, cultivate, traffic, produce, transfer, ship, receive, handle, or sell this drug or controlled substance? |
[ Text ] |
|
|
What were the circumstances surrounding your illegal possession, purchase, manufacturing, cultivation, trafficking, production, transference, shipping, receiving, handling, or selling of this drug or controlled substance? |
[ Text ] |
|
|
Did you illegally possess, purchase, manufacture, cultivate, traffic, produce, transfer, ship, receive, handle, or sell this drug or controlled substance while in a national security position? |
|
[] Yes |
[] No |
Please explain. (Include when and how many times you illegally possessed, purchased, manufactured, cultivated, trafficked, produced, transferred, shipped, received, handled, or sold this drug or controlled substance while in a national security position.) |
[ Text ] |
|
|
Did you illegally possess, purchase, manufacture, cultivate, traffic, produce, transfer, ship, receive, handle, or sell this drug or controlled substance while employed in a criminal justice or public safety position? ("While employed" does not necessarily mean your use was "on the clock" or "on duty".) |
|
[] Yes |
[] No |
What criminal justice or public safety position were you in? |
[ Dropdown ] |
|
|
Please explain. (Include when and how many times you illegally possessed, purchased, manufactured, cultivated, trafficked, produced, transferred, shipped, received, handled, or sold this drug or controlled substance while employed in a criminal justice or public safety position.) |
[ Text ] |
|
|
Do you intend to illegally possess, purchase, manufacture, cultivate, traffic, produce, transfer, ship, receive, handle, or sell this drug or controlled substance in the future? |
|
[] Yes |
[] No |
Why? |
[ Text ] |
|
|
Why? |
[ Text ] |
|
|
Do you have another instance of illegally possessing, purchasing, manufacturing, cultivating, trafficking, producing, transferring, shipping, receiving, handling, or selling any drug or controlled substance in the past five years or since the age of 16 (if you are under 21) to report? |
|
[] Yes |
[] No |
Have you ever used an illegal drug or misused a controlled substance (excluding marijuana or cannabis derivatives) while in a national security position? (Answer "No" if this occurred in the past five years and you listed it above.) |
|
[] Yes |
[] No |
What type of drug did you illegally use or controlled substance did you misuse while in a national security position? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When was the first time you used this illegal drug or misused this controlled substance while in a national security position? |
[ mm/yyyy ] |
[] Estimated |
|
When was the last time you used this illegal drug or misused this controlled substance while in a national security position? |
[ mm/yyyy ] |
[] Estimated |
|
How many times did you use this illegal drug or misuse this controlled substance while in a national security position? |
[ Text ] |
|
|
What were the circumstances surrounding your use of this illegal drug or misuse of this controlled substance while in a national security position? |
[ Text ] |
|
|
Do you have another instance of using an illegal drug or misusing a controlled substance while in a national security position to report? |
|
[] Yes |
[] No |
Have you ever used an illegal drug or misused a controlled substance (excluding marijuana or cannabis derivatives) while employed in a criminal justice or public safety position? ("While employed" does not necessarily mean your use was "on the clock" or "on duty". Answer "No" if this occurred in the past five years and you listed it above.) |
|
[] Yes |
[] No |
What type of drug did you illegally use or controlled substance did you misuse while employed in a criminal justice or public safety position? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When was the first time you used this illegal drug or misused this controlled substance while employed in a criminal justice or public safety position? |
[ mm/yyyy ] |
[] Estimated |
|
When was the last time you used this illegal drug or misused this controlled substance while employed in a criminal justice or public safety position? |
[ mm/yyyy ] |
[] Estimated |
|
How many times did you use this illegal drug or misuse this controlled substance while employed in a criminal justice or public safety position? |
[ Text ] |
|
|
What criminal justice or public safety position were you in? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What were the circumstances surrounding your use of this illegal drug or misuse of this controlled substance while employed in a criminal justice or public safety position? |
[ Text ] |
|
|
Do you have another instance of using an illegal drug or misusing a controlled substance (excluding marijuana or cannabis derivatives) while employed in a criminal justice or public safety position to report? |
|
[] Yes |
[] No |
Were you ordered to get counseling or treatment as a result of your illegal use of drugs or controlled substances (excluding marijuana or cannabis derivatives), or your misuse of prescription drugs in the past five years or since the age of 16 (if you are under 21)? |
|
[] Yes |
[] No |
Who ordered you to get this counseling or treatment? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Did you get this counseling or treatment? |
|
[] Yes |
[] No |
Please explain. (Include why you did not get this counseling or treatment, the consequences of not getting it, if any, and any other important details.) |
[ Text ] |
|
|
Was this order a result of your intentional misuse of prescription drugs? |
|
[] Yes |
[] No |
What is the name of the prescription drug? (List all, if more than one.) |
[ Text ] |
|
|
Was this order a result of your illegal use of drugs or controlled substances? |
|
[] Yes |
[] No |
What is the type of drug or controlled substance? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When did you get this counseling or treatment? |
[ Text ] |
[] Present |
|
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy ] |
[] Estimated |
|
Who is or was your counselor or treatment provider? |
[ Text ] |
[] I Don't Know |
|
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
Does your treatment provider still practice? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is the name of the practice? |
[ Text ] |
[] I Don't Know |
|
Is your counselor, treatment provider, or the practice in the U.S.? |
|
[] Yes |
[] No |
What is their phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is their email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
What is the address of your counselor, treatment provider, or the practice?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation? |
[ Text ] |
|
|
Where is your counselor, treatment provider, or the practice located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
|
|
Did you complete this counseling or treatment? |
|
[] Yes |
[] No |
Why was treatment not completed?
What is the current status of your counseling or treatment?
|
[ Text ]
[ Text ]
|
|
|
Do you have another instance where you were ordered to get counseling or treatment as a result of your illegal use of drugs, controlled substances (excluding marijuana or cannabis derivatives), or misuse of prescription drugs in the past five years or since the age of 16 (if you are under 21) to report? |
|
[] Yes |
[] No |
Have you voluntarily been to counseling or treatment as a result of your illegal use of drugs or controlled substances (excluding marijuana or cannabis derivatives), or your misuse of prescription drug in the past five years or since the age of 16 (if you are under 21)? |
|
[] Yes |
[] No |
Was this voluntary counseling based on advice or a recommendation from one or more of the following? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Is or was your counseling or treatment a result of your intentional misuse of prescription drugs? |
|
[] Yes |
[] No |
What is the name of the prescription drug? (List all, if more than one.) |
[ Text ] |
|
|
Is or was your counseling or treatment a result of your illegal use of drugs or controlled substances? |
|
[] Yes |
[] No |
What is the type of drug or controlled substance? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When did you get this counseling or treatment? |
[ Text ] |
|
|
From |
[ mm/yyyy ] |
[] Estimated |
|
To |
[ mm/yyyy] |
[] Estimated |
[] Present |
Who is or was your counselor or treatment provider? |
[ Text ] |
[] I Don't Know |
|
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
What is the name of their practice? |
[ Text ] |
[] I Don't Know |
|
Does your counselor or treatment provider still practice? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What is their phone number? (You may list more than one.) |
[Country Code|Number|Extension|Type] |
[] [Day/Night/Both] |
[] I Don't Know |
What is their email address? (You may list more than one.) |
[ Address + Type ] |
[] I Don't Know |
|
Is your counselor, treatment provider, or the practice in the U.S.? |
|
[] Yes |
[] No |
What is the address of your counselor, treatment provider, or the practice?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation? |
[ Text ] |
|
|
Where is your counselor, treatment provider, or the practice located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
|
|
Did you complete this counseling or treatment? |
|
[] Yes |
[] No |
What is the current status of your counseling or treatment? |
[ Text ] |
|
|
Do you have another instance where you voluntarily went to counseling or treatment as a result of your illegal use of drugs, controlled substances, or misuse of prescription drugs in the past five years or since the age of 16 (if you are under 21) to report? |
|
[] Yes |
[] No |
In this section, “marijuana and cannabis derivative use,” cannabis derivative refers to any cannabis-derived substance containing greater than .3% tetrahydrocannabinol (THC). You do NOT need to answer yes to questions regarding your use of cannabis derivatives if you have solely used products that did not exceed .3% THC, such as most products containing CBD oil.
Have you used marijuana or a cannabis derivative in the last 90 days? |
|
[] Yes |
[] No |
When, within the last five years, was the first time you used marijuana or a cannabis derivative? |
[ mm/yyyy ] |
[] Estimated |
|
When, within the last five years, was the most recent time you used marijuana or a cannabis derivative? |
[ mm/yyyy ] |
[] Estimated |
|
How often have you used marijuana or a cannabis derivative in the last five years? |
[ Text ] |
|
|
What were the circumstances surrounding your use of marijuana or a cannabis derivative? |
[ Text ] |
|
|
Did you use marijuana or a cannabis derivative while in a national security position in the last 90 days? (A national security position is defined as any position in a department or agency, where the occupant of which could bring about, by virtue of the nature position, a material adverse effect on the national security regardless of whether the occupant has access to classified information and regardless of whether the occupant is an employee, military service member, or contractor.) |
|
[] Yes |
[] No |
Please explain. (Include when and how many times you used marijuana or a cannabis derivative while in a national security position.) |
[ Text ] |
|
|
Did you use marijuana or a cannabis derivative while employed in a criminal justice or public safety position in the last 90 days? ("While employed" does not necessarily mean your use was "on the clock” or “on duty".) |
|
[] Yes |
[] No |
What criminal justice or public safety position were you in? |
[ Dropdown ] |
|
|
Please explain. (Include when and how many times you used marijuana or a cannabis derivative while employed in a criminal justice or public safety position.) |
[ Text ] |
|
|
Have you ever used marijuana or a cannabis derivative while in a national security position? (Answer "No" if this occurred in the past 90 days and you listed it above.) |
|
[] Yes |
[] No |
When was the first time you used marijuana or a cannabis derivative while in a national security position? |
[ mm/yyyy ] |
[] Estimated |
|
When was the most recent time you used marijuana or a cannabis derivative while in a national security position? |
[ mm/yyyy ] |
[] Estimated |
|
How often did you use marijuana or a cannabis derivative while in a national security position? |
[ Text ] |
|
|
How many times did you use marijuana or a cannabis derivative while in this national security position? |
[ Text ] |
|
|
What were the circumstances surrounding your use of marijuana or a cannabis derivative while in a national security position? |
[ Text ] |
|
|
Do you have another instance of using marijuana or a cannabis derivative while in a national security position to report? |
|
[] Yes |
[] No |
Have you ever used marijuana or a cannabis derivative while employed in a criminal justice or public safety position? ("While employed" does not necessarily mean your use was "on the clock” or “on duty".) (Answer "No" if this occurred in the past 90 days and you listed it above.) |
|
[] Yes |
[] No |
When was the first time you used marijuana or a cannabis derivative while in a criminal justice or public safety position? |
[ mm/yyyy ] |
[] Estimated |
|
When was the last time you used marijuana or a cannabis derivative while in a criminal justice or public safety position? |
[ mm/yyyy ] |
[] Estimated |
|
How often did you use marijuana or a cannabis derivative while in a criminal justice or public safety position? |
[ Text ] |
|
|
How many times did you use marijuana or a cannabis derivative while in a criminal justice or public safety position? |
[ Text ] |
|
|
What criminal justice or public safety position were you in when you used marijuana or a cannabis derivative? |
[ Dropdown ] |
|
|
What were the circumstances surrounding your use of marijuana or a cannabis derivative while in this criminal justice or public safety position? |
[ Text ] |
|
|
Do you have another instance of using marijuana or a cannabis derivative while in a criminal justice or public safety position to report? |
|
[] Yes |
[] No |
In the past five years, have you been involved in the illegal manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling, sale, or purchase of marijuana or a cannabis derivative? |
|
[] Yes |
[] No |
When was the approximate start date of your involvement in the described activity? |
[ mm/yyyy ] |
[] Estimated |
|
When was the approximate end date of your involvement in the described activity? |
[ mm/yyyy ] |
[] Estimated |
|
How many times did you illegally possess, purchase, manufacture, cultivate, traffic, produce, transfer, ship, receive, handle, or sell marijuana or a cannabis derivative? |
[ Text ] |
|
|
Describe the circumstances of your involvement in the described activity? |
[ Text ] |
|
|
Did you illegally possess, purchase, manufacture, cultivate, traffic, produce, transfer, ship, receive, handle, or sell marijuana or a cannabis derivative while in a national security position?
Do you have another instance of having been involved in the illegal manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling, sale, or purchase of marijuana or cannabis derivative? |
|
[] Yes
[] Yes
|
[] No
[] No |
Please explain. (Include when and how many times you illegally possessed, purchased, manufactured, cultivated, trafficked, produced, transferred, shipped, received, handled, or sold this drug or controlled substance while in a national security position.) |
[ Text ] |
|
|
Did you illegally possess, purchase, manufacture, cultivate, traffic, produce, transfer, ship, receive, handle, or sell marijuana or a cannabis derivative while employed in a criminal justice or public safety position? ("While employed" does not necessarily mean your use was "on the clock” or “on duty".) |
|
[] Yes |
[] No |
What criminal justice or public safety position were you in? |
[ Dropdown ] |
|
|
Please explain. (Include when and how many times you illegally possessed, purchased, manufactured, cultivated, trafficked, produced, transferred, shipped, received, handled, or sold marijuana or a cannabis derivative while employed in a criminal justice or public safety position.) |
[ Text ] |
|
|
This section asks for information regarding any personnel vetting investigations the U.S. Government has conducted on you as part of the personnel vetting process. All individuals who work for or on behalf of the U.S. federal government are investigated at least once. After the initial investigation, further investigations depend on many variables.
Some investigations result in a security clearance determination or a determination of eligibility to occupy a sensitive position. This section asks questions regarding your eligibility determination or security clearance determination, if applicable. Information requested includes whether or not you were granted eligibility to occupy a sensitive position or a security clearance or have had either denied, suspended, or revoked. The U.S. federal agency that investigated you may or may not be the same U.S. federal agency that granted, denied, suspended, or revoked your security clearance.
This section also asks for information regarding whether or not the U.S. Government has debarred you from Federal employment. If you were found unsuitable under 5 CFR Part 731 by the U.S. Office of Personnel Management or an agency, a period during which you were denied examination for, and appointment to, all or specific covered positions within the U.S. Government is considered a debarment period. Your debarment could be either government-wide or from a particular agency or positions within that agency.
Investigations are also used to determine whether you are eligible for a Personal Identity Verification (PIV) credential. This credential grants you physical access to Federal space and/or logical access to federal information technology (IT) systems. This section asks questions regarding any prior credentialing decisions where you were denied a PIV or had a PIV suspended or revoked, as applicable.
We also want to know if a foreign government has ever investigated you or granted you a security clearance. Foreign means non-U.S. -- that is, outside of the 50 U.S. states, District of Columbia, and U.S. territories.
In the last five years, has the U.S. Government investigated your background as part of the personnel vetting process, such as for your suitability or fitness for employment, your eligibility for a PIV credential, or for a national security position or security clearance? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
Which federal agency investigated your background? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another investigation to report within the last five years? |
|
[] Yes |
[] No |
Has the U.S. Government ever granted you a security clearance? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
Which federal agency granted you this security clearance? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another security clearance to report? |
|
[] Yes |
[] No |
Has the U.S. Government ever suspended your security clearance? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What federal agency suspended your security clearance? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When did this federal agency suspend your security clearance? |
[ mm/yyyy ] |
[] Estimated |
[] I Don't Know |
Why did this federal agency suspend your security clearance? |
[ Text ] |
|
|
What was the outcome of your security clearance suspension? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another security clearance suspension to report? |
|
[] Yes |
[] No |
Has the U.S. Government ever revoked your security clearance? (An administrative downgrade or administrative termination of a security clearance is not a revocation.) |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
What federal agency revoked your security clearance? |
[ Dropdown ] |
|
|
|
Please explain. |
[ Text ] |
|
|
When did this federal agency revoke your security clearance? |
[ mm/yyyy ] |
[] Estimated |
[] I Don't Know |
Why did this federal agency revoke your security clearance? |
[ Text ] |
|
|
Do you have another security clearance revocation to report? |
|
[] Yes |
[] No |
Has the U.S. Government ever denied you a security clearance? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
Which federal agency denied you a security clearance? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When did this federal agency deny you a security clearance? |
[ mm/yyyy ] |
[] Estimated |
[] I Don't Know |
Why did this federal agency deny you a security clearance? |
[ Text ] |
|
|
Do you have another security clearance denial to report? |
|
[] Yes |
[] No |
Has the U.S. Government ever suspended your Personal Identity Verification (PIV) credential eligibility? |
|
[] Yes |
[] No |
What federal agency suspended your PIV credential eligibility? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What was the outcome of your PIV credential eligibility suspension? |
[ Dropdown ] |
|
|
When did this federal agency suspend your PIV credential eligibility? |
[ mm/yyyy ] |
[] Estimated |
[] I Don't Know |
Why did this federal agency suspend your PIV credential eligibility? |
[ Text ] |
|
|
Please explain. |
[ Text ] |
|
|
When was your PIV credential eligibility reinstated? |
[ mm/yyyy ] |
[] Estimated |
[] I Don't Know |
Do you have another instance in which the U.S. Government suspended your PIV credential eligibility? |
|
[] Yes |
[] No |
Has the U.S. Government ever revoked your PIV credential eligibility? |
|
[] Yes |
[] No |
What federal agency revoked your PIV credential eligibility? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
|
When did this federal agency revoke your PIV credential eligibility? |
[ mm/yyyy ] |
[] Estimated |
[] I Don't Know |
Why did this federal agency revoke your PIV credential eligibility? |
[ Text ] |
|
|
Do you have another instance in which the U.S. Government revoked your PIV credential eligibility? |
|
[] Yes |
[] No |
Has the U.S. Government ever denied you PIV credential eligibility? |
|
[] Yes |
[] No |
Which federal agency denied you PIV credential eligibility? |
[ Dropdown ] |
|
|
|
Please explain. |
[ Text ] |
|
|
|
When did this federal agency deny you PIV credential eligibility? |
[ mm/yyyy ] |
[] Estimated |
[] I Don't Know |
Why did this federal agency deny you a PIV credential eligibility? |
[ Text ] |
|
|
Do you have another instance in which the U.S. Government denied you a PIV credential eligibility? |
|
[] Yes |
[] No |
Have you ever been debarred from federal government employment? |
|
[] Yes |
[] No |
Which federal agency debarred you from federal government employment? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
When were you debarred from federal government employment?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
Why were you debarred from federal government employment?
Do you have another instance in which you were debarred from federal government employment? |
[ Text ] |
|
|
|
|
[] Yes |
[] No |
|
|
|
|
|
|
|
|
Has a foreign (non-U.S.) government ever investigated your background or granted you a security clearance? |
|
[] Yes |
[] No |
|
|
[] I Don't Know |
|
Which foreign government investigated you? |
[ Dropdown ] |
|
|
Did this foreign government grant you a security clearance? |
|
[] Yes |
[] No |
|
|
[] I Don't Know
|
|
Do you have another instance in which this or another foreign (non-U.S.) government investigated your background or granted you a security clearance? |
|
[] Yes |
[ ] No |
This section asks for information regarding any federal financial debt you have, including federal tax debt and any federal non-tax debt. Examples of federal non-tax debt include past due federally guaranteed or insured loans such as student and home mortgage loans, overpayment of benefits, or other debts to the U.S. Government. This section also focuses on the actions you have taken to address past due financial obligations, as applicable.
For this section:
• Past due:
- Means a payment was not made by its due date or by the end of the grace period, if applicable.
- For other debts paid in installments, such as loans, "past due" means a payment was not made by its due date or by the end of the grace period, if applicable.
- You are not "past due" if you were approved for a tax extension and you filed and paid your taxes by the extension due date.
• A tax year is the 12 months covered by a tax return.
• A guarantor is an individual who promises to pay a borrower's debt in the event the borrower defaults on their loan obligation.
Are there any tax year(s) within the past five years for which you have failed to file a federal tax return? Answer "No" if 1) you were not required to file because you did not earn enough money or 2) you were not required by law to file Federal income taxes. |
|
[] Yes |
[] No |
What tax year did you fail to file? (Input one tax year at a time. There will be an opportunity to input multiple entries.) |
[ yyyy] |
|
|
Why did you not file these taxes? |
[ Text ] |
|
|
Do you intend to file these taxes? |
|
[] Yes |
[] No |
When do you intend to file these taxes? |
[ mm/yyyy ] |
[] Estimated |
|
Why? |
[ Text ] |
|
|
Do you have another instance in which you failed to file your federal taxes in the past five years? Answer "No" if 1) you were not required to file because you did not earn enough money or 2) you were not required by law to file federal income taxes.
|
|
[] Yes |
[] No |
*** End Of Branch *** |
|||
|
|
|
|
|
|
|
|
Have you failed to pay the amount due on your federal taxes for any tax year(s) in the past five years? (Answer "No" if you 1) were not required to file or pay because you did not earn enough money, 2) did not owe the IRS money (you received or were entitled to a refund), or 3) were not required by law to file or pay federal income taxes.) |
|
[] Yes |
[] No |
For what tax year have you failed to pay the amount due? (Input one tax year at a time. There will be an opportunity to input multiple entries.) |
[ yyyy] |
|
|
How much do you owe? |
[ Text ] |
[] I Don't Know |
|
What actions have you taken to pay these taxes? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Please explain. |
[ Text] |
|
|
Are there other tax year(s) in the past five years for which you have you failed to pay the amount due on your federal taxes? Answer "No" if you 1) were not required to file or pay because you did not earn enough money, 2) did not owe the IRS money (you received or were entitled to a refund), or 3) were not required by law to file or pay federal income taxes. |
|
[] Yes |
[] No |
Are you currently past due on any federal non-tax debt? (This includes past due federally guaranteed or insured loans such as student and home mortgage loans, overpayment of benefits, and other debts to the U.S. Government. List if you are the sole debtor, a cosigner, or a guarantor.) |
|
[] Yes |
[] No |
What is the name of the government agency or organization you owe? (Do not use acronyms or abbreviations in the name.) |
|
[ Text ] |
|
|
What type of federal non-tax debt are you past due on? (Check one. There will be an opportunity to input multiple entries.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
What is the loan or account number associated with this debt? |
[ Text ] |
|
|
What type of property is involved? |
[ Text ] |
[] Not Applicable (Text) |
|
How much are you past due (in U.S. dollars)? |
[ Text ] |
[] Estimated |
|
Why are you past due on this debt? |
[ Text ] |
|
|
When did you become past due on this debt? |
[ mm/yyyy ] |
[] Estimated |
|
Have you had a judgment entered against you or a lien placed against your property as a result of this debt? |
|
[] Yes |
[] No |
Which did you receive? |
[ Text ] |
[] Judgment |
[] Lien |
What is the name of the court or government office where this judgment or lien is recorded? (Do not use acronyms or abbreviations in the name.) |
[ Text ] |
|
|
What is the address of this court or government office?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
What is the amount of the judgment or lien (in U.S. dollars)? |
[ Text ] |
|
|
What actions have you taken to resolve this debt? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another instance in which you are currently past due on federal non-tax debt? (This includes past due federally guaranteed or insured loans such as student and home mortgage loans, overpayment of benefits, and other debts to the U.S. Government. List if you are the sole debtor, a cosigner, or a guarantor.) |
|
[] Yes |
[] No |
This section asks for information regarding your use of information technology (IT) systems.
For this section:
• IT systems include all related computer hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage, or protection of information.
• The term "illegal" applies whether or not you were arrested, charged, or convicted of a crime.
• Your truthful responses and any information derived from your responses will not be used as evidence against you in a subsequent criminal proceeding. This applies whether or not you are employed by the Federal Government.
• Do NOT include classified information or any specifics regarding other protected information or classified IT systems in any of your responses.
Have you illegally or without proper authorization accessed or tried to access any IT system in the past five years? |
|
[] Yes |
[] No |
When did you illegally or without proper authorization access or try to access an IT system? |
[ mm/yyyy ] |
[] Estimated |
|
Where did you illegally or without proper authorization access or try to access this IT system? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Is this location in the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is this located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
What is the name of the IT system you illegally or without proper authorization accessed or tried to access? |
[ Text ] |
|
|
What is the name of the agency, organization, entity, or individual that owned or operated this IT system? |
[ Text ] |
[] I Don't Know |
|
Did you succeed in accessing this IT system illegally or without proper authorization? |
|
[] Yes |
[] No |
What type of information did you access? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
How many times did you access this IT system? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
|
Did you share any of the information you accessed with anyone? |
|
[] Yes |
[] No |
Who?
Last Name |
[ Text ] |
[] Letter(s) Only |
|
First Name |
[ Text ] |
[] Letter(s) Only |
|
Middle Name |
[ Text ] |
[] Letter(s) Only |
[] No Middle Name |
|
|
[] I Don't Know |
|
Suffix |
[ Dropdown ] |
|
|
|
|
[] None |
|
How many times did you try to access this IT system? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Why did you illegally or without proper authorization access or try to access this IT system? |
[ Text ] |
|
|
Did you receive any of the following actions for accessing or trying to access this IT system illegally or without proper authorization? (Select all that apply.) |
[ Dropdown ] |
|
|
Provide details. (Include a description of the action taken against you, who took this action, when you received this action, where you received this action, and any other details.) |
[ Text ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another instance in which you illegally or without proper authorization accessed an IT system or tried to in the past five years? |
|
[] Yes |
[] No |
Have you illegally or without proper authorization modified, destroyed, or manipulated information on an IT system or tried to in the past five years? |
|
[] Yes |
[] No |
When did you illegally or without proper authorization modify, destroy, or manipulate information on an IT system or try to? |
[ mm/yyyy ] |
[] Estimated |
|
Where did you illegally or without proper authorization modify, destroy or manipulate information on an IT system or try to? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Is this location in the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is this located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
What is the name of the IT system you illegally or without proper authorization changed or destroyed information on or tried to? |
[ Text ] |
|
|
What is the name of the agency, organization, entity, or individual that owned or operated this IT system? |
[ Text ] |
[] I Don't Know |
|
Did you succeed in modifying, destroying, or manipulating information on this IT system illegally or without proper authorization? |
|
[] Yes |
[] No |
What type of information did you modify, destroy or manipulate? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
|
How many times did you modify, destroy, or manipulate information on this IT system illegally or without proper authorization? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
How many times did you try to modify, destroy, or manipulate information on this IT system illegally or without proper authorization? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Why did you illegally or without proper authorization modify, destroy, or manipulate information on this IT system or try to? |
[ Text ] |
|
|
Did you receive any of the following actions for modifying, destroying, or manipulating information on this IT system or trying to illegally or without proper authorization? (Select all that apply.) |
[ Dropdown ] |
|
|
Provide details. (Include a description of the action taken against you, who took this action, when you received this action, where you received this action, and any other details.) |
[ Text ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another instance in which you illegally or without proper authorization changed or destroyed information on an IT system or tried to in the past five years? |
|
[] Yes |
[] No |
Have you illegally or without proper authorization denied others access to information on an IT system or tried to in the past five years? |
|
[] Yes |
[] No |
When did you illegally or without proper authorization deny others access to information on an IT system or try to? |
[ mm/yyyy ] |
[] Estimated |
|
Where did you illegally or without proper authorization deny others access to information on an IT system or try to? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Is this location in the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is this located?
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
What is the name of the IT system you illegally or without proper authorization denied others access to information on or tried to deny others access to information on? |
[ Text ] |
|
|
What is the name of the agency, organization, entity, or individual that owned or operated this IT system? |
[ Text ] |
[] I Don't Know |
|
Did you succeed in denying others access to information on this IT system illegally or without proper authorization? |
|
[] Yes |
[] No |
What type of information did you deny others access to? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
How many times did you deny others access to information on this IT system? |
[ Dropdown ] |
|
|
Please explain |
[ Text ] |
|
|
How many times did you try to deny others access to information on this IT system? |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Why did you illegally or without proper authorization deny others access to information on this IT system or try to? |
[ Text ] |
|
|
Did you receive any of the following actions for denying others access to information on this IT system or trying to illegally or without proper authorization? (Select all that apply.) |
[ Dropdown ] |
|
|
Provide details. (Include a description of the action taken against you, who took this action, when you received this action, where you received this action, and any other details.) |
[ Text ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another instance in which you illegally or without proper authorization denied others access to information on an IT system or tried to in the past five years? |
|
[] Yes |
[] No |
Have you illegally or without proper authorization introduced, used, or removed hardware, software, or media from an IT system or tried to in the past five years? |
|
[] Yes |
[] No |
When did you illegally or without proper authorization introduce, use, or remove hardware, software, or media from an IT system or try to? |
[ mm/yyyy ] |
[] Estimated |
|
Where did you illegally or without proper authorization introduce, use, or remove hardware, software, or media from an IT system or try to? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Is this location in the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street (include Apt #, Unit #, or Suite #, if applicable) |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is this located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code for the U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
|
|
What is the name of the IT system you illegally or without proper authorization introduced, used, or removed hardware, software, or media from or tried to? |
[ Text ] |
|
|
|
What is the name of the agency, organization, entity, or individual that owned or operated this IT system? |
[ Text ] |
[] I Don't Know |
|
Did you succeed in introducing, using, or removing hardware, software, or media from an IT system illegally or without proper authorization? |
|
[] Yes |
[] No |
How many times did you introduce, use, or remove hardware, software, or media from this IT system? |
[ Dropdown ] |
|
|
Please explain |
[ Text ] |
|
|
Why did you illegally or without proper authorization introduce, use, or remove hardware, software, or media from this IT system or try to? |
[ Text ] |
|
|
Did you receive any of the following actions for introducing, using, or removing hardware, software, or media from this IT system or trying to illegally or without proper authorization? (Select all that apply.) |
[ Dropdown ] |
|
|
Provide details. (Include a description of the action taken against you, who took this action, when you received this action, where you received this action, and any other details.) |
[ Text ] |
|
|
Please explain. |
[ Text ] |
|
|
Do you have another instance in which you illegally or without proper authorization introduced, used, or removed hardware, software, or media from an IT system or tried to in the past five years? |
|
[] Yes |
[] No |
This section asks for information regarding your handling of protected information, as applicable.
For this section:
• Protected information includes information protected by the Privacy Act, personally identifiable information, proprietary information, classified information, and other sensitive or protected information.
• The term "illegal" applies whether or not you were arrested, charged, or convicted of a crime.
• Your truthful responses and any information derived from your responses will not be used as evidence against you in a subsequent criminal proceeding. This applies whether or not you are employed by the Federal Government.
• Do NOT include classified information or any specifics regarding other protected information or classified IT systems in any of your responses.
Have you illegally or without proper authorization accessed or tried to access any protected information in the past five years? |
|
[] Yes |
[] No |
When did you illegally or without proper authorization access or try to access this protected information? |
[ mm/yyyy ] |
[] Estimated |
|
Where did you illegally or without proper authorization access or try to access this protected information? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Is this location in the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is this located?
Please provide physical address [Text]
(not mailing address).
City |
[ Text ] |
|
|
Country |
[ Text ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
|
|
Did you succeed in accessing protected information? |
|
[] Yes |
[] No |
What did you do with this protected information? |
[ Text ] |
|
|
Why did you illegally or without proper authorization access or try to access this protected information? |
[ Text ] |
|
|
Did you receive any of the following actions for accessing or trying to access this protected information? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Provide details. (Include a description of the action taken against you, who took this action, when you received this action, where you received this action, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you illegally or without proper authorization accessed or tried to access protected information in the past five years? |
|
[] Yes |
[] No |
Have you deliberately failed to comply with rules or regulations for safeguarding protected information in the past five years? |
|
[] Yes |
[] No |
When did you deliberately fail to comply with rules or regulations for the safeguarding of this protected information? |
[ mm/yyyy ] |
[] Estimated |
|
Where did you deliberately fail to comply with rules or regulations for the safeguarding of this protected information? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Is this location in the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
State or Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Is this a U.S. military installation? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation? |
[ Text ] |
|
|
Where is this located?
City |
[ Text ] |
|
|
Country |
[ Text ] |
|
|
Is this a U.S. military installation or U.S. diplomatic facility? |
|
[] Yes |
[] No |
What is the name of this U.S. military installation or U.S. diplomatic facility? |
[ Text ] |
[] Not Applicable (Text) |
|
What is the APO/FPO/DPO ZIP Code? |
[ Text ] |
|
|
Why did you deliberately non-comply with rules or regulations for safeguarding this protected information? |
[ Text ] |
|
|
Did you receive any of the following actions for deliberately non-complying with rules or regulations for safeguarding this protected information? (Select all that apply.) |
[ Dropdown ] |
|
|
Please explain. |
[ Text ] |
|
|
Provide details. (Include a description of the action taken against you, who took this action, when you received this action, where you received this action, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you deliberately non-complied with rules or regulations for safeguarding protected information in the past five years? |
|
[] Yes |
[] No |
PREAMBLE:
The following pertains to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment, security, or credentialing decision.
For the purposes of this section:
Advocacy is defined as: Attempting to persuade or incite others to act. It includes, but is not limited to, making calls, distributing flyers, fundraising, posting on social media, etc. with the intent to persuade or incite others to engage in acts or activities.
Terrorism is defined as: Any activity that involves criminal acts dangerous to human life or potentially destructive of critical infrastructure, and appears to be intended to:
• Intimidate or coerce a civilian population; or
• Influence the policy of a government by intimidation or coercion; or
• Affect the conduct of a government by mass destruction, assassination, or kidnapping
Critical infrastructure is defined as: Assets, systems, and networks, whether physical or virtual, are considered so vital to the United States that their incapacitation or destruction would have a debilitating effect on security, national economic security, national public health or safety, or any combination thereof
Have you ever been a member of an organization that, at the time of your membership, was both (i) dedicated to the use of violence or force to overthrow the United States Government or a State or tribal government of the United States, and (ii) engaged in activities to that end? |
|
[] Yes |
[] No |
What is the name of this organization? (Provide the full name without acronyms or abbreviations.) |
[ Text ] |
|
|
Does this organization have a physical address in the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
U.S. State/Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Does this organization have a physical address outside of the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Does this organization have a web page? |
|
[] Yes |
[] No |
What is the web page address? |
[ Text ] |
|
|
When were you a member of this organization?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Why are you still a member of this organization? |
[ Text ] |
|
|
Why did you stop being a member of this organization? |
[ Text ] |
|
|
Did you hold any positions in this organization? |
|
[] Yes |
[] No |
What positions did you hold? |
[ Text ] |
|
|
Did you make any financial contributions to this organization? |
|
[] Yes |
[] No |
How much? (Approximate in U.S. dollars.) |
[ Text ] |
|
|
Were you aware of this organization’s dedication to the use of violence or force to overthrow the United States Government or a State or tribal government of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
Were you a member of the organization with the intent to use violence or force to overthrow the United States Government or a State or tribal government of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
As a member, did you use violence or force with the intent to overthrow the United States Government or a State or tribal government of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
Why did you become a member of this organization? |
[ Text ] |
|
|
What was your role in this organization? (Describe what you did, who you did it for, why you did it, where you did it, if others were involved, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you were a member of an organization that, at the time of your membership, was both (i) dedicated to the use of violence or force to overthrow the United States Government or a State or tribal government of the United States, and (ii) engaged in activities to that end to report? |
|
[] Yes |
[] No |
Have you ever knowingly engaged in activities designed to overthrow the United States Government, or a State or tribal government of the United States, by violence or force? |
|
[] Yes |
[] No |
Why did you knowingly engage in activities designed to overthrow the United States Government, or a State or tribal government of the United States, by violence or force? |
[ Text ] |
|
|
When did you knowingly engage in activities designed to
overthrow the United States Government, or a
State or tribal government of the United States,
by violence or force?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ ] Present [ mm/yyyy ] |
[] Estimated |
|
What activities did you knowingly engage in that were designed to overthrow the United States Government, or a State or tribal government of the United States, by violence or force? (Describe what you did, who you did it for, where you did it, if others were involved, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you knowingly engaged in activities designed to overthrow the United States Government, or a State or tribal government of the United States, by violence or force to report? |
|
[] Yes |
[] No |
Have you ever advocated any acts or activities designed to overthrow the United States Government or a State or tribal government of the United States, by violence or force? |
|
[] Yes |
[] No |
Why did you advocate activities designed to overthrow the United States Government, or a State or tribal government of the United States, by violence or force? |
[ Text ] |
|
|
When did you advocate activities to overthrow the U.S. Government, or a State or tribal government of the United States, by violence or force?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
What activities did you advocate designed to overthrow the United States Government, or a State or tribal government of the United States, by violence or force? (Describe what you did, who you did it for, where you did it, if others were involved, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you advocated activities designed to overthrow the United States Government, or a State or tribal government of the United States, by violence or force to report? |
|
[] Yes |
[] No |
Have you ever been a member of an organization that, at the time of your membership, advocated for acts of force or violence to discourage others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
What is the name of this organization? (Provide the full name without acronyms or abbreviations.) |
[ Text ] |
|
|
Does this organization have a physical address in the United States? |
|
[] Yes |
[] No |
What is the address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
U.S. State/Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Does this organization have a physical address outside of the United States? |
|
[] Yes |
[] No |
What is the address?
Please provide physical address (not mailing address).
|
[ Text ] |
|
|
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Does this organization have a web page? |
|
[] Yes |
[] No |
What is the web page address? |
[ Text ] |
|
|
When were you a member of this organization?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Why are you still a member of this organization? |
[ Text ] |
|
|
Why did you stop being a member of this organization? |
[ Text ] |
|
|
Did you hold any positions in this organization? |
|
[] Yes |
[] No |
What positions did you hold? |
[ Text ] |
|
|
Did you make any financial contributions to this organization? |
|
[] Yes |
[] No |
How much? (Approximate in U.S. dollars.) |
[ Text ] |
|
|
While you were a member, were you aware of the organization’s advocacy of acts of force or violence to discourage or prevent others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
Did you join this organization or engaged in activities as a member with the intent to advocate acts of force or violence to discourage or prevent others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
As a member, did you advocate acts of force or violence to discourage or prevent others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
Why did you become a member of this organization? |
[ Text ] |
|
|
What was your role in this organization? (Describe what you did, who you did it for, why you did it, where you did it, if others were involved, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you were a member of an organization that, at the time of your membership, advocated for acts of force or violence to discourage or prevent others from exercising their rights under the United States Constitution or the constitution of any State of the United States to report? |
|
[] Yes |
[] No |
Have you ever been a member of an organization that at the time of your membership, engaged in acts of force or violence to discourage others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
What is the name of this organization? (Provide the full name without acronyms or abbreviations.) |
[ Text ] |
|
|
Does this organization have a physical address in the United States? |
|
[] Yes |
[] No |
What is the address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
U.S. State/Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Does this organization have a physical address outside of the United States? |
|
[] Yes |
[] No |
What is the address?
Please provide physical address (not mailing address).
|
[ Text ] |
|
|
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Does this organization have a web page? |
|
[] Yes |
[] No |
|
What is the web page address? |
[ Text ] |
|
|
When were you a member of this organization?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Why are you still a member of this organization? |
[ Text ] |
|
|
Why did you stop being a member of this organization? |
[ Text ] |
|
|
Did you hold any positions in this organization? |
|
[] Yes |
[] No |
What positions did you hold? |
[ Text ] |
|
|
Did you make any financial contributions to this organization? |
|
[] Yes |
|
[] No |
How much? (Approximate in U.S. dollars.) |
[ Text ] |
|
|
At the time of your membership, were you aware the organization engaged in acts of force or violence to discourage others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
Did you join the organization or engage in activities as a member with the intent to engage in acts of force or violence to discourage others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
As a member, did you engage in acts of force or violence to discourage or prevent others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
|
Why did you become a member of this organization? |
[ Text ] |
|
|
What was your role in this organization? (Describe what you did, who you did it for, why you did it, where you did it, if others were involved, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you were a member of an organization that, at the time of your membership, engaged in acts of force or violence to discourage others from exercising their rights under the United States Constitution or the constitution of any State of the United States? |
|
[] Yes |
[] No |
Are you now or have you ever been a member of an organization that, at the time of your membership, used unlawful force or violence? |
|
[] Yes |
[] No |
What is the name of this organization? (Provide the full name without acronyms or abbreviations.) |
[ Text ] |
|
|
Does this organization have a physical address in the United States? |
|
[] Yes |
[] No |
What is the address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
U.S. State/Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Does this organization have a physical address outside of the United States? |
|
[] Yes |
[] No |
What is the address?
Please provide physical address (not mailing address).
|
[ Text ] |
|
|
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Does this organization have a web page? |
|
[] Yes |
[] No |
What is the web page address? |
[ Text ] |
|
|
When were you a member of this organization?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Why are you still a member of this organization? |
[ Text ] |
|
|
Why did you stop being a member of this organization? |
[ Text ] |
|
|
|
Did you hold any positions in this organization? |
|
[] Yes |
[] No |
What positions did you hold? |
[ Text ] |
|
|
Did you make any financial contributions to this organization? |
|
[] Yes |
[] No |
How much? (Approximate in U.S. dollars.) |
[ Text ] |
|
|
As a member, did you use unlawful force or violence? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
|
Why did you become a member of this organization? |
[ Text ] |
|
|
What was your role in this organization? (Describe what you did, who you did it for, why you did it, where you did it, if others were involved, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you were a member of an organization that, at the time of your membership, used unlawful force or violence? |
|
[] Yes |
[] No |
Have you ever planned, contributed to, attempted, or carried out an unlawful act of force or violence targeted at a person, group of people, or property? If yes, explain (complete the additional details section), including: |
|
[] Yes |
[] No |
Was the target an individual or individuals based on their race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability or genetic information? |
|
[] Yes |
[] No |
Why did you target this individual or individuals? |
[ Text ] |
|
|
When did you target this individual or individuals?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[mm/yyyy ] |
[] Estimated |
[]Present |
What did you do? (Describe how you planned, contributed to, attempted, or carried out this unlawful act of force or violence; who you did it for; where you did it; if others were involved; and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you targeted an individual or individuals based on their race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability or genetic information? |
|
[] Yes |
[] No |
Was the target an official of the United States Government or the government of a State, local, or tribal government of the United States? |
|
[] Yes |
[] No |
Why did you target this government official? |
[ Text ] |
|
|
When did you target this government official?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[mm/yyyy ] |
[] Estimated |
[] Present |
What did you do? (Describe how you planned, contributed to, attempted, or carried out this unlawful act of force or violence; who you did it for; where you did it; if others were involved; and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you targeted an official of the United States Government or the Government of a State, local, or tribal government of the United States? |
|
[] Yes |
[] No |
Was the target property of the United States Government or the government of a State, local or tribal government of the United States? |
|
[] Yes |
[] No |
Was this property critical infrastructure? |
|
[] Yes |
[] No |
Why did you target this property? |
[ Text ] |
|
|
When did you target this property?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
What did you do? (Describe how you planned, contributed to, attempted, or caried out this unlaw act of force or violence; who you did it for; where you did it; if others were involved; and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you targeted property of the United States Government or the Government of a State, local or tribal government of the United States? |
|
[] Yes |
[] No |
Was the targeted property critical infrastructure? (Answer "No" if you listed in the question above.) |
|
[] Yes |
[] No |
Why did you target this critical infrastructure? |
[ Text ] |
|
|
When did you target this critical infrastructure?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
What did you do? (Describe how you planned, contributed to, attempted, or caried out this unlaw act of force or violence; who you did it for; where you did it; if others were involved; and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you targeted critical infrastructure? |
|
[] Yes |
[] No |
Have you ever advocated unlawful acts of violence against individuals based on their race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, or genetic information? |
|
[] Yes |
[] No |
Why did you advocate unlawful acts of violence against this individual or individuals? |
[ Text ] |
|
|
When did you advocate unlawful acts of violence against this individual or individuals?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
What did you do? (Describe what you did, who you did it for, where you did it, if others were involved, and any other details.) |
[ Text ] |
|
|
Do you have another instance in which you advocated unlawful acts of violence against an individual or individuals based on their race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability or genetic information? |
|
[] Yes |
[] No |
Are you now or have you ever been a member of an organization dedicated to domestic or international terrorism? |
|
[] Yes |
[] No |
What is the name of this organization? (Provide the full name without acronyms or abbreviations.) |
[ Text ] |
|
|
Does this organization have a physical address in the U.S.? |
|
[] Yes |
[] No |
What is the address?
Street |
[ Text ] |
|
|
City |
[ Text ] |
|
|
U.S. State/Territory |
[ Dropdown ] |
|
|
ZIP Code |
[ Text ] |
|
|
Does this organization have a physical address outside of the U.S.? |
|
[] Yes |
[] No |
|
What is the address?
Please provide physical address (not mailing address).
|
[ Text ] |
|
|
City |
[ Text ] |
|
|
Country |
[ Dropdown ] |
|
|
Does this organization have a web page? |
|
[] Yes |
[] No |
What is the web page address? |
[ Text ] |
|
|
When were you a member of this organization?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Why are you still a member of this organization? |
[ Text ] |
|
|
Why did you stop being a member of this organization? |
[ Text ] |
|
|
Did you hold any positions in this organization? |
|
[] Yes |
[] No |
What positions did you hold? |
[ Text ] |
|
|
Did you make any financial contributions to this organization? |
|
[] Yes |
[] No |
How much? (Approximate in U.S. dollars.) |
[ Text ] |
|
|
At the time you were a member, were you aware of the organization’s dedication to domestic or international terrorism? |
|
[] Yes |
[] No |
Please explain. |
[ Text ] |
|
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Were you a member of this organization or engage in activities as a member with the intent to further acts of domestic or international terrorism? |
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[] Yes |
[] No |
Please explain. |
[ Text ] |
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Did you intentionally engage in acts of domestic or international terrorism? |
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[] Yes |
[] No |
Please explain. |
[ Text ] |
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Why did you become a member of this organization? |
[ Text ] |
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What was your role in this organization? (Describe what you did, who you did it for, why you did it, where you did it, if others were involved, and any other details.) |
[ Text ] |
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Do you have another instance in which you were a member of an organization that, at the time of your membership, was dedicated to domestic or international terrorism? |
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[] Yes |
[] No |
Have you ever knowingly engaged in any acts of domestic or international terrorism? |
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[] Yes |
[] No |
What acts of domestic or international terrorism did you engage in? (Describe what you did, who you did it for, why you did it, where you did it, and any other details.) |
[ Text ] |
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Why did you engage in these activities of domestic or international terrorism? |
[ Text ] |
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When did you engage in these activities of domestic or international terrorism?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
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To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Do you have another instance in which you engaged in acts of domestic or international terrorism? |
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[] Yes |
[] No |
Have you ever knowingly associated with anyone involved in activities to further domestic or international terrorism? |
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[] Yes |
[] No |
When did you associate with this individual?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
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To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Why do you still associate with this individual? |
[ Text ] |
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Why did you stop associating with this individual? |
[ Text ] |
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What is or was your relationship with this individual? (Describe how you met, how often you are or were in contact, what activities you did together, whether this individual has any leverage over you, and any other details.) |
[ Text ] |
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Do you have another instance in which you knowingly associated with an individual involved in activities to further domestic or international terrorism? |
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[] Yes |
[] No |
Have you ever advocated any acts of domestic or international terrorism? |
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[] Yes |
[] No |
What acts of domestic or international terrorism did you advocate? (Describe what you did, who you did it for, why you did it, where you did it, and any other details.) |
[ Text ] |
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Why did you advocate these activities of domestic or international terrorism? |
[ Text ] |
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When did you advocate these activities of domestic or international terrorism?
From (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
|
To (Month/Year) |
[ mm/yyyy ] |
[] Estimated |
[] Present |
Do you have another instance in which you advocated acts of domestic or international terrorism? |
[ Text ] |
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2023-07-29 |