Consent And Sf85 Sf85P Questionnaire Details

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QuestionAnswer
Form NameSf85P Form Fillable
Form Length95 pages
Fillable?No
Fillable fields0
Avg. time to fill out23 min 45 sec
Other namessf85 usps, sf85 or sf85p, sf85 form usps, sf85 sf85p questionnaire usps

Form Preview Example

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the office that provided you the form.

All questions on this form must be answered completely and truthfully in order that the Government may make the determinations described below on a complete record. Penalties for inaccurate or false statements are discussed below. 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 Sections 21, 25, and 27, however, neither your truthful responses nor information derived from those responses will be used as evidence against you in a subsequent criminal proceeding.

Note: If you complete the SF 85P, an Authorization for Release of Medical Information Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) will be provided to you only in the event information arises in an investigation that requires further inquiry for resolution, and only to resolve such issues. This release authorizes an investigator to ask your health practitioner(s) only the questions specified on the release concerning mental health consultations of which the practitioner might be aware. If you are completing the SF 85P with the supplemental SF 85P-S, this release will be provided to you if you respond "yes" to the question regarding Your Medical Record. You may also be asked to complete a specific release if more detailed information is needed from your provider.

Purpose of this Form

This form will be used by the United States (U.S.) Government in conducting background investigations and reinvestigations of persons under consideration for, or retention of, public trust positions as defined in 5 CFR

731.This form may also be used by agencies in determining whether a subject performing work for, or on behalf of, the Government under a contract should be deemed eligible for logical or physical access when duties to be performed by an employee of a contractor are equivalent to the duties performed by an employee in a public trust position. For applicants, this form is to be used only after a conditional offer of employment has been made. This form is not to be used for National Security sensitive positions.

Providing this information is voluntary. If you do not provide each item of requested information, however, we will not be able to complete your investigation, which will adversely affect your eligibility for a public trust position or your ability to obtain or retain Federal or contract employment, or logical or physical access. It is imperative that the information provided be true and accurate, to the best of your knowledge. Any information that you provide is evaluated on the basis of its currency, seriousness, relevance to the position and duties, and consistency with all other information about you. Withholding, misrepresenting, or falsifying information may affect your eligibility for a public trust position, or your ability to obtain or retain Federal or contract employment. In addition, withholding, misrepresenting, or falsifying information may affect your eligibility for physical and logical access to federally controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also negatively affect your employment prospects and job status, and the potential consequences include, but are not limited to, removal, debarment from Federal service, or prosecution.

This form is a permanent document that may be used as the basis for future investigations, suitability or fitness for Federal employment, fitness for contract employment, 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 previous SF 85P questionnaires.

The investigation conducted on the basis of information provided on this form may be selected for studies and analyses in support of evaluating and improving the effectiveness and efficiency of the investigative and adjudicative methodologies. All study results released to the general public will delete personal identifiers such as name, social security number, and date and place of birth.

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, 13764, 10577, 13467, and 13488; sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 731, and 736 of title 5, Code of Federal Regulations (CFR), and Federal information processing standards.

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, as amended by EO 13478.

Your spouse's SSN is needed solely to allow the investigative service provider to make inquiries regarding whether there is relevant conduct on your part as a result of your relationship with your spouse. Your spouse is not subject of the investigation.

The Investigative Process

Background investigations for public trust positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and loyal to the U.S. The information that you provide on this form and your Declaration for Federal Employment (OF 306) may be confirmed during the investigation. 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, although you may have previously indicated on applications or other forms that you do not want your current employer to be contacted. If you have a security freeze on your consumer or credit report file, then we may not be able to complete your investigation, which can adversely affect your eligibility for a public trust position or your ability to obtain Federal or contract employment. To avoid such delays, you must request that the consumer reporting agencies lift the freeze in these instances.

In addition to the questions on this form, inquiry also is made about your adherence to security requirements your honesty and integrity, falsification, misrepresentation, and any other behavior, activities, or associations that tend to demonstrate a person is not reliable, trustworthy, or loyal.

After a suitability /fitness determination is made, you may also be subject to continuous vetting which may include periodic reinvestigations to ensure your continuing suitability for employment.

Your Personal Interview

Some investigations will include an interview with you as a routine part of the investigative process. The investigator may ask you to explain your answers to any question on this form. This provides you the opportunity to update, clarify, and explain information on your form more completely, 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 investigation, and declining to be interviewed may result in your investigation being delayed or canceled.

For the interview, 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 verify your identity, as instructed by your investigator. These documents may include certification of any legal name change, Social Security card, passport, and/or your birth certificate. You may also be asked to provide documents regarding information that you provide on this form, or about other matters requiring specific attention. These matters include (a) alien registration or naturalization documents; (b) delinquent loans or taxes, bankruptcies, judgments, liens, or other financial obligations; (c) agreements involving child custody or support, alimony, or property settlements; (d) arrests, convictions, probation, and/or parole; or (e) other matters described in court records.

Page 1

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Instructions for Completing this Form

1.Follow the instructions provided to you by the office that gave you this form and any other clarifying instructions, provided by that office, to assist you with completion of this 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.

2.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.

3.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 drop down feature.

4.When entering a U.S. address or location, select the state or territory from the "States" drop down list that will be provided. For locations outside of the U.S. and its territories, select the country in the "Country" drop down list and leave the "State" field blank.

5.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.

6.For telephone numbers in the U.S., ensure that the area code is included.

7.All dates provided in this form must be in Month/Day/ Year or Month/Year

format. Use numbers (01-12) to indicate months. For example, July 29,1968, should be written as 07/29/1968. 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 “Estimate” box.

Final Determination on Your Suitability

Final determination on your suitability for a public trust position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made. The United States Government does not discriminate on the basis of prohibited categories, including but not limited to race, color, religion, sex (including pregnancy and gender identity), national origin, disability, or sexual orientation when making determinations of suitability for a public trust position.

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, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent record for future placements. Your prospects of placement 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 position, and the information will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of background 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. The office that gave you this form will provide you a copy of its routine uses.

Office of Personnel Management (OPM) Routine Uses

The Privacy Act routine uses of agencies conducting or requesting investigations, or with authorized custody over your investigative information, commonly include some or all of the following:

a.To designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government or the Government of the District of Columbia having a need to investigate, evaluate, or make a determination regarding loyalty to the United States; qualifications, suitability, or fitness for Government employment or military service; eligibility for logical or physical access to federally-controlled facilities or information systems;eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.

b.To an element of the U.S. Intelligence Community as identified in E.O.12333, as amended, for use in intelligence activities for the purpose of protecting United States national security interests.

c.To any source from which information is requested in the course of an investigation, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of information requested.

d.To the appropriate Federal, state, local, tribal, foreign, or other public authority responsible for investigating, prosecuting, enforcing, or implementing a statute, rule, regulation, or order where OPM becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation.

e.To an agency, office, or other establishment in the executive, legislative,or judicial branches of the Federal Government in response to its request,in connection with its current employee’s, contractor employee’s, or military member’s retention; loyalty; qualifications, suitability, or fitness for employment; eligibility for logical or physical access to federally-controlled facilities or information systems; eligibility for access to classified information or to hold a sensitive position; qualifications or fitness to perform work for or on behalf of the Government under contract, grant, or other agreement; or access to restricted areas.

f.To provide information to a congressional office from the record of an individual in response to an inquiry from the congressional office made at the request of that individual. However, the investigative file, or parts thereof, will only be released to a congressional office if OPM receives a notarized authorization or signed statement under 28 U.S.C. 1746 from the subject of the investigation.

g.To disclose information to contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the Federal Government.

h.For agencies that use adjudicative support services of another agency, at the request of the original agency, the results will be furnished to the agency providing the adjudicative support.

i.To provide criminal history record information to the FBI, to help ensure the accuracy and completeness of FBI and OPM records.

j.To appropriate agencies, entities, and persons when (1) OPM suspects or has confirmed that there has been a breach of the system of records; (2) OPM has determined that as a result of the suspected or confirmed breach there is a risk of harm to individuals, the agency (including its information systems, programs and operations), the Federal Government,or national security; and (3) the disclosure made to such agencies,entities, and persons is reasonably necessary to assist in connection with OPM’s efforts to respond to the suspected or confirmed breach or to prevent, minimize, or remedy such harm.

Page 2

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

k.To another Federal agency or Federal entity, when OPM determines that information from this system of records is reasonably necessary to assist the recipient agency or entity in (1) responding to a suspected or confirmed breach or (2) preventing, minimizing, or remedying the risk of harm to individuals, the agency (including its information systems,programs and operations), the Federal Government, or national security,resulting from a suspected or confirmed breach.

l.To disclose information to another Federal agency, to a court, or a party in litigation before a court or in an administrative proceeding being conducted by a Federal agency, when the Government is a party to the judicial or administrative proceeding. In those cases where the Government is not a party to the proceeding, records may be disclosed if a subpoena has been signed by a judge.

m.To disclose information to the National Archives and Records Administration for use in records management inspections.

n.To disclose information to the Department of Justice, or in a proceeding before a court, adjudicative body, or other administrative body before which OPM is authorized to appear, when:

(1)OPM, or any component thereof; or

(2)Any employee of OPM in his or her official capacity; or

(3)Any employee of OPM in his or her individual capacity where the Department of Justice or OPM has agreed to represent the employee; or

(4)The United States, when OPM determines that litigation is likely to affect OPM or any of its components; is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or OPM is deemed by OPM to be relevant and necessary to the litigation, provided, however, that the disclosure is compatible with the purpose for which records were collected.

o.For the Merit Systems Protection Board--To disclose information to officials of the Merit Systems Protection Board or the Office of the Special Counsel, when requested in connection with appeals, special studies of the civil service and other merit systems, review of OPM rules and regulations, investigations of alleged or possible prohibited personnel practices, and such other functions, e.g., as promulgated in 5U.S.C. 1205 and 1206, or as may be authorized by law.

p.To disclose information to an agency Equal Employment Opportunity(EEO) office or to the Equal Employment Opportunity Commission when requested in connection with investigations into alleged or possible discrimination practices in the Federal sector, or in the processing of a Federal-sector-sector EEO complaint.

q.To disclose information to the Federal Labor Relations Authority or its General Counsel when requested in connection with investigations of allegations of unfair labor practices or matters before the Federal Service Impasses Panel.

r.To another Federal agency’s Office of Inspector General when OPM becomes aware of an indication of misconduct or fraud during the applicant’s submission of the standard forms.

s.To another Federal agency’s Office of Inspector General in connection with its inspection or audit activity of the investigative or adjudicative processes and procedures of its agency as authorized by the Inspector General Act of 1978, as amended, exclusive of requests for civil or criminal law enforcement activities.

t.To a Federal agency or state unemployment compensation office upon its request in order to adjudicate a claim for unemployment compensation benefits when the claim for benefits is made as the result of a qualifications, suitability, fitness, security, identity credential, or access determination.

u.To appropriately cleared individuals in Federal agencies, to determine whether information obtained in the course of processing the background investigation is or should be classified.

v.To the Office of the Director of National Intelligence for inclusion in its Scattered Castles system in order to facilitate reciprocity of background investigations and security clearances within the intelligence community or assist agencies in obtaining information required by the Federal Investigative Standards.

w.To the Director of National Intelligence, or assignee, such information as may be requested and relevant to implement the responsibilities of the Security Executive Agent for personnel security, and pertinent personnel security research and oversight, consistent with law or executive order.

x.To Executive Branch Agency insider threat, counterintelligence, and counter terrorism officials to fulfill their responsibilities under applicable Federal law and policy, including but not limited to E.O. 12333, 13587and the National Insider Threat Policy and Minimum Standards.

y.To the appropriate Federal, State, local, tribal, foreign, or other public authority in the event of a natural or man made disaster. The record will be used to provide leads to assist in locating missing subjects or assist in determining the health and safety of the subject. The record will also be used to assist in identifying victims and locating any surviving next of kin.

z.To Federal, State, and local government agencies, if necessary, to obtain information from them which will assist OPM in its responsibilities as the authorized Investigation Service Provider in conducting studies and analyses in support of evaluating and improving the effectiveness and efficiency of the background investigation methodologies.

aa.To an agency, office, or other establishment in the executive, legislative,or judicial branches of the Federal Government in response to its request, in connection with the classifying of jobs, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency’s decision on the matter.

Public Burden Information

Public burden reporting for this collection of information is estimated toaverage155minutesperresponse,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 OPM Forms Officer, U.S. Office of Personnel Management, Attn: OMB Number 3206-0258, 1900 E Street, N.W., Washington, DC 20415. The OMB clearance number, 3206-0258, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Page 3

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

 

LOCATION CODES

Form approved: OMB No. 3206 0258

Alabama

AL

Hawaii

HI

Massachusetts

MA

New Mexico

NM

South Dakota

SD

Alaska

AK

Idaho

ID

Michigan

MI

New York

NY

Tennessee

TN

Arizona

AZ

Illinois

IL

Minnesota

MN

North Carolina

NC

Texas

TX

Arkansas

AR

Indiana

IN

Mississippi

MS

North Dakota

ND

Utah

UT

California

CA

Iowa

IA

Missouri

MO

Ohio

OH

Vermont

VT

Colorado

CO

Kansas

KS

Montana

MT

Oklahoma

OK

Virginia

VA

Connecticut

CT

Kentucky

KY

Nebraska

NE

Oregon

OR

Washington

WA

Delaware

DE

Louisiana

LA

Nevada

NV

Pennsylvania

PA

West Virginia

WV

District of Columbia

DC

Maine

ME

New Hampshire

NH

Rhode Island

RI

Wisconsin

WI

Florida

FL

Maryland

MD

New Jersey

NJ

South Carolina

SC

Wyoming

WY

Georgia

GA

 

 

 

 

 

 

 

 

American Samoa

AS

Johnson Atoll

JQ

Midway Islands

MQ

Palmyra Atoll

LQ

Wake Island

WQ

Baker Island

FQ

Kingman Reef

KQ

Navassa Island

BQ

Puerto Rico

PR

APO/FPO America

AA

Guam

GU

Marshall Islands

MH

Northern Mariana Islands

MP

Virgin Islands, United

VI

APO/FPO Europe

AE

Howland Island

HQ

Micronesia, Federated

FM

Palau

PW

States

 

APO/FPO Pacific

AP

Jarvis Island

DQ

States

 

 

 

 

 

 

 

AGENCY USE BLOCK "AUB"

Investigating agency user only

Codes: (FIPC CODES)

Case Number:

FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION PROVIDED IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE, THOSE DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.

A Type of investigation

B Extra coverage/Advanced results

C Risk level

 

 

 

 

 

 

 

 

 

 

E Nature of action code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F Date of action (Month/Day/Year)

G Geographic location

H Position code

 

I Position title

 

 

 

J SON (Submitting Office Number)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

K Location of Official Personnel Folder

 

None

 

 

At SON

 

 

Other

 

Other address/Web address of e-OPF

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

NPRC

 

 

e-OPF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L SOI (Security Office Identifier)

M Location of Security Folder

 

 

None

 

 

At SOI

 

 

 

e-OPF

Other address/Web address of e-OPF

Zip Code

 

 

 

 

 

 

 

 

NPI

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N IPAC

 

O TAS

 

 

 

 

 

P Obligating document number

Q BETC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R Accounting data and/or Agency case number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S Investigative requirement

 

 

 

Initial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reinvestigation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRequesting Official - Name

Title

Signature

Email address

 

 

 

Telephone number (Include Ext.)

 

 

Date (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U Secondary Requesting Official - Name

 

Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email address

Telephone number (Include Ext.)

V Applicant affiliation

 

FED CIV

 

 

 

CON

 

 

 

 

 

 

MIL

 

 

 

Other

W Deployment/PCS (if imminent)

 

 

 

 

 

 

 

 

 

 

From (Month/Day/Year)

Est.

To (Month/Day/Year)

Estimated Permanent Relocation

Reason(s) for temporary duty assignment or PCS

Point of contact at location

 

Telephone number (Include Ext.)

 

Address/Unit/Duty location (Include City or Post Name)

 

 

 

 

 

 

 

Agency Special Instructions for the Investigative Service Provider.

Commercial and Government Entity (CAGE) Code

Contract Number

Page 4

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE PRECEDING INSTRUCTIONS.

I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the

YES

NO

penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), or removal and debarment from Federal

 

 

Service.

 

 

Section 1 - Full Name

Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Last Name

First Name

Middle Name

Suffix

Section 2 - Date of Birth

Provide your date of birth. (Month/Day/Year)

Est.

Section 3 - Place of Birth

Provide your place of birth.

 

 

 

City

County

State

Country (Required)

Section 4 - Social Security Number

Provide your U.S. Social Security Number.

Not applicable

Section 5 - Other Names Used

Have you used any other names?

YES

NO (If NO, proceed to Section 6)

Complete the following if you have responded 'Yes' to having used other names.

Provide your other name(s) used and the period of time you used it/them [for example: your maiden name, name(s) by a former marriage, former name(s), alias(es), or nickname(es)]. If you have only initials in your name(s), provide them and indicate "Initial only." If you do not have a middle name (s), indicate "No Middle Name" (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Provide other name used

 

 

 

 

 

 

 

 

 

 

#1 Last name

 

 

 

First name

 

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From (Month/Year)

 

To (Month/Year)

Present

Maiden name?

Provide the reason(s) why the name changed

 

 

 

 

 

 

 

 

 

 

 

Est.

 

Est.

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide other name used

 

 

 

 

 

 

 

 

 

 

#2 Last name

 

 

 

First name

 

 

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From (Month/Year)

To (Month/Year)

Est.

Present Est.

Maiden name?

Provide the reason(s) why the name changed

 

 

YES

NO

 

 

 

 

Provide other name used

 

 

 

#3 Last name

First name

Middle name

Suffix

From (Month/Year)

To (Month/Year)

Est.

Present Est.

Maiden name?

Provide the reason(s) why the name changed

YES

NO

 

 

 

 

 

Provide other name used

 

 

 

#4 Last name

First name

Middle name

Suffix

From (Month/Year)

To (Month/Year)

Est.

Present Est.

Maiden name?

Provide the reason(s) why the name changed

YES

NO

 

 

 

 

 

Section 6 - Your Identifying Information

Provide your identifying information.

Height

Weight (in pounds)

Hair color

(feet) (inches)

Eye color

Sex

Female

Male

Enter your Social Security Number before going to the next page

Page 5

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 7 - Your Contact Information

Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your background investigation.

Home e-mail address

 

 

 

 

Work e-mail address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

Day

 

International or DSN phone number

Day

 

International or DSN phone number

Day

 

 

 

Home telephone number Extension

Night

 

Work telephone number

 

Extension

Night

 

Mobile/Cell telephone number

Extension

Night

 

 

 

 

Both

 

 

 

 

 

Both

 

 

 

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 8 - U.S. Passport Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you possess a U.S. passport (current or expired)?

 

 

 

 

 

 

 

 

 

YES

NO (If NO, proceed to Section 9)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following information for the most recent U.S. passport you currently possess.

 

Click HERE for U.S. State Department passport help

 

Passport number

Issue date (Month/Day/Year) Expiration date (Month/Day/Year)

 

 

 

 

 

 

Est.

 

 

 

Est.

 

http://travel.state.gov/passport

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name in which passport was first issued.

 

 

 

 

 

 

 

 

 

Last name

 

 

 

 

First name

 

 

Middle name

Suffix

 

 

Section 9 - Citizenship

Select the box that reflects your current citizenship status.

I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.

(Proceed to Section 10)

I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country.

(Complete 9.1)

I am a derived U.S. citizen. (Complete 9.3)

I am not a U.S. citizen. (Complete 9.4)

I am a naturalized U.S. citizen. (Complete 9.2)

9.1Complete the following if you answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country. Provide type of documentation of U.S. citizen born abroad.

FS 240

DS 1350

FS 545

Other (Provide explanation)

 

 

 

 

 

 

 

 

Provide document number for U.S. citizen born abroad.

Provide the date the document was issued. (Month/Day/Year)

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

Provide the name in which document was issued.

 

 

 

 

Last name

 

 

First name

 

Middle name

 

Suffix

 

 

 

 

 

Provide your citizenship certificate number.

Provide the date the certificate was issued. (Month/Day/Year)

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

Provide the place of issuance.

 

 

 

 

 

 

City

 

 

State

Country

 

 

 

 

 

 

 

 

Provide the name in which the certificate was issued.

 

 

 

 

Last name

 

 

First name

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

Were you born on a U.S. military installation?

Provide the name of the base.

 

 

YES

NO (If NO, proceed to Section 10)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 6

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 9 - Citizenship - (CONTINUED)

Form approved: OMB No. 3206 0258

9.2Complete the following if you answered that you are a naturalized U.S. citizen.

Provide the date of entry into the U.S.

(Month/Day/Year)

Est.

Provide the location of entry into the U.S.

 

City

State

Provide country(ies) of prior citizenship.

 

#1 Country

#2 Country

Do/did you have a U.S. alien registration number?

YES

NO

Provide your U.S. alien registration number on Certificate of Naturalization - utilize USCIS, CIS, or INS registration, I-551, I-766.

Provide your Certificate of Naturalization number (N550 or N570). Provide the date the Certificate of Naturalization was issued. (Month/Day/Year)

Est.

Provide the name of the court that issued the Certificate of Naturalization.

Provide the address of the court that issued the Certificate of Naturalization.

 

Street

City

State

Zip Code

 

Provide the name in which the Certificate of Naturalization was issued.

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

Provide the basis of naturalization.

 

 

 

 

 

 

 

 

 

 

Based on my own individual naturalization application

 

 

 

 

 

 

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.3 Complete the following if you answered that you are a derived U.S. citizen.

 

 

 

 

 

 

 

 

 

 

 

Provide your alien registration number (on Certificate of

Provide your Permanent Resident Card

Provide your Certificate of Citizenship

 

Citizenship — utilize USCIS, CIS or INS registration number)

number (I-551)

number (N560 or N561)

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name in which the document was issued.

 

 

 

 

 

Last name

 

First name

 

Middle name

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the date document was issued

(Month/Day/Year)

Provide the basis of derived citizenship.

 

 

 

 

 

 

Est.

 

By operation of law through my U.S. citizen parent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

9.4Complete the following if you answered that you are not a U.S. citizen.

Provide your residence status.

Provide your date of entry in the U.S. (Month/Day/Year)

 

Est.

 

 

Provide your country(ies) of citizenship.

#1 Country

#2 Country

Provide your place of entry in the U.S.

 

City

State

Provide your alien registration number (I-551, I-766)

Provide document expiration

date (I-766 ONLY) (Month/Day/Year)

Est.

Provide type of document issued. (I-94, U.S. Visa - red foil number, I-20, DS-2019, etc.)

 

 

 

I-94

U.S. Visa (red foil number)

I-20

DS-2019

 

 

 

Other

(Provide explanation)

 

 

 

 

 

 

 

 

 

Provide document number.

Provide the date document was issued (Month/Day/Year)

 

Provide document expiration date. (Month/Day/Year)

 

 

 

Est.

 

 

Est.

 

 

 

 

 

Provide the name in which the document was issued.

 

 

 

Last name

 

 

First name

Middle name

Suffix

Enter your Social Security Number before going to the next page

Page 7

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information

10.1 Do you now or have you EVER held dual/multiple citizenships?

YES

NO (If NO, proceed to 10.2)

 

 

 

Complete the following if you answered 'Yes' to having EVER held dual/multiple citizenships.

 

 

 

 

 

Entry #1

 

 

Provide country of citizenship.

How did you acquire this non-U.S. citizenship you now have or previously had?

During what period of time did you hold citizenship with this country? (Provide the date range that you held this citizenship, beginning with the date it was acquired through its termination or "Present," whichever is appropriate.)

From Date (Month/Year)

To Date (Month/Year)

Present

Est.

 

 

Est.

 

 

 

Do you currently hold citizenship with this country?

 

 

 

 

 

 

YES

NO

 

Provide explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide country of citizenship.

During what period of time did you hold citizenship with this country?

 

 

 

 

 

(Provide the date range that you held this citizenship, beginning with the date it

 

 

 

 

 

was acquired through its termination or "Present," whichever is appropriate.)

 

How did you acquire this non-U.S. citizenship you now have or previously had?

From Date (Month/Year)

 

To Date (Month/Year)

Present

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

Do you currently hold citizenship with this country?

 

 

 

 

 

 

YES

NO

 

Provide explanation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.2 Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?

YES

NO (If NO, proceed to Section 11)

 

 

 

 

 

 

Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.

Entry #1

Provide the country in which the passport (or identity card) was issued.

 

Provide the date the passport (or identity card) was issued. (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

Provide the place the passport (or identity card) was issued.

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name in which passport (or identity card) was issued.

 

 

 

 

 

 

 

 

 

Last name

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

Provide the passport (or identity card) number.

 

Provide the passport (or identity card) expiration date. (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Have you EVER used this passport (or identity card) for foreign travel?

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

 

 

From date (Month/Year)

 

 

To date (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#5

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#6

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 8

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (CONTINUED)

Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.

Entry #2

Provide the country in which the passport (or identity card) was issued.

 

Provide the date the passport (or identity card) was issued. (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the place the passport (or identity card) was issued.

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name in which passport (or identity card) was issued.

 

 

 

 

 

 

 

 

 

Last name

 

First name

 

 

 

Middle name

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

Provide the passport (or identity card) number.

 

Provide the passport (or identity card) expiration date. (Month/Day/Year)

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Have you EVER used this passport (or identity card) for foreign travel?

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

 

 

From date (Month/Year)

 

 

To date (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#1

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#2

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#3

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#4

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#5

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

#6

 

 

 

 

 

 

 

Est.

 

Est.

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 9

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 11 - Where You Have Lived

Form approved: OMB No. 3206 0258

List the places where you have lived beginning with your present residence and working back 7 years. Residences for the entire period must be accounted for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you

were not physically located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list residence before your 18th birthday unless to provide a minimum of 2 years residence history.

You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.

For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew you for periods of residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for residence.

Enter residence information.

Entry #1

Provide dates of residence.

From (Month/Year)

 

To (Month/Year)

 

Est.

 

 

 

 

Present

Est.

Is/was this residence:

 

Owned by you

Rented or leased by you

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

 

 

APO or FPO

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

 

 

Provide date of last contact.

Last name

 

 

First name

 

Middle name

 

Suffix

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relationship to this person (Select all that apply).

 

 

 

 

 

 

 

Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following contact information for this person.

 

 

 

 

 

 

 

I don't know

 

 

 

 

I don't know

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

International or DSN phone number

International or DSN phone number

Evening telephone number

 

Extension

 

Daytime telephone number

 

Extension

Cell/mobile telephone number

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide e-mail address for this person.

I don't know

Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does the person who knew you have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 10

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 11 - Where You Have Lived - (CONTINUED)

Form approved: OMB No. 3206 0258

Enter residence information.

Entry #2

Provide dates of residence.

From (Month/Year)

 

To (Month/Year)

 

Est.

 

 

 

 

Present

Est.

Is/was this residence:

 

Owned by you

Rented or leased by you

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

 

 

APO or FPO

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

 

 

Provide date of last contact.

Last name

 

 

First name

 

Middle name

 

Suffix

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relationship to this person (Select all that apply).

 

 

 

 

 

 

 

Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following contact information for this person.

 

 

 

 

 

 

 

I don't know

 

 

 

 

I don't know

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

International or DSN phone number

International or DSN phone number

Evening telephone number

 

Extension

 

Daytime telephone number

 

Extension

Cell/mobile telephone number

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide e-mail address for this person.

I don't know

Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does the person who knew you have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 11

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 11 - Where You Have Lived - (CONTINUED)

Enter residence information.

Entry #3

Provide dates of residence.

From (Month/Year)

 

To (Month/Year)

 

Est.

 

 

 

 

Present

Est.

Is/was this residence:

 

Owned by you

Rented or leased by you

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

 

 

APO or FPO

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

 

 

Provide date of last contact.

Last name

 

 

First name

 

Middle name

 

Suffix

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relationship to this person (Select all that apply).

 

 

 

 

 

 

 

Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following contact information for this person.

 

 

 

 

 

 

 

I don't know

 

 

 

 

I don't know

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

International or DSN phone number

International or DSN phone number

Evening telephone number

 

Extension

 

Daytime telephone number

 

Extension

Cell/mobile telephone number

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide e-mail address for this person.

I don't know

Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does the person who knew you have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 12

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 11 - Where You Have Lived - (CONTINUED)

Enter residence information.

Entry #4

Provide dates of residence.

From (Month/Year)

 

To (Month/Year)

 

Est.

 

 

 

 

Present

Est.

Is/was this residence:

 

Owned by you

Rented or leased by you

Military housing

Other (Provide explanation)

Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

 

 

APO or FPO

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

 

 

Provide date of last contact.

Last name

 

 

First name

 

Middle name

 

Suffix

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your relationship to this person (Select all that apply).

 

 

 

 

 

 

 

Neighbor

Friend

Landlord

Business associate

Other (Provide explanation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the following contact information for this person.

 

 

 

 

 

 

 

I don't know

 

 

 

 

I don't know

 

 

 

I don't know

 

 

 

 

 

 

 

 

 

 

 

 

International or DSN phone number

 

International or DSN phone number

International or DSN phone number

Evening telephone number

 

Extension

 

Daytime telephone number

 

Extension

Cell/mobile telephone number

 

Extension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide e-mail address for this person.

I don't know

Provide street address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does the person who knew you have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 13

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 12 - Where You Went to School

Do not list education before your 18th birthday, unless to provide a minimum of two years of education history.

(a)Have you attended any schools in the last 7 years?

YES NO

(b)Have you received a degree or diploma more than 7 years ago? YES NO (If NO to 12(a) and 12(b), proceed to Section 13A)

Entry #1

Provide the dates of attendance.

 

Select the most appropriate below to describe your school.

From Date (Month/Year)

To Date(Month/Year)

Present

High School

Vocational/Technical/Trade School

Est.

 

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

 

 

 

 

 

Provide the name of the school.

Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For

assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Provide the name of the person who knows/knew you at school:

Last name

First name

I don't know

Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number for this person.

 

 

I don't know

Provide email address for this person.

I don't know

 

 

 

 

 

 

 

 

Telephone number

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a degree/diploma?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide type of degrees(s)/diploma(s) received and date(s) awarded.

Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,

Other degree/diploma

Date awarded

Est.

• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #2

Provide the dates of attendance.

 

Select the most appropriate below to describe your school.

From Date (Month/Year)

To Date(Month/Year)

Present

High School

Vocational/Technical/Trade School

Est.

 

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

 

 

 

 

 

Provide the name of the school.

Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For

assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Provide the name of the person who knows/knew you at school:

Last name

First name

I don't know

Enter your Social Security Number before going to the next page

Page 14

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 12 - Where You Went to School - (CONTINUED)

Entry #2 (CONTINUED)

Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number for this person.

 

 

I don't know

Provide email address for this person.

I don't know

 

 

 

 

 

 

 

 

Telephone number

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a degree/diploma?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide type of degrees(s)/diploma(s) received and date(s) awarded.

Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,

Other degree/diploma

Date awarded

Est.

• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entry #3

Provide the dates of attendance.

 

Select the most appropriate below to describe your school.

From Date (Month/Year)

To Date(Month/Year)

Present

High School

Vocational/Technical/Trade School

Est.

 

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

 

 

 

 

 

Provide the name of the school.

Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise,

provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Provide the name of the person who knows/knew you at school:

First name

 

Last name

I don't know

 

 

 

 

 

 

 

Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number for this person.

 

 

I don't know

Provide email address for this person.

I don't know

 

 

 

 

 

 

 

 

Telephone number

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a degree/diploma?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide type of degrees(s)/diploma(s) received and date(s) awarded.

Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,

Other degree/diploma

Date awarded

Est.

• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 15

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 12 - Where You Went to School - (CONTINUED)

Entry #4

Provide the dates of attendance.

 

Select the most appropriate below to describe your school.

From Date (Month/Year)

To Date(Month/Year)

Present

High School

Vocational/Technical/Trade School

Est.

 

Est.

College/University/Military College

Correspondence/Distance/Extension/Online School

 

 

 

 

 

Provide the name of the school.

Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained. For

assistance determining the school address, refer to http://ope.ed.gov/accreditation/search.aspx (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Provide the name of the person who knows/knew you at school:

Last name

First name

I don't know

Provide current address for this person (including apartment number). (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number for this person.

 

 

I don't know

Provide email address for this person.

I don't know

 

 

 

 

 

 

 

 

Telephone number

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you receive a degree/diploma?

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

Provide type of degrees(s)/diploma(s) received and date(s) awarded.

Degree/diploma (• High School Diploma, • Associate's, • Bachelor's, • Master's,

Other degree/diploma

Date awarded

Est.

• Doctorate, • Professional Degree (e.g. MD, DVM, JD), • Other)

(Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 16

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 13A - Employment Activities

Form approved: OMB No. 3206 0258

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

Entry #1

Select your employment activity:

 

Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

and 13A.6)

(Complete 13A.2, 13A.5 and 13A.6)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

 

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Non-government employment (excluding self- employment) (Complete 13A.2, 13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6)

Entry #1

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.

Provide dates of employment.

 

 

 

 

 

Select the employment status for

 

Provide your assigned duty station during this period.

From Date

To Date

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

Present

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide your most recent rank/position title.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

 

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do you or did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

Provide the rank/position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

I don't know

Provide supervisor's telephone number. Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

City

 

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do/did your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 17

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #1

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number

 

Extension

 

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Periods of Activity with this Employer-Provide additional periods of activity if you worked for this employer on more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment as entries below).

 

Not

From date (Month/Year)

 

 

To date (Month/Year)

 

 

Position Title

Supervisor

 

 

Applicable

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is/was your physical work address different than your employer's address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

Provide telephone number

Extension

 

International or DSN phone number

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

APO or FPO

 

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

 

 

 

Provide the position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

 

I don't know

Provide supervisor's telephone number. Extension

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

 

City

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did/does your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 18

Provide the telephone number for this address.
Telephone numberExtension

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #1

13A.3 Complete the following if employment type is self-employment

 

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

 

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

Extension

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is your physical work address different than your employment address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

International or DSN phone number

Day Night

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of someone that can verify your self-employment.

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the telephone number for this person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

Extension

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your self-employment verifier have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 19

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #1

Entry #1

Entry #1

13A.4 Complete the following if employment type is unemployment.

Provide dates of unemployment.

 

 

 

Provide the name of someone that can verify your unemployment activities

From Date (Month/Year)

To Date(Month/Year)

 

 

and means of support.

 

 

Present

Last name

First name

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

Provide the telephone number for this person.

Verifier telephone number Extension

 

International or DSN phone number

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your unemployment verifier have an APO/FPO address?

YES

 

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

Provide the reason for leaving the employment activity.

For this employment have any of the following happened to you in the last seven (7) years?

Fired Quit after being told you would be fired Left by mutual agreement following charges or allegations of misconduct Left by mutual agreement

following notice of unsatisfactory performance.

YES

NO (If NO, proceed to 13A.6)

 

 

 

 

 

 

 

 

 

 

 

Select your type of incident:

Reason:

 

 

Employment departure date

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for being fired.

 

Provide the date you were fired. (Month/Year)

 

 

 

 

Fired

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for quitting.

 

Provide the date you quit after being told you would be

 

 

 

 

Quit after being told you would be

 

 

 

fired. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

fired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations

 

 

 

 

Left by mutual agreement following

 

 

 

of misconduct. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

charges or allegations of misconduct

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) for unsatisfactory performance.

Provide the date you left by mutual agreement following

 

 

 

 

Left by mutual agreement following

 

 

 

a notice of unsatisfactory performance. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notice of unsatisfactory performance

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?

 

 

YES

NO

 

 

 

 

 

 

 

#1

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#2

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 20

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 13A - Employment Activities

Form approved: OMB No. 3206 0258

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

Entry #2

Select your employment activity:

 

Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

and 13A.6)

(Complete 13A.2, 13A.5 and 13A.6)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

 

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Non-government employment (excluding self- employment) (Complete 13A.2, 13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6)

Entry #2

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.

 

Provide dates of employment.

 

 

 

 

 

Select the employment status for

 

 

Provide your assigned duty station during this period.

 

 

 

 

 

 

 

 

 

From Date

To Date

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

Present

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your most recent rank/position title.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

 

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do you or did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

Provide the rank/position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

I don't know

Provide supervisor's telephone number. Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

City

 

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address for your supervisor, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do/did your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 21

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #2

13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employer.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number

 

Extension

 

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

 

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Periods of Activity with this Employer-Provide additional periods of activity if you worked for this employer on more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment as entries below).

Not

From date (Month/Year)

 

 

To date (Month/Year)

 

 

Position Title

Supervisor

Applicable

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is/was your physical work address different than your employer's address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

Provide telephone number

Extension

 

International or DSN phone number

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

APO or FPO

 

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your supervisor.

 

 

 

 

 

Provide the position title of your supervisor.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the email address of your supervisor.

 

I don't know

Provide supervisor's telephone number. Extension

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

Street

 

 

City

State

Zip Code

Country

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Did/does your supervisor have an APO/FPO address while at this location?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

NO

Enter your Social Security Number before going to the next page

Page 22

Provide the telephone number for this address.
Telephone numberExtension

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #2

13A.3 Complete the following if employment type is self-employment

 

Provide dates of employment.

 

 

 

 

 

 

 

Select the employment status for

 

Provide most recent position title.

 

From Date

To Date

 

 

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

 

 

Present

 

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of your employment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

 

 

 

City

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide telephone number.

 

Extension

 

 

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(a)Is your physical work address different than your employment address?

YES NO (If NO, proceed to (b))

Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

International or DSN phone number

Day Night

(b)If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).

(b.1) Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and

Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

 

Street Address/Unit/Duty Location

 

 

City or Post Name

 

 

State

 

Zip Code

 

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(b.2) Do you or did you have an APO/FPO address while at this location?

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

Address

 

 

 

 

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the name of someone that can verify your self-employment.

 

 

 

 

 

 

 

 

 

 

Last name

 

 

First name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

 

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the telephone number for this person.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

Extension

 

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your self employment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your self-employment verifier have an APO/FPO address?

YES

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

NO

Enter your Social Security Number before going to the next page

Page 23

Standard Form 85P

Revised December 2017

U.S. Office of Personnel Management

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR

PUBLIC TRUST POSITIONS

Form approved: OMB No. 3206 0258

Section 13A - Employment Activities - (CONTINUED)

Entry #2

Entry #2

Entry #2

13A.4 Complete the following if employment type is unemployment.

Provide dates of unemployment.

 

 

 

Provide the name of someone that can verify your unemployment activities

From Date (Month/Year)

To Date(Month/Year)

 

 

and means of support.

 

 

Present

Last name

First name

 

 

 

 

 

 

 

 

Est.

 

 

Est.

 

 

 

 

 

 

 

 

 

 

Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street

City

State

Zip Code

Country

Provide the telephone number for this person.

Verifier telephone number Extension

 

International or DSN phone number

 

 

 

Day

 

Night

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address for your unemployment verifier, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Does your unemployment verifier have an APO/FPO address?

YES

 

 

Address

APO or FPO

APO/FPO State Code

Zip Code

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

Provide the reason for leaving the employment activity.

For this employment have any of the following happened to you in the last seven (7) years?

Fired Quit after being told you would be fired Left by mutual agreement following charges or allegations of misconduct Left by mutual agreement

following notice of unsatisfactory performance.

YES

NO (If NO, proceed to 13A.6)

 

 

 

 

 

 

 

 

 

Select your type of incident:

Reason:

 

 

Employment departure date

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for being fired.

 

Provide the date you were fired. (Month/Year)

 

 

 

Fired

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason for quitting.

 

Provide the date you quit after being told you would be

 

 

 

Quit after being told you would be

 

 

 

fired. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

fired

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the charges or allegations of misconduct.

Provide the date you left following charges or allegations

 

 

 

Left by mutual agreement following

 

 

 

of misconduct. (Month/Year)

 

 

 

 

 

 

 

 

 

charges or allegations of misconduct

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide the reason(s) for unsatisfactory performance.

Provide the date you left by mutual agreement following

 

 

 

Left by mutual agreement following

 

 

 

a notice of unsatisfactory performance. (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notice of unsatisfactory performance

 

 

 

 

 

Est.

 

 

 

 

 

 

 

 

 

 

 

13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other.

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?

 

 

YES

NO

 

 

 

 

 

 

 

#1

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#2

Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

#4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined.

Date: (Month/Year)

 

 

 

 

 

 

Est.

 

 

 

 

 

 

 

Enter your Social Security Number before going to the next page

Page 24

Standard Form 85P

QUESTIONNAIRE FOR

Revised December 2017

U.S. Office of Personnel Management

PUBLIC TRUST POSITIONS

5 CFR Parts 731, 732, and 736

Section 13A - Employment Activities

Form approved: OMB No. 3206 0258

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 7 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

Entry #3

Select your employment activity:

 

Active military duty station (Complete 13A.1, 13A.5

State Government (Non-Federal employment)

and 13A.6)

(Complete 13A.2, 13A.5 and 13A.6)

National Guard/Reserve (Complete 13A.1, 13A.5

Self-employment (Complete 13A.3, 13A.5 and

and 13A.6)

13A.6)

USPHS Commissioned Corps (Complete 13A.1,

Unemployment (Complete 13A.4)

13A.5 and 13A.6)

 

Other Federal employment (Complete 13A.2,

Federal Contractor (Complete 13A.2, 13A.5 and

13A.5 and 13A.6)

13A.6)

Non-government employment (excluding self- employment) (Complete 13A.2, 13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6)

Entry #3

13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.

 

Provide dates of employment.

 

 

 

 

 

Select the employment status for

 

 

Provide your assigned duty station during this period.

 

 

 

 

 

 

 

 

 

From Date

To Date

 

 

 

this position:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month/Year)

(Month/Year)

 

Present

 

Full-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide your most recent rank/position title.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Est.

 

 

 

Est.

 

 

Part-time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

 

 

Street

 

 

 

City

 

 

 

 

State

Zip Code

Country

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone number

 

 

Extension

International or DSN phone number

 

 

 

 

 

 

 

 

 

 

 

Day

Night

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).

(a)Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)

Street Address/Unit/Duty Location

City or Post Name

State

Zip Code

Country

(b)Do you or did you have an APO/FPO address while at this location?

YES

 

 

Address

 

 

APO or FPO

 

 

APO/FPO State Code

Zip Code