In today's security-conscious environment, completing the Electronic Personnel Security Questionnaire, commonly known as the SF86, is a crucial step for individuals looking to secure positions that require a certain level of trust and confidentiality within the United States. Updated periodically to reflect the evolving nature of security clearance processes, the version revised as of July 13, 2005, serves as a comprehensive guide for applicants. This intricate form, accessible through the Electronic Questionnaires for Investigations Processing (e-QIP) system, is not a mere formality but a detailed check list ensuring that the federal government has all the necessary information to conduct a thorough background check. The SF86 Worksheet advises applicants to indicate 'Unknown' only when certain details, such as names, are irrevocably unattainable, emphasizing the importance of accuracy and completeness in the disclosure of personal information, citizenship status, and residence history, among other things. Applicants must painstakingly trace their past residences, citizenship details, and any changes in personal information over a decade, underscoring the meticulous nature of the security clearance process. Speaking volumes to the thoroughness required in safeguarding national security, this document underlines the critical balance between individual privacy and collective safety.
| Question | Answer |
|---|---|
| Form Name | Electronic Personnel Questionnaire Form |
| Form Length | 34 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 8 min 30 sec |
| Other names | epsq sf 86, security questionnaire sf86 worksheet, electronic personnel security questionnaire, how to epsq sf86 |
Updated 09/24/2002
Revised 07/13/2005
ELECTRONIC PERSONNEL
SECURITY QUESTIONNAIRE
SF86 WORKSHEET
This document is meant to be a detailed “Check List” in preparation for completing the SF86 on the Electronic Questionnaires for Investigations Processing
Keep the following in mind when completing the SF86:
•Indicate Unk (Unknown) if names are ABSOLUTELY irretrievable.
Module 1: PERSONAL INFORMATION
Name: First: ______________________ Middle: _______________ Last: _____________________
Suffix (i.e.: II, III, or Jr.)*: _________________ SSN: __________________________
Birth Date: ________________________ (YYYY/MM/DD)
City/State of Birth: _____________________________________ |
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County of Birth *: __________________________ |
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Country of Birth: __________________________ |
Gender: Male |
Female |
Maiden name (if applicable): First: ________________ Middle: __________ Last: ________________
Work Phone: |
__________________________ Day / Evening (CIRCLE ONE). |
Home Phone: |
__________________________ Day / Evening (CIRCLE ONE). |
Height: |
______________ (Feet/Inches: e.g., 5/11) |
Weight: |
_____________ (Pounds) |
Hair color: |
_______________________ |
Eye color: |
_______________________ |
Module 2: OTHER NAMES USED
Have you ever used another name: (Y / N)
If yes, FROM: _________________ To: _________________ (YYYY/MM/DD)
Name Used (Include first, middle, and last names):
_________________________________________________
Module 3: CITIZENSHIP
What is your current citizenship status? (SELECT ONE): (1) US Citizen (2) Not a US Citizen
*Can be left blank
Follow Path (1) or (2) depending on your answer. Answer questions and follow arrows/directions as appropriate.
(1)US Citizen (You were either: born in the USA; born in a US Territory/Possession; Born Abroad of US Parents; or Naturalized)
Enter Mother’s Maiden Name: _________________________________________________
FirstMiddle Last
Were you born in the US (US Citizen) or in a US Territory/Possession (US National)? (Y / N) If No, follow arrow to the next question…
If Yes, answer the following:
Are you now or were you a dual citizen of the US and another county? If No, Proceed to Module 4, Residences
If Yes, answer the following:
Enter the name of the country where you hold/held dual citizenship in addition to the United States: ______________________. Go to Module 4, Residences
Where you born abroad of US parents? (Y / N)
If No, you have either a Naturalization or Citizenship Certificate. Follow arrow… If Yes, answer the following:
Citizenship Certificate Number: ______________________
Issue Date: ___________________ (If none, enter Form 240 Date)
City: ________________________ (If none, enter N/A)
State: ________________________ (If none, enter DC)
State Dept. Form 240 Date: __________________________ (YYYY/MM/DD)
Proceed to question immediately below (US passport)…
Do you currently hold or did you previously hold a US passport? (Y / N)
If No, follow arrow to the next question…
If Yes, answer the following:
Passport Number: ________________________
Passport Issue Date: ______________________ (YYYY/MM/DD)
Proceed to question directly below (Dual Citizenship)…
Are you now or were you a dual citizen of the US and another county? (Y / N)
If No, proceed to Module 4, Residences
If Yes, answer the following:
Enter the name of the country where you hold/held dual citizenship in addition to the United States: ______________________________.
Go to Module 4, Residences
Provide the following information:
Naturalization or Citizenship Certificate Number: ___________________
* Can be left blank |
2 |
Module 3: CITIZENSHIP (cont.)
Issue Date: ______________________________ (YYYY/MM/DD)
City: ___________________________________
State: ___________________________________
Court Name: _____________________________ (If none, enter N/A)
Proceed to question immediately below (U.S. passport)…
Do you currently hold or did you previously hold an U.S. passport? (Y / N)
If No, follow arrow to the next question…
If Yes, answer the following:
Passport Number: ________________________
Passport Issue Date: ______________________ (YYYY/MM/DD)
Proceed to question directly below (Dual Citizenship)…
Are you now or were you a dual citizen of the U.S. and another county? (Y / N)
If No, proceed to Module 4, Residences.
If Yes, answer the following:
Enter the name of the country where you hold/held dual citizenship in addition to the United States: ______________________________.
Go to Module 4, Residences.
(2)Not a U.S. Citizen (You were born outside the USA and do NOT have U.S. citizenship)
Enter Mother’s Maiden Name: _________________________________________________
FirstMiddle Last
Answer the following:
Alien Registration Number: ______________________
Date Entered U.S.: ___________________
City: ________________________
State: ________________________
Country of Citizenship: ______________________________
Module 4: WHERE YOU HAVE LIVED
•Note: Provide 10 years of residence info. If the residence is over 5 years old, do NOT include a “Person who knew you at this address”. The references should not be a spouse, former spouse, or other relative.
(1)Where have you lived? (Start with your PRESENT location).
FROM: _____________ TO: PRESENT (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
* Can be left blank |
3 |
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Person who knew you at this address: (Include first, middle, and last names): _____________________________
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: __________________________________________________
(2) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Complete only if residence was within the last five years): Person who knew you at this address
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: __________________________________________________
* Can be left blank |
4 |
(3) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Complete only if residence was within the last five years): Person who knew you at this address
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: __________________________________________________
(4) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Complete only if residence was within the last five years): Person who knew you at this address
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
* Can be left blank |
5 |
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: ________________________________________________________________
(5) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Complete only if residence was within the last five years): Person who knew you at this address
______________________________
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: _______________________________________________________
(6) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
* Can be left blank |
6 |
(Complete only if residence was within the last five years): Person who knew you at this address
______________________________
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: _______________________________________________________
(7) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Complete only if residence was within the last five years): Person who knew you at this address
______________________________
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: _______________________________________________________
(8) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
* Can be left blank |
7 |
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Complete only if residence was within the last five years): Person who knew you at this address
______________________________
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: _______________________________________________________
(9) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Complete only if residence was within the last five years): Person who knew you at this address
______________________________
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
* Can be left blank |
8 |
Telephone Number: _______________________________________________________
(10) Your NEXT ADDRESS:
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the residence hard to find? (Y / N) If yes…
Explain: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
(Complete only if residence was within the last five years): Person who knew you at this address
______________________________
FROM: _____________ TO: ______________ (YYYY/MM/DD)
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Telephone Number: _______________________________________________________
Module 5: WHERE YOU WENT TO SCHOOL
Option 1: Did you attend school, beyond Jr. High, within the last 5 years? (Y / N)
If “NO,” go to Option 2, below…
If “YES,” answer the following…
FROM: _______________________ To: ______________________
Type of education? (Pick One)
1.High School
2.College/University/Military College
3.Vocational/Technical/Trade
School Name: _________________________________________________
Degree/Diploma/Other: __________________________________________
* Can be left blank |
9 |
Award Date: ___________________________________________________
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Person who knew you at above school (ONLY if the education occurred w/in the last 3 years). The reference
should not be a spouse, former spouse, or other relative.
Full Name (Include first, middle, and last names): __________________________________________________
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Phone: _______________________________________________________________________
Option 2: If you answered “no” to Option 1 above, review the following…
Have you attended school beyond high school? (Y / N)
•Note: If all education occurred more than 5 years, list most recent beyond high school, regardless of date.
If Yes, answer the following…
FROM: _______________________ To: ______________________
Type of Education? (Pick One)
1.College/University/Military College
2.Vocational/Technical/Trade
School Name: _________________________________________________
Degree/Diploma/other: __________________________________________
Award Date: ___________________________________________________
ADDRESS LINE 1: ________________________________________________________________
ADDRESS LINE 2*: _______________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
* Can be left blank |
10 |
Module 6: YOUR EMPLOYMENT ACTIVITIES
(Provide 10 years of employment info. You should list all
(1)Your CURRENT EMPLOYMENT:
FROM: ______________________ To: PRESENT (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
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2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
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3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
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|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
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BRANCH: (If Military): |
____________________________________________ |
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EMPLOYER NAME: |
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Global Technical Services Employer Phone: |
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Your position/title: ______________________________ |
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Employer’s ADDRESS LINE 1: 4000 Sandshell Drive |
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Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): Fort Worth, TX 76137 USA
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (No). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
* Can be left blank |
11 |
(2)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
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|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
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BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
(3)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
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|
|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
|
|
* Can be left blank |
12 |
BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
(4)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
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|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
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|
BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
* Can be left blank |
13 |
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
(5)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
|
|
|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
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|
BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
* Can be left blank |
14 |
(6)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
|
|
|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
|
|
BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
(7)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
|
|
|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
|
|
* Can be left blank |
15 |
BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
(8)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
|
|
|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
|
|
BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
* Can be left blank |
16 |
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
(9)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
|
|
|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
|
|
BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
* Can be left blank |
17 |
(10)Your PREVIOUS EMPLOYMENT:
FROM: _____________ TO: ____________ (YYYY/MM/DD)
TYPE OF EMPLOYMENT (Select one):
1. |
Active Military Duty Station |
6. |
|
|
|
|
|
2. |
National Guard/Reserve |
7. Unemployment (SEE FAQ SHEET) |
|
3. |
U.S.P.H.S. Commissioned Corps |
8. Federal Contractor |
|
|
|
|
|
4. |
Other Federal Employment |
9. |
Other |
5. |
State Government |
|
|
BRANCH: (If Military): ____________________________________________
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the work site address different from the employer address? (Yes). If yes…
SITE ADDRESS LINE 1: ___________________________________________________________
SITE ADDRESS LINE 2*: __________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Module 6: (Employment cont.) Were you in federal civil service prior to the last 10 years? (Y/N)
•Note: Enter all Federal Employment prior to the last 10 years (Do NOT list if already reported above!).
FROM: _____________ TO: ____________ (YYYY/MM/DD)
EMPLOYER NAME: _________________________ Employer Phone: ___________________
Your position/title: ______________________________
JOB ADDRESS LINE 1: ____________________________________________________________
JOB ADDRESS LINE 2*: ___________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
* Can be left blank |
18 |
Supervisor’s full name (Include first, middle, and last names): ________________________________________
Supervisor’s phone: ______________________
Is the employer’s address different from the job location address? (Y / N). If yes…
Employer’s ADDRESS LINE 1: ______________________________________________________
Employer’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ________________________________________________
Is the supervisor’s address different from the job location address? (Y / N). If yes…
Supervisor’s ADDRESS LINE 1: _____________________________________________________
Supervisor’s ADDRESS LINE 2*: _____________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
Module 7: PEOPLE WHO KNOW YOU WELL
•Note: Provide three people living in the USA who know you well. The references should not be a spouse, former spouse, or other relative. Try not to list someone listed elsewhere on your form. The reference’s combined association with you must cover the last SEVEN yearS OF COMBINED ASSOCIATION.
(1)FROM: ________________ TO: ___________________ (YYYY/MM/DD)
Name: First: ___________________ Middle: _________ Last: ____________________________
Address (Home or Work?): ______________________________________________________________
City/State/ZIP: ____________________________________________________________________
Phone: ______________________________________ Day / Evening (circle one).
(2)FROM: ________________ TO: ___________________ (YYYY/MM/DD)
Name: First: ___________________ Middle: _________ Last: ____________________________
Address (Home or Work?): ______________________________________________________________
City/State/ZIP: ____________________________________________________________________
Phone: ______________________________________ Day / Evening (circle one).
(3)FROM: ________________ TO: ___________________ (YYYY/MM/DD)
Name: First: ___________________ Middle: _________ Last: ____________________________
Address (Home or Work?): ______________________________________________________________
City/State/ZIP: ____________________________________________________________________
Phone: ______________________________________ Day / Evening (circle one).
* Can be left blank |
19 |
Module 8: YOUR SPOUSE (Current Marriage or Widowed)
•Note: If divorced, complete the section under “YOUR FORMER SPOUSE (Divorced),” below.
Current Marital status (circle one):
1) |
Never married (Go to Mod 9) |
4) |
Legally separated |
2) |
Married |
5) |
Widowed |
3) |
Separated |
|
|
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth date: ____________ (YYYY/MM/DD)
City/State of Birth: _____________________________________________________
Country of Birth: ______________________________________________________
SSN (if none, write “none”): _________________________________
Maiden Name (Include first, middle, and last names, if applicable): _______________________________________
Date of Marriage: _____________ Place of Marriage: _________________________________
(YYYY/MM/DD)(City, State/Country)
Address (Not applicable if same as yours or if spouse is deceased): _________________________________________
_________________________________________________________________________________
Other Names Used By Spouse (Include first, middle, and last names, if applicable): ____________________________
Spouse’s Citizenship: _________________________
ANSWER ONLY IF APPLICABLE:
Alien # / Naturalization #: _______________________________________________________
If separated, date of separation? ________________ (YYYY/MM/DD)
City/State/Country where Separation Records are located: ____________________________________
________________________________________________________________________________
Is the above individual deceased? (Y / N) If yes, Widowed Date: ____________ (YYYY/MM/DD)
Module 8: YOUR FORMER SPOUSE (Divorced)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth date: ______________ (YYYY/MM/DD)
City/State of Birth: _____________________________________________________
Country of Birth: ______________________________________________________
Date of Marriage: _____________ Place of Marriage: _________________________________
(YYYY/MM/DD) |
(City, State/Country) |
* Can be left blank |
20 |
Divorce Date: _____________ (YYYY/MM/DD)
City/State/Country of Divorce: _______________________________________________________
Former Spouse’s Address/Phone # (Omit if former spouse is deceased): ________________________________
_________________________________________________________________________________
Former Spouse’s Citizenship: _________________________
Other marriages? Use the Continuation Space at the end of this worksheet.
Module 9: YOUR RELATIVES AND ASSOCIATES
Entry List Options:
1. |
Mother |
8. |
Brother |
15. |
|
2. |
Father |
9. |
Sister |
16. |
Guardian |
3. |
Stepmother |
10. |
Stepbrother |
17. |
Other Relative1 |
4. |
Stepfather |
11. |
Stepsister |
18. |
Associate2 |
5. |
Foster parent |
12. |
19. |
Adult Currently Living With You |
|
6. |
Child (including adopted) |
13. |
|
|
|
7. |
Stepchild |
14. |
|
|
1)Include only foreign national relatives not listed in
2)Include only foreign national associates with whom you or your spouse are bound by affection, obligation or close and continuing contact.
(1)RELATIONSHIP: Mother - Mandatory Entry (If you were adopted, you should list your adoptive mother. If you do not know who your biological parents are, you may enter “UNK” in the first name and omit the remaining data. Using “UNK” is applicable for other relatives on the SF86.)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if your mother is living, was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
ΩIf your mother was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.
* Can be left blank |
21 |
(2)RELATIONSHIP: Father - Mandatory Entry (If you were adopted, you should list your adoptive father. If you do not know who your biological parents are, you may enter “UNK” in the first name and omit the remaining data. Using “UNK” is applicable for other relatives on the SF86.)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if your father is living, was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
(3) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
ΩIf this relative was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.
* Can be left blank |
22 |
(4) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
(5) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
ΩIf this relative was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.
* Can be left blank |
23 |
(6) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
(7) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
ΩIf this relative was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.
* Can be left blank |
24 |
(8) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
(9) RELATIONSHIP: ________________ (Select from Relative/Associate Entry List above)
Current Name: ________________________________________________________________
First Middle Lastsuffix*
Birth Date: __________________ Country of Birth: ____________________________
(YYYY/MM/DD)
Address Line 1 (Leave blank if unknown or individual is deceased): _______________________________________
Address Line 2*: _________________________________________________________________
CITY/STATE/COUNTRY/ZIP (or FPC): ______________________________________________________________
CitizenshipΩ: _______________________
The following proof of citizenship will be required in Module 10 of the SF86 (Citizenship of Your Relatives and Associates) ONLY if the living relative was born outside the USA, and is currently living in the USA. If applicable, select one document type and provide the required information:
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
State |
1) |
Naturalization Certificate |
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
ΩIf this relative was born abroad of U.S. parents, provide date of State Department Form 240 and any remarks under item #4 Other, above.
* Can be left blank |
25 |
Module 10: CITIZENSHIP OF YOUR RELATIVES AND ASSOCIATES
If you currently have a
Current Name: ________________________________________________________________
|
First |
Middle |
Last |
|
suffix* |
||
|
Birth Date: __________________ (YYYY/MM/DD) |
|
|
|
|
||
|
|
|
|
|
|
|
|
|
Citizenship Document |
Certif./Regist. # |
Issue Date |
Court Name |
City |
|
State |
1) |
Naturalization Certificate |
|
|
|
|
|
|
2) |
Citizenship Certificate |
|
|
N/A |
|
|
|
3) |
Alien Registration |
|
N/A |
N/A |
|
|
|
|
|
|
|
|
|
|
|
4) |
Other (Explain) |
|
|
|
|
|
|
Module 11: YOUR MILITARY HISTORY
Have you ever been in the military? (Y / N) If yes...
List all of your military service below, including service in the Reserve, National Guard, U.S. Merchant Marine and Foreign Military Service. Start with the most recent period of service and work backward. If you had a break in service, each separate period should be listed. Please include a copy(s) of your DD214 with this questionnaire.
FROM: ________________ TO: _______________ |
Branch of Service: _____________________ |
Country: ___________________ (Foreign Service) |
Grade: ________(Current or one held at end of svc. - |
|
Merchant Marine list a 3 char grade) |
Status: ___________________ (Active, Active Reserve, Inactive)
State: ______________ (For National Guard) Service Number: _________________ (i.e. SSN)
Module 12: YOUR FOREIGN ACTIVITIES - PROPERTY
Do you have any foreign property, business connections, or financial interests? (Y / N) If yes… FROM: __________________ TO: _________________ (YYYY/MM/DD)
FIRM NAME/COUNTRY: ____________________________________________
REMARKS: ______________________________________________________________________
_________________________________________________________________________________
Module 13: YOUR FOREIGN ACTIVITIES - EMPLOYMENT
Are you now or have you ever been employed by or acted as a consultant for a foreign government, firm or agency? (Y / N) If yes…
FROM: _____________________ TO: ___________________ (YYYY/MM/DD)
Firm and/or Government/ Country: ____________________________________________________
* Can be left blank |
26 |
REMARKS: ______________________________________________________________________
_________________________________________________________________________________
Module 14: YOUR FOREIGN ACTIVITIES - CONTACT WITH FOREIGN GOVERNMENT
Have you ever had any conduct with a foreign government, its establishments (embassies or consulates), or it’s representatives, whether inside or outside the U.S., other than on official U.S. Government business? (Does not include routine visa applications and border crossing contacts.) (Y / N) If yes…
FROM: _____________________ TO: _________________ (YYYY/MM/DD)
Firm and/or Government/ Country: ____________________________________________________
REMARKS: ______________________________________________________________________
_________________________________________________________________________________
Module 15: YOUR FOREIGN ACTIVITIES - PASSPORT
In the last 7 years, have you had an active passport that was issued by a foreign government? If yes…
Issue Date: __________________ (YYYY/MM/DD) Expiration Date: ________________ (YYYY/MM/DD)
Issuing Country: __________________________________
REMARKS: ______________________________________________________________________
_________________________________________________________________________________
Module 16: FOREIGN COUNTRIES YOU HAVE VISITED
Have you traveled outside the United States on other than official U.S. Government orders in the last 7 years? (Travel as a dependent or contractor must be listed.) Do not repeat travel covered in
modules 4, 5, and 6. If yes…
FROM: _______________ TO: _________________ (YYYY/MM/DD)
Purpose of Visit (Select One): Pleasure, Education, Business or Other
Country visited: ____________________
Other countries visited during this trip? (If Yes, indicate Purpose and Country Visited): __________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Additional Entries? Use the Continuation Space at the end of this worksheet.
* Can be left blank |
27 |
Module 17: YOUR MILITARY RECORD
Have you ever received other than an honorable discharge from the military? (Y / N) If yes…
Discharge Date:
Type of |
1. |
Bad Conduct |
4. |
Entry Level Separation |
|
Discharge |
2. |
Dishonorable |
5. |
General |
|
(Select One): |
|
|
|
|
|
3. |
Dismissal |
6. |
Other (Please specify): |
||
|
Module 18: YOUR SELECTIVE SERVICE RECORD
If you are a male born after December 31, 1959, enter your Selective Service Registration Number: _______________________. (For Info. CALL
If you have not registered with the Selective Service System, provide reason for legal exemption:
________________________________________________________________________________
________________________________________________________________________________
Module 19: YOUR MEDICAL RECORD
In the last 7 years, have you consulted a mental health professional (psychiatrist, psychologist, counselor, etc.) or have you consulted with another health care provider about a mental health related condition? (Y / N) If No, proceed to Module 20. If Yes, answer the following…
Did the mental health related consultation (s) involve only marital, family, or grief counseling not related to violence by you? (Y / N) If Yes, proceed to Module 20. If No, answer the following…
Provide the following information about the Therapist/Doctor:
Name: (First) ___________________ Middle: _________ Last: ____________________________
Address: _________________________________________________________________________
City/State/Country/ZIP: _____________________________________________________________
Dates of Care: FROM: ________________ TO: ___________________ (YYYY/MM/DD)
Other consultations? Use the Continuation Space at the end of this worksheet.
Module 20: YOUR EMPLOYMENT RECORD
Has any of the following happened to you in the last 10 years? (Y / N)
1.Fired from a job
2.Quit a job after being told you’d been fired
3.Left a job by mutual agreement following allegations of misconduct
4.Left a job by mutual agreement following allegations of unsatisfactory performance
5.Left a job for other reasons under unfavorable circumstances
If Yes, Provide: Employer(s) Name(s): ________________________________________________
* Can be left blank |
28 |
Date(s) of Employment(s): FROM: _________________ TO: __________________ (YYYY/MM/DD)
Type of Termination (select from list above): _____________________________________________
_______________________________________________________________________________
Module 21: YOUR POLICE RECORD - FELONY OFFENSES
Have you ever been charged with or convicted of any felony offense? ⊗ (Y / N) If Yes, provide the following:
Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________
Action: ___________________________ Authority/Court: _______________________________
City/State/Zip: ______________________________________ Country: ______________________
Module 22: YOUR POLICE RECORD - FIREARMS/EXPLOSIVES OFFENSES
Have you ever been charged with or convicted of a firearms or explosives offense?⊗ (Y / N) If Yes, provide the following:
Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________
Action: ___________________________ Authority/Court: _______________________________
City/State/Zip: ______________________________________ Country: ______________________
Module 23: YOUR POLICE RECORD - PENDING CHARGES
Are there currently any charges pending against you for any offense?⊗ (Y / N) If Yes, provide the following:
Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________
Action: ___________________________ Authority/Court: _______________________________
City/State/Zip: ______________________________________ Country: ______________________
Module 24: YOUR POLICE RECORD - ALCOHOL/DRUG OFFENSES
Have you ever been charged with or convicted of any offense(s) to alcohol or drugs? ⊗ (Y / N) If Yes, provide the following:
Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________
Action: ___________________________ Authority/Court: _______________________________
City/State/Zip: ______________________________________ Country: ______________________
⊗For these items, report information regardless of whether the record in your case has been "sealed" or otherwise stricken from the record. The single exception to this requirement is for certain 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. 360.
* Can be left blank |
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Module 25: YOUR POLICE RECORD - MILITARY COURT
In the last 7 years, have you been subject to court martial or other disciplinary proceedings under the Uniform Code of Military Justice? (Include
Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________
Action: ___________________________ Authority/Court: _______________________________
City/State/Zip: ______________________________________ Country: ______________________
Module 26: YOUR POLICE RECORD - OTHER OFFENSES
In the last 7 years, have you been arrested for, charged with, or convicted of any offense(s) not listed in modules 21, 22, 23, 24, or 25? (Leave out traffic fines of less than $150.00 unless the violation was alcohol or drug related.) ⊗ (Y / N) If Yes, provide the following:
Offense Date: ____________ (YYYY/MM/DD) Nature of Offense: _____________________________
Action: ___________________________ Authority/Court: _______________________________
City/State/Zip: ______________________________________ Country: ______________________
Module 27: YOUR USE OF ILLEGAL DRUGS AND DRUG ACTIVITY - ILLEGAL USE OF DRUGS
Since the age of 16 or in the last 7 years, which ever is shorter, have you illegally used any controlled substance, for example, marijuana, cocaine, crack cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), amphetamines, depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSC, PCP, etc.), or prescription drugs? (Y / N)
the following:
Controlled Substance/Prescription Drug Used: __________________________________________
From: ______________________ To: ______________________ (YYYY/MM/DD)
Number of Times Used: ____________________________________________________________
Module 28: YOUR USE OF ILLEGAL DRUGS AND DRUG ACTIVITY - USE IN SENSITIVE POSITION
Have you ever illegally used a controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official; while possessing a security clearance; or while in a position directly and immediately affecting public safety? (Y / N) If Yes, provide the following:
Controlled Substance/Prescription Drug Used: __________________________________________
From: ______________________ To: ______________________ (YYYY/MM/DD)
Number of Times Used: ____________________________________________________________
⊗For these items, report information regardless of whether the record in your case has been "sealed" or otherwise stricken from the record. The single exception to this requirement is for certain 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. 360. |
(Page30) |
Module 29: YOUR USE OF ILLEGAL DRUGS AND DRUG ACTIVITY - DRUG ACTIVITY
In the last 7 years, have you been involved in the illegal purchase, manufacture, trafficking, production, transfer, shipping, receiving, or sale of any narcotic, depressant, stimulant, hallucinogen, or cannabis, for your own intended profit or that of another? (Y / N) If Yes, no further information is required.
Module 30: YOUR USE OF ALCOHOL
In the last 7 years has your use of alcoholic beverages (such as liquor, beer, wine) resulted in any
From: ______________________ To: ______________________ (YYYY/MM/DD)
Counselor/Doctor Name:
First: ________________________ Middle: ______________ Last: _________________________
Address: _________________________________________________________________________
City/State/Country/ZIP: _____________________________________________________________
Module 31: YOUR INVESTIGATION RECORD - INVESTIGATIONS/CLEARANCES GRANTED
Has the United States Government ever investigated your background and or granted you a security clearance?
Date Granted: |
|
(YYYY/MM/DD) |
|
|
|
Investigating Agency (SELECT ONE): |
Clearance (SELECT ONE): |
||||
1) |
Defense Department |
0) |
Not Required |
6) |
L |
2) |
State Department |
1) |
Confidential |
7) |
Other: |
3) |
Office of Personnel Management |
2) |
Secret |
|
|
4) |
FBI |
3) |
Top Secret |
|
|
5) |
Treasury Department |
4) |
Sensitive Compartmented Information |
||
6) |
Other: |
5) |
Q |
|
|
Module 32: YOUR INVESTIGATION RECORD - CLEARANCE ACTIONS
To your knowledge, have you ever had a clearance or access authorization denied, suspended, or revoked or have you ever been debarred from government employment? (Note: An administrative downgrade or termination of a security clearance is not a revocation.) (Y / N) If Yes, provide the following:
Action Date: ______________ (YYYY/MM/DD)
Agency/Dept. Taking Action: _____________________________________
* Can be left blank |
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Module 33: YOUR FINANCIAL RECORD - BANKRUPTCY
In the last 7 years, have you filed a petition under any chapter of the bankruptcy code (to include Chapter 13)? (Y / N) If Yes, provide the following:
File Date: ______________ Name Action Occurred Under: ________________________________
Amount: _____________ Court Name: _______________________________________________
City/State/Zip: ____________________________________________________________________
Module 34: YOUR FINANCIAL RECORD - WAGE GARNISHMENTS
In the last 7 years, have you had your wages garnished for any reason? (Y / N) If Yes, provide the following:
Execution Date: ___________ Name Action Occurred Under: ______________________________
Amount: _____________ Court/Agency Name: ________________________________________
Address/City/State/Zip: _____________________________________________________________
Module 35: YOUR FINANCIAL RECORD - REPOSSESSIONS
In the last 7 years, have you had any property repossessed for any reason? (Y / N) If Yes, provide the following:
Repossession Date: ___________ Name Action Occurred Under: ___________________________
Amount: _____________ Agency Name: _____________________________________________
Address/City/State/Zip: _____________________________________________________________
Module 36: YOUR FINANCIAL RECORD - TAX LIEN
In the last 7 years, have you had a lien placed against your property for failing to pay taxes and other debts? (Y / N) If Yes, provide the following:
Lien Date: _____________ Name Action Occurred Under: ________________________________
Amount: _____________ Court/Agency Name: ________________________________________
City/State/Zip: ____________________________________________________________________
Module 37: YOUR FINANCIAL RECORD - UNPAID JUDGEMENTS
In the last 7 years, have you had any judgments against you that have not been paid? (Y / N) If Yes, provide the following:
Judgment Date: __________ Name Action Occurred Under: _______________________________
Amount: _____________ Court Name: _______________________________________________
* Can be left blank |
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City/State/Zip: ____________________________________________________________________
Module 38: YOUR FINANCIAL DELINQUENCIES - 180 DAYS
In the last 7 years, have you been over
INCURRED DATE: ________________ SATISFIED DATE: ________________ (YYYY/MM/DD)
Amount: ___________________ Type of Loan/Obligation: _______________________________
Account Number: __________________________________________________________________
Creditor/Obligee Name: _____________________________________________________________
Address/City/State/Zip: _____________________________________________________________
Module 39: YOUR FINANCIAL DELINQUENCIES - 90 DAYS
Are you currently over 90 days delinquent on any debt(s)? (Y / N) If Yes, provide the following: INCURRED DATE: ________________ SATISFIED DATE: ________________ (YYYY/MM/DD)
Amount: ___________________ Type of Loan/Obligation: _______________________________
Account Number: __________________________________________________________________
Creditor/Obligee Name: _____________________________________________________________
Address/City/State/Zip: _____________________________________________________________
Module 40: PUBLIC RECORD CIVIL COURT ACTIONS
In the last 7 years, have you been a party to any public record civil court actions not listed elsewhere on this form? (Y / N) If Yes, provide the following:
DATE: _____________ (YYYY/MM/DD) Nature of Action: __________________________________
Result of Action: ____________________________ Court Name: ___________________________
County: _________________________ City/State/Country/Zip: ____________________________
________________________________ Party To This Action: _____________________________
Module 41: YOUR ASSOCIATION RECORD - MEMBERSHIP
Have you ever been an officer or a member or made a contribution to an organization dedicated to the violent overthrow of the United States Government and which engages in illegal activities to that end, knowing that the organization engages in such activities with the specific intent to further such activities? (Y / N) If Yes, provide details of your association:
Comments: _______________________________________________________________________
_________________________________________________________________________________
* Can be left blank |
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Module 42: YOUR ASSOCIATION RECORD - ACTIVITIES
Have you ever knowingly engaged in any acts or activities designed to overthrow the United States Government by force? (Y / N) If Yes, provide details of such acts or activities:
Comments: _______________________________________________________________________
_________________________________________________________________________________
Module 43: GENERAL REMARKS
Do you have any additional remarks to enter in your application? If Yes, provide comments:
Comments: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Continuation Space (If more space is needed, use blank sheet(s) of paper): ___________
_________________________________________________________________________________
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