[THESE INSTRUCTIONS SUPERCEDE QNSP FORM INSTRUCTIONS]{.underline}

SUPPLEMENTAL INSTRUCTIONS FOR THE ACCESS AUTHORIZATION PACKET SUBMISSION

CHECKLIST FOR "L" AND "Q" CLEARANCE APPLICANTS

*[PLEASE FOLLOW THIS CHECKLIST WHEN FILLING OUT THE QNSP. IT WILL
BENEFIT BOTH YOU AND THE S-6 SECURITY SPECIALIST]{.underline}*.

1\. \_\_\_ CLEARANCE REQUEST/RECERTIFICATION/SUITABLITY FORM

(AL F 5631.2C) URL - <http://enterprise.lanl.gov/forms/5631.2c.pdf>

(To be completed by Supervisor and/or Clearance Sponsor)

-   Complete entire form TYPED, excluding sections that specify DOE USE
    ONLY

-   Appropriate signature and date of Laboratory, JCNNM or PTLA
    Requesting Official

> are imperative.

**2. \_\_\_** **QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS** (SF86)
for

-   **[Applicants for "Q" Access Authorization - Initial, Reinstatement,
    Upgrade]{.mark} --**

> In all areas requesting information for 7 years, **YOU MUST** provide
> information for the

most recent **10** years. All other questions are to be answered as
instructed.

-   **[Applicants for "L" Access Authorization]{.mark}** -- In all
    areas, **YOU MUST** provide

> information for the most recent 7 years. All other questions are to be
> answered as
>
> instructed.

-   **[Reinvestigation]{.mark}** - Q clearance - **YOU MUST** provide
    information for the most recent

> 5 years and L clearance - **YOU MUST** provide information for the
> most recent 10
>
> years.

-   **Type or legibly print your answers in black ink (Illegible or
    colored ink forms**

**will not be processed by DOE).**

-   **A response to all questions is required. If the question is not
    applicable, write**

> **N/A or UNKNOWN in the space provided.**

-   With the exception of page 1, the social security number is required
    on the lower

right hand corner of each page of the QNSP.

**3. \_\_\_** **SECURITY ACKNOWLEDGEMENT** (DOE F 5631.18)

[**http://enterprise.lanl.gov/forms/5631.2c.pdf**](http://enterprise.lanl.gov/forms/5631.2c.pdf)

-   Signature of subject and date are required on the front and back,
    along with the

> place at which Security Acknowledgment is signed and name of employer.
>
> (This form does not need to be signed in front of a Security
> Specialist.)

**4. \_\_\_** **DOE LETTER - available at S-6 Clearance Processing**

-   Signature and date required on page 2.

**5. \_\_\_** **FAIR CREDIT REPORTING ACT** (DOE F 472.1) - **available
at S-6 Clearance**

**Processing**

-   Signature, date, and social security number are required on the last
    page of this form

**6. \_\_\_** **(Contractors ONLY) SUITABILITY FORM - available at S-6
Clearance Processing**

-   Please have this form signed and completed by a supervisor from your
    contract company

**7. \_\_\_** **PROOF OF CITIZENSHIP - [for initial and reciprocal
clearances only]{.mark}**

-   Please provide one of the following (must be an original):

Birth Certificate

Naturalization papers

Certificate of Citizenship issued by Immigration & Naturalization
Service

Form FS-240: Report of Birth Abroad of a Citizen of the United States

A United States Passport (current or expired)

A Record of Military Processing (DD Form 214)

**8. \_\_\_** **FINGERPRINT CARDS (2) - [Initial, Reinstate and
Upgrades]{.mark}.**

-   Fingerprint cards are available at S-6 Clearance Processing. Please
    complete the information

on the cards. Your fingerprints will be taken in the Clearance
Processing Security Office at

the time the Initial Clearance package is ready to be turned in. If you
are **out-of-State,** please

have these done at your local Police Department or other fingerprinting
facility. Fingerprint cards

are available at the S-6 Clearance Office by calling 667-7253.

> **IMPORTANT:** Please make sure that both your signature and that of
> the individual taking
>
> the fingerprints are on the cards.

**9. \_\_\_** *(If applicable)* **ADDITIONAL INFORMATION FOR CASES
INVOLVING FOREIGN RESIDENCE OR CITIZENSHIP (DOE M 472.1-1) - available
at S-6 Clearance**

**Processing.**

-   Applies to naturalized citizens, persons who have dual citizenship
    and persons

> who have resided in a foreign country to include military service.

-   Answer each question thoroughly. If additional paper is used,
    include your

> name, social security number and signature.

**10. \_\_\_** *(If applicable)* **REPRESENTATIVE OF FOREIGN INTEREST**

**STATEMENT - available at Clearance Processing.**

-   Any individual who holds a position with a foreign-owned company is

> required to complete this form.

**11. \_\_\_** *[(If applicable)]{.underline}* **DATA REPORT ON
SPOUSE/CO-HABITANT** (DOE F 5631.34) **URL -
http://enterprise.lanl.gov/forms/5631.34.pdf**

-   To be completed by individuals who are cohabitating in a spouse-like

> relationship.

# ADDITIONAL QNSP INSTRUCTIONS:

-   **Initial all changes made (eraser marks, white out, scratch outs,
    strikeovers,**

> **etc...)**

-   **Question 10: all college and university degrees should be listed
    no matter when**

> **that education occurred.**

-   **Question 11: Employment activities -- for LANL employees -- Street
    address is:**

> **P.O. Box 1663 and your mail stop.**

-   **Question 14 (Code 19): Place of birth and social security number
    are required.**

-   **Questions 19-30 are sensitive questions and must be answered "yes"
    or "no. If**

> **"yes," an explanation is required.**

-   **Part II, question 23F should read: "traffic fines of less than
    \$250.00"**

-   **Question 27A needs to be marked "yes" or "no" even though the box
    appears to**

> **be missing.**

-   **Pages 9 and 10 need to be signed, dated and completed as
    instructed.**

-   **Page 11 needs to be signed, dated and completed if question 21 has
    been**

> **answered "yes."**

-   ***(If applicable)* Selective Service telephone numbers are (847)
    688-6888 or (847)**

> **688-2576 URL - https://www4.sss.gov/regver/verif_response.asp**

-   **If you have read the following instructions and still need further
    assistance, please call 667-7253.**

+---------------------+---------------------------------+-------------+
| Standard Form 86    |                                 | Form        |
|                     |                                 | approved:   |
| Revised September   |                                 |             |
| 1995                |                                 | O.M.B. No   |
|                     |                                 | 3206 0007   |
| **U.S. Office of    |                                 |             |
| Personnel           |                                 | NSN 7540‑00 |
| Management**        |                                 | 634‑4036    |
|                     |                                 |             |
| **5 CFR** Parts     |                                 | 86‑111      |
| 731, **732. and     |                                 |             |
| 736**               |                                 |             |
+---------------------+---------------------------------+-------------+

**      *Press TAB to advance to next field.***

**Questionnaire for National Security Positions**

Follow instructions fully or we cannot process your form. Be sure to
sign and date the certification statement on page 9 and the release on
page 10. If you *have any questions,* call the office that **gave you
the form.**

+-----------------------------------+-----------------------------------+
| **Purpose of this Form**          | You may also be asked to bring    |
|                                   | documents about information you   |
| The U.S. Government conducts      | provided on the form or other     |
| background investigations and     | matters requiring specific        |
| reinvestigations to establish     | attention. These matters include  |
| that military personnel,          | alien registration, delinquent    |
| applicants for or incumbents in   | loans or taxes, bankruptcy,       |
| national security positions,      | judgments, liens, or other        |
| either employed by the Government | financial obligations, agreements |
| or working for Government         | involving child custody or        |
| contractors, licensees,           | support, alimony or property      |
| certificate holders, and          | settlements, arrests,             |
| grantees, are eligible for a      | convictions, probation, and/or    |
| required security clearance.      | parole.                           |
| Information from this form is     |                                   |
| used primarily as the basis for   | **Organization of this Form**     |
| investigation for access to       |                                   |
| classified information or special | This form has two parts. Part 1   |
| nuclear information or material.  | asks for background information,  |
| Complete this form only after a   | including where you have lived,   |
| conditional offer of employment   | gone to school, and worked. Part  |
| has been made for a position      | 2 asks about your activities and  |
| requiring a security clearance.   | such matters as firings from a    |
|                                   | job, criminal history record, use |
| Giving us the information we ask  | of illegal drugs, and abuse of    |
| for is voluntary. However, we may | alcohol.                          |
| not be able to complete your      |                                   |
| investigation, or complete it in  | In answering all questions on     |
| a timely manner, if you don\'t    | this form, keep in mind that your |
| give us each item of information  | answers are considered together   |
| we request. This may affect your  | with the information obtained in  |
| placement or security clearance   | the investigation to reach an     |
| prospects .                       | appropriate adjudication.         |
|                                   |                                   |
| **Authority to Request this       | **Instructions for Completing     |
| Information**                     | this Form**                       |
|                                   |                                   |
| Depending upon the purpose of     | 1\. Follow the instructions given |
| your investigation, the U.S.      | to you by the person who gave you |
| Government is authorized to ask   | the form and any other clarifying |
| for this information under        | instructions furnished by that    |
| Executive Orders 10450, 10865,    | person to assist you in           |
| 12333, and 12356; sections 3301   | completion of the form. Find out  |
| and 9101 of title 5, U.S. Code;   | how many copies of the form you   |
| sections 2165 and 2201 of title   | are to turn in. You must sign and |
| 42, U.S. Code; sections 781 to    | date, in black ink, the original  |
| 887 of title 50, U.S. Code; and   | and each copy you submit. You     |
| parts 5, 732, and 736 of Title 5, | should retain a copy of the       |
| Code of federal Regulations.      | completed form for your records.  |
|                                   |                                   |
| Your Social Security number is    | 2\. Type or legibly print your    |
| needed to keep records accurate,  | answers in black ink (if your     |
| because other people may have the | form is not legible, it will not  |
| same name and birth date.         | be accepted). You may also be     |
| Executive Order 9397 also asks    | asked to submit your form in an   |
| Federal agencies to use this      | approved electronic format.       |
| number to help identify           |                                   |
| individuals in agency records.    | 3\. All questions on this form    |
|                                   | must be answered. If no response  |
| **The Investigative Process**     | is necessary or applicable,       |
|                                   | indicate this on the form (for    |
| Background investigations for     | example, enter \'\'None\' or      |
| national security positions are   | \"N/A\"). If you find that you    |
| conducted to develop information  | cannot report an exact date,      |
| to show whether you are reliable, | approximate or estimate the date  |
| trustworthy, of good conduct and  | to the best of your ability and   |
| character, and loyal to the       | indicate this by marking          |
| United States. The information    | \'\'APPROX.\" or \"EST.\"         |
| that you provide on this form is  |                                   |
| confirmed during the              | 4\. Any changes that you make to  |
| investigation. Investigation may  | this form after you sign it must  |
| extend beyond the time covered by | be initialed and dated by you.    |
| this form when necessary to       | Under certain limited             |
| resolve issues. Your current      | circumstances, agencies may       |
| employer must be contacted as     | modify the form consistent with   |
| part of the investigation, even   | your intent.                      |
| if you have previously indicated  |                                   |
| on applications or other forms    | 5\. You must use the State codes  |
| that you do not want this.        | (abbreviations) listed on the     |
|                                   | back of this page when you fill   |
| In addition to the questions on   | out this form. Do **not           |
| this form, inquiry also is made   | abbreviate** the names of cities  |
| about a person\'s adherence to    | or foreign countries.             |
| security requirements, honesty    |                                   |
| and integrity, vulnerability to   | 6\. The 5‑digit postal ZIP codes  |
| exploitation or coercion,         | are needed to speed the           |
| falsification, misrepresentation, | processing of your investigation. |
| and any other behavior,           | The office that provided the form |
| activities, or associations that  | will assist you in completing the |
| tend to show the person is not    | ZIP codes.                        |
| reliable, trustworthy, or loyal.  |                                   |
|                                   | 7\. All telephone numbers must    |
| **Your Personal Interview**       | include area codes.               |
|                                   |                                   |
| Some investigations will include  | 8\. All dates provided on this    |
| an interview with you as a normal | form must be in Month/Day/Year or |
| part of the investigative         | Month/Year format. Use numbers (1 |
| process. This provides you the    | ‑12) to indicate months. For      |
| opportunity to update, clarify,   | example, June 8, 1978, should be  |
| and explain information on your   | shown as 6/8/78.                  |
| form more completely, which often |                                   |
| helps to complete your            | 9\. Whenever \"City (Country)\"   |
| investigation faster. It is       | is shown in an address block,     |
| important that the interview be   | also provide in that block the    |
| conducted as soon as possible     | name of the country when the      |
| after you are contacted.          | address is outside the United     |
| Postponements will delay the      | States.                           |
| processing of your investigation, |                                   |
| and declining to be interviewed   | 10\. If you need additional space |
| may result in your investigation  | to list your residences or        |
| being delayed or canceled.        | employmen                         |
|                                   | ts/self‑employments/unemployments |
| **You will** be asked to bring    | or education, you should use a    |
| identification with your picture  | continuation sheet, SF 86A. If    |
| on it, such as a valid State      | additional space is needed to     |
| driver\'s license, to the         | answer other items, use a blank   |
| interview. There are other        | piece of paper.                   |
| documents you may be asked to     |                                   |
| bring to verify your identity     | **Each blank piece of paper you   |
| **as well. These include          | use must contain your name and    |
| documentation of any legal name   | Social Security Number at the top |
| change, Social Security card,     | of the page.**                    |
| and/or birth certificate.**       |                                   |
+-----------------------------------+-----------------------------------+

+-----------------------------------+----------------------------------+
| **Final Determination on Your     | **truthfully and completely.**   |
| Eligibility**                     | You will have adequate           |
|                                   | opportunity to explain any       |
| Final determination on your       | information you give us on the   |
| eligibility for access to         | form and to make your comments   |
| classified **Information is the** | part of the record.              |
| responsibility of the Federal     |                                  |
| agency that requested your        | **Disclosure of Information**    |
| investigation. You may be         |                                  |
| provided the opportunity          | The information you give us is   |
| personally to explain, refute, or | for the purpose of investigating |
| clarify any **information**       | you for a national security      |
| before a final decision is made.  | position; we will protect it     |
|                                   | from unauthorized disclosure.    |
| **Penalties for Inaccurate or     | The collection, maintenance, and |
| False Statements**                | disclosure of background         |
|                                   | investigative information is     |
| **The** U.S. Criminal Code (title | governed by the Privacy Act. The |
| 18, section 1001) provides that   | agency which requested the       |
| knowingly falsifying or           | investigation and the agency     |
| concealing a material fact is a   | which conducted the              |
| felony which may result in fines  | investigation have published     |
| of up to \$10,000, and/or 5 years | notices in the Federal Register  |
| imprisonment, or both. In         | describing the systems of        |
| addition, Federal agencies        | records in which your records    |
| generally fire, do not grant a    | will be maintained. You may      |
| security clearance, or disqualify | obtain copies of the relevant    |
| individuals who have materially   | notices from the person who gave |
| and deliberately falsified these  | you this form. The information   |
| forms, and this remains a part of | on this form, and information we |
| the permanent record for future   | collect during an investigation  |
| placements. Because the position  | may be disclosed without your    |
| for which you are being           | consent as permitted by the      |
| considered is a sensitive one,    | Privacy Act (5 USC 552a (b) )    |
| your trustworthiness is a very    | and as follows:                  |
| important consideration in        |                                  |
| deciding your eligibility for a   |                                  |
| security clearance. Your          |                                  |
| prospects of placement or         |                                  |
| security clearance **are better   |                                  |
| if you answer all questions**     |                                  |
+-----------------------------------+----------------------------------+

  -----------------------------------------------------------------------
  **PRIVACY ACT ROUTINE USES**

  -----------------------------------------------------------------------

+-----------------------------------+-----------------------------------+
| 1\. To the Department of Justice  | 5\. To a Federal, State, local,   |
| when: (a) the agency or any       | foreign, tribal, or other public  |
| component thereof, or (b) any     | authority the fact that this      |
| employee of the agency In his or  | system of records contains        |
| her official capacity; or (c) any | Information relevant to the       |
| employee of the agency In his or  | retention of an employee, or the  |
| her Individual capacity where the | retention of a security           |
| Department of Justice has agreed  | clearance, contract, license,     |
| to represent the employee; or (d) | grant, or other benefit. The      |
| the United States Government, is  | other agency or licensing         |
| a party to litigation or has      | organization may then make a      |
| Interest In such litigation, and  | request supported by written      |
| by careful review, the agency     | consent of the Individual for the |
| determines that the records are   | entire record If It so chooses.   |
| both relevant and necessary to    | No disclosure will be made unless |
| the litigation and the use of     | the Information has been          |
| such records by the Department of | determined to be sufficiently     |
| Justice Is therefore deemed by    | reliable to support a referral to |
| the agency to be for a purpose    | another office within the agency  |
| that Is compatible with the       | or to another Federal agency for  |
| purpose for which the agency      | criminal, civil, administrative,  |
| collected the records.            | personnel, or regulatory action.  |
|                                   |                                   |
| 2\. To a court or adjudicative    | 6\. To contractors, grantees,     |
| body In a proceeding when: (a)    | experts, consultants, or          |
| the agency or any component       | volunteers when necessary to      |
| thereof, or (b) any employee of   | perform a function or service     |
| the agency in his or her official | related to this record for which  |
| capacity; or (c) any employee of  | they have been engaged. Such      |
| the agency In his or her          | recipients shall be required to   |
| Individual capacity where the     | comply with the Privacy Act of    |
| Department of Justice has agreed  | 1974, as amended.                 |
| to represent the employee: or (d) |                                   |
| the United States Government, Is  | 7\. To the news media or the      |
| a party to litigation or has      | general public, factual           |
| interest in such litigation, and  | information the disclosure of     |
| by careful review, the agency     | which would be in the public      |
| determines that the records are   | Interest and which would not      |
| both relevant and necessary to    | constitute an unwarranted         |
| the litigation and the use of     | Invasion of personal privacy.     |
| such records Is therefore deemed  |                                   |
| by the agency to be for a purpose | 8\. To a Federal, State, or local |
| that Is compatlble wlth the       | agency, or other appropriate      |
| purpose for which the agency      | entities or individuals, or       |
| collected the records.            | through established liaison       |
|                                   | channels to selected foreign      |
| 3\. Except as noted In question   | governments, In order to enable   |
| 24, when a record on its face, or | an intelligence agency to carry   |
| in conjunction with other         | out its responsibilities under    |
| records, Indicates a violation or | the National Security Act of 1947 |
| potential violation of law,       | as amended, the CIA Act of 1949   |
| whether civil, criminal, or       | as amended, Executive Order 12333 |
| regulatory In nature, and whether | or any successor order,           |
| arising by general statute,       | applicable national security      |
| particular program statute,       | directives, or classified         |
| regulation, rule, or order issued | implementing procedures approved  |
| pursuant thereto, the relevant    | by the Attorney General and       |
| records may be disclosed to the   | promulgated pursuant to such      |
| appropnate Federal, foreign,      | statutes, orders or directives.   |
| State, local, tribal, or other    |                                   |
| public authority responsible for  | 9\. To a Member of Congress or to |
| enforcing, Investigating or       | a Congressional staff member in   |
| prosecuting such violation or     | response to an inquiry of the     |
| charged with enforcing or         | Congressional office made at the  |
| Implementing the statute, rule,   | written request of the            |
| regulation, or order.             | constituent about whom the record |
|                                   | Is maintained.                    |
| 4\. To any source or potential    |                                   |
| source from whlch Information Is  | 10\. To the National Archives and |
| requested In the course of an     | Records Administration for        |
| investigation concerning the      | records management Inspections    |
| hiring or retention of an         | conducted under 44 USC 2904 and   |
| employee or other personnel       | 2906.                             |
| action, or the issuing or         |                                   |
| retention of a security           | 11\. To the Office of Management  |
| clearance, contract, grant,       | and Budget when necessary to the  |
| license, or other benefit, to the | review of private relief          |
| extent necessary to Identify the  | legislation.                      |
| Individual, Inform the source of  |                                   |
| the nature and purpose of the     |                                   |
| Investigation, and to Identify    |                                   |
| the type of Information           |                                   |
| requested.                        |                                   |
+-----------------------------------+-----------------------------------+

  -----------------------------------------------------------------------
  **STATE CODES (ABBREVIATIONS)**

  -----------------------------------------------------------------------

<table style="width:100%;">
<colgroup>
<col style="width: 14%" />
<col style="width: 5%" />
<col style="width: 15%" />
<col style="width: 4%" />
<col style="width: 14%" />
<col style="width: 5%" />
<col style="width: 14%" />
<col style="width: 4%" />
<col style="width: 13%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><p>Alabama</p>
<p>Alaska</p>
<p>Arizona</p>
<p>Arkansas</p>
<p>California</p>
<p>Colorado</p>
<p>Connecticut</p>
<p>Delaware</p>
<p>Florida</p>
<p>Georgia</p>
<p>American Samoa</p>
<p>Trust Territory</p></td>
<td><p>AL</p>
<p>AK</p>
<p>AZ</p>
<p>AR</p>
<p>CA</p>
<p>CO</p>
<p>CT</p>
<p>DE</p>
<p>FL</p>
<p>GA</p>
<p>AS</p>
<p>TT</p></td>
<td><p>Hawaii</p>
<p>Idaho</p>
<p>Illinois</p>
<p>Indiana</p>
<p>Iowa</p>
<p>Kansas</p>
<p>Kentucky</p>
<p>Louisiana</p>
<p>Maine</p>
<p>Maryland</p>
<p>Dist. of Columbia</p>
<p>Virgin Islands</p></td>
<td><p>Hl</p>
<p>ID</p>
<p>IL</p>
<p>IN</p>
<p>IA</p>
<p>KS</p>
<p>KY</p>
<p>LA</p>
<p>ME</p>
<p>MD</p>
<p>DC</p>
<p>Vi</p></td>
<td><p>Massachusetts</p>
<p>Michigan</p>
<p>Minnesota</p>
<p>Mississippi</p>
<p>Missouri</p>
<p>Montana</p>
<p>Nebraska</p>
<p>Nevada</p>
<p>New Hampshire</p>
<p>New Jersey</p>
<p>Guam</p></td>
<td><p>MA</p>
<p>Ml</p>
<p>MN</p>
<p>MS</p>
<p>MO</p>
<p>MT</p>
<p>NE</p>
<p>NV</p>
<p>NH</p>
<p>NJ</p>
<p>GU</p></td>
<td><p>New Mexico</p>
<p>New York</p>
<p>North Carolina</p>
<p>North Dakota</p>
<p>Ohio</p>
<p>Oklahoma</p>
<p>Oregon</p>
<p>Pennsylvania</p>
<p>Rhode Island</p>
<p>South Carolina</p>
<p>Northern Marianas</p></td>
<td><p>NM</p>
<p>NY</p>
<p>NC</p>
<p>ND</p>
<p>OH</p>
<p>OK</p>
<p>OR</p>
<p>PA</p>
<p>RI</p>
<p>SC</p>
<p>CM</p></td>
<td><p>South Dakota</p>
<p>Tennessee</p>
<p>Texas</p>
<p>Utah</p>
<p>Vermont</p>
<p>Virginia</p>
<p>Washington</p>
<p>West Virginia</p>
<p>Wisconsin</p>
<p>Wyoming</p>
<p>Puerto Rico</p></td>
<td><p>SD</p>
<p>TN</p>
<p>TX</p>
<p>UT</p>
<p>VT</p>
<p>VA</p>
<p>WA</p>
<p>WV</p>
<p>WI</p>
<p>WY</p>
<p>PR</p></td>
</tr>
</tbody>
</table>

  -----------------------------------------------------------------------
  **PUBLIC BURDEN INFORMATION**

  -----------------------------------------------------------------------

Public burden reporting for this collection of information is estimated
to average 90 minutes per response, 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 Reports and Forms Management Officer, U.S.
Office of Personnel Management, 1900 E Street, N.W., Room GHP‑500,
Washington, D.C. 20415. Do not send your completed form to this address.

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<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><p>Standard Form 86</p>
<p>Revised September 1995</p>
<p><strong>U.S. Office of Personnel Management</strong></p>
<p><strong>5 CFR</strong> Parts 731, <strong>732. and
736</strong></p></td>
<td colspan="10"><p><strong>QUESTIONNAIRE FOR</strong></p>
<p><strong>NATIONAL SECURITY POSITIONS</strong></p></td>
<td colspan="5"></td>
<td colspan="10"><p>Form approved:</p>
<p>O.M.B. No 3206 0007</p>
<p>NSN 7540-00-634-4036</p>
<p>86‑111</p></td>
</tr>
<tr class="even">
<td colspan="8"><strong>Part 1</strong></td>
<td colspan="12"><p>Investigating Agency Use Only</p>
<p><strong>     </strong></p></td>
<td colspan="6"><p>Codes</p>
<p><strong>     </strong></p></td>
<td colspan="13"><p>Case Number</p>
<p><strong>     </strong></p></td>
</tr>
<tr class="odd">
<td colspan="39"><em><strong>Agency Use Only (Complete items A through P
using Instructions provided by the investigating
agency).</strong></em></td>
</tr>
<tr class="even">
<td colspan="9"><strong>A</strong> Type of</td>
<td colspan="6"><strong>B</strong> Extra</td>
<td colspan="6"><strong>C</strong> Sensitivity</td>
<td colspan="2"><strong>D</strong> Access</td>
<td colspan="5"><strong>E</strong> Nature of</td>
<td colspan="3"><strong>F</strong> Date of</td>
<td colspan="3">Month</td>
<td colspan="4">Day</td>
<td>Year</td>
</tr>
<tr class="odd">
<td colspan="3">Investigation</td>
<td colspan="6"><strong>     </strong></td>
<td>Coverage</td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2">Level</td>
<td colspan="4"><strong>     </strong></td>
<td></td>
<td><strong>     </strong></td>
<td colspan="2">Action Code</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2">Action</td>
<td></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="4"><strong>  </strong></td>
<td colspan="2"><strong>  </strong></td>
</tr>
<tr class="even">
<td colspan="13"><strong>G</strong> Geographic</td>
<td colspan="4"><strong>H</strong> Position</td>
<td colspan="22"><strong>I</strong> Position</td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Location</strong></td>
<td colspan="10"><strong>     </strong></td>
<td colspan="4"><strong>Code</strong></td>
<td><strong>     </strong></td>
<td colspan="4">Title</td>
<td colspan="18"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="7"><strong>J</strong> SON</td>
<td colspan="11"><strong>K</strong> Location of Official None</td>
<td colspan="18">Other Address</td>
<td colspan="3">Zip Code</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="6"><p><strong>Personnel</strong></p>
<p><strong>Folder</strong></p></td>
<td colspan="6"><p> <strong>NPRC</strong></p>
<p> <strong>At SON</strong></p></td>
<td colspan="17"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="7"><strong>L</strong> SOI</td>
<td colspan="11"><strong>M</strong> Location of None</td>
<td colspan="18">Other Address</td>
<td colspan="3">Zip Code</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="6"><strong>Security Folder</strong></td>
<td colspan="6"><p> <strong>At Sol</strong></p>
<p> <strong>NPI</strong></p></td>
<td colspan="17"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="7"><strong>N</strong> OPAC-ALC</td>
<td colspan="4"></td>
<td colspan="25"><strong>O</strong> Accounting Data and/or</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4">Number</td>
<td colspan="7"><strong>     </strong></td>
<td colspan="8">Agency Case Number</td>
<td colspan="17"><strong>     </strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="5"><strong>P</strong> Requesting</td>
<td colspan="14">Name and Title</td>
<td colspan="8">Signature</td>
<td colspan="5">Telephone Number</td>
<td colspan="7">Date</td>
</tr>
<tr class="odd">
<td colspan="4">Official</td>
<td colspan="15"><strong>     </strong></td>
<td colspan="8"></td>
<td colspan="5">(<strong>   )     </strong></td>
<td colspan="7"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="39"><em><strong>Persons completing this form should begin
with the questions below.</strong></em></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><strong>1</strong> FULL</td>
<td colspan="13">- If you have only initials in your name, use them and
state (IO).</td>
<td colspan="15">- If you are a ‘”Jr.,” Sr.,” etc., enter this in the
box after</td>
<td colspan="6"><strong>2</strong> DATE OF</td>
</tr>
<tr class="even">
<td colspan="3">NAME</td>
<td colspan="13">- If you have no middle name, enter “NMN.”</td>
<td colspan="15">Your middle name.</td>
<td></td>
<td colspan="5">BIRTH</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Last Name</strong></td>
<td colspan="10">First Name</td>
<td colspan="6">Middle Name</td>
<td colspan="3"><strong>Jr., II, etc.</strong></td>
<td colspan="3"><strong>Month</strong></td>
<td colspan="2"><strong>Day</strong></td>
<td><strong>Year</strong></td>
</tr>
<tr class="even">
<td colspan="12"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>  </strong></td>
<td colspan="2"><strong>  </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td><strong>3</strong></td>
<td colspan="15">PLACE OF BIRTH - Use the two letter code for the
State.</td>
<td colspan="11"></td>
<td colspan="10"><strong>4 SOCIAL SECURITY NUMBER</strong></td>
</tr>
<tr class="even">
<td colspan="8">City</td>
<td colspan="8">County</td>
<td colspan="3">State</td>
<td colspan="8">Country <em>(If not in the United States)</em></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
<td colspan="3"><strong>  </strong></td>
<td colspan="8"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>5</strong></td>
<td colspan="35"><p><strong>OTHER NAMES USED</strong></p>
<p>Give other names you used and the period of time you used them
<em>(for example: your maiden name, name(s) by a former marriage, former
name(s), alias(es), or</em></p>
<p><em>nickname(s)).</em> If the other name is your <strong>maiden
name</strong>, put “<strong>nee</strong>” in front of it.</p></td>
</tr>
<tr class="odd">
<td colspan="10">Name</td>
<td colspan="3">Month/Year</td>
<td colspan="2"></td>
<td colspan="3">Month/Year</td>
<td colspan="11">Name</td>
<td colspan="4">Month/Year</td>
<td colspan="2"></td>
<td colspan="2">Month/Year</td>
</tr>
<tr class="even">
<td colspan="10"><strong>#1      </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2">To</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="11"><strong>#3      </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="2"><strong>To</strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="10">Name</td>
<td colspan="3">Month/Year</td>
<td colspan="2"></td>
<td colspan="3">Month/Year</td>
<td colspan="11">Name</td>
<td colspan="4">Month/Year</td>
<td colspan="2"></td>
<td colspan="2">Month/Year</td>
</tr>
<tr class="even">
<td colspan="10"><strong>#2      </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2">To</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="11"><strong>#4</strong> <strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="2"><strong>To</strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>6</strong></td>
<td colspan="4"><strong>OTHER</strong></td>
<td colspan="5">Height <em>(feet and inches)</em></td>
<td colspan="5">Weight <em>(pounds)</em></td>
<td colspan="10">Hair Color</td>
<td colspan="4">Eye Color</td>
<td colspan="8">Sex <em>(mark one box)</em></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"><p><strong>IDENTIFYING</strong></p>
<p><strong>INFORMATION</strong></p></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"> Female Male</td>
</tr>
<tr class="odd">
<td><strong>7</strong></td>
<td colspan="4"><strong>TELEPHONE</strong></td>
<td colspan="15">Work <em>(include Area Code and extension)</em></td>
<td colspan="17">Home <em>(include area code)</em></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"><strong>NUMBERS</strong></td>
<td colspan="15"> Day Night (<strong>   )     </strong></td>
<td colspan="17"> Day Night (<strong>   )     </strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="5"></td>
<td colspan="17"></td>
<td colspan="6"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td><strong>8</strong></td>
<td colspan="5"><strong>CITIZENSHIP</strong></td>
<td colspan="17"> I am a U.S. citizen or national by birth in the U.S.
or U.S. territory/possession.</td>
<td colspan="6"><strong>Answer Items b and d</strong></td>
<td colspan="8"><strong>b Your Mother’s Maiden Name</strong></td>
</tr>
<tr class="odd">
<td><strong>a</strong></td>
<td colspan="5"><strong>Mark the box at the right that reflects your
current</strong></td>
<td colspan="17"> I am a U.S. citizen, but I was NOT born in the
U.S.</td>
<td colspan="6"><strong>Answer Items b, c, and d</strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"><strong>citizenship status, and follow its
instructions.</strong></td>
<td colspan="17"> I am not a U.S. citizen.</td>
<td colspan="6"><strong>Answer Items b, and e</strong></td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"></td>
<td colspan="28"></td>
</tr>
<tr class="even">
<td><strong>c</strong></td>
<td colspan="8"><strong>UNITED STATES CITIZENSHIP</strong></td>
<td colspan="28">If you are a U.S. Citizen, but were not born in the
U.S., provide information about one or more of the following proofs of
your citizenship.</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="36"><strong>Naturalization Certificate <em>(Where was the
certificate issued?)</em></strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="13">Court</td>
<td colspan="9">City</td>
<td colspan="3">State</td>
<td colspan="5">Certificate Number</td>
<td colspan="6">Month/Day/Year Issued</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="13"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
<td colspan="3"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="36"><strong>Citizenship Certificate <em>(Where was the
certificate issued?)</em></strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="22">City</td>
<td colspan="3">State</td>
<td colspan="5">Certificate Number</td>
<td colspan="6">Month/Day/Year Issued</td>
</tr>
<tr class="even">
<td></td>
<td colspan="22"><strong>     </strong></td>
<td colspan="3"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="36"><strong>State Department Form 240 - Report of Birth
Abroad of a Citizen of the United States</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="6"></td>
<td colspan="4">Month/Day/Year</td>
<td colspan="26">Explanation</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="6">Give the date the form was prepared and give an
explanation if needed.</td>
<td colspan="4"><strong>     </strong></td>
<td colspan="26"><strong>     </strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="36"><strong>U.S. Passport</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="12"></td>
<td colspan="18">Passport Number</td>
<td colspan="6">Month/Day/Year Issued</td>
</tr>
<tr class="even">
<td></td>
<td colspan="12">This may be either a current or previous U.S.
Passport.</td>
<td colspan="18"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>d</strong></td>
<td colspan="5"><strong>DUAL CITIZENSHIP</strong></td>
<td colspan="12">If you are <em>(or were)</em> a dual citizen of the
United States and another</td>
<td colspan="19">Country</td>
</tr>
<tr class="even">
<td></td>
<td colspan="5"></td>
<td colspan="12">country, provide the name of that country in the space
to the right.</td>
<td colspan="19"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>e</strong></td>
<td colspan="36"><strong>ALIEN</strong> If you are an alien, provide the
following information:</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3"></td>
<td colspan="13">City</td>
<td colspan="2">State</td>
<td colspan="5">Date you entered the U.S.</td>
<td colspan="6">Alien Registration Number</td>
<td colspan="7">Country(ies) of Citizenship</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">Place you entered the United States</td>
<td colspan="13"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="2"><p>Month</p>
<p><strong>  </strong></p></td>
<td><p>Day</p>
<p><strong>  </strong></p></td>
<td colspan="2"><p>Year</p>
<p><strong>  </strong></p></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
</tr>
</tbody>
</table>

**Page 1**

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 14%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 9%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>9</strong></td>
<td colspan="20"><strong>WHERE YOU HAVE LIVED</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="20"><p>List the places where you have lived, beginning with
the most recent (#1) and working back 7 years. All periods must be
accounted for in your list. Be sure to indicate the actual physical
location of your residence: do not use a post office box as an address,
do not list a permanent address when you were actually living at a
school address, etc. Be sure to specify your location as closely as
possible: for example, do not list only your base or ship, list your
barracks number or home port. You may omit temporary military duty
locations under 90 days (list your permanent address instead), and you
should use your APO/FPO address if you lived overseas.</p>
<p>For any address in the last 5 years, list a person who knew you at
that address, and who preferably still lives in that area (do not list
people for residences completely outside this 5-year period, and do not
list your spouse, or other relatives). Also for addresses in the last
five years, if the addresses is “General Delivery,” a Rural or Star
Route, or may be difficult to locate, provide directions for locating
the residence on an attached continuation sheet.</p></td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="6">Street Address</td>
<td>Apt. #</td>
<td colspan="6">City (County)</td>
<td colspan="2">State</td>
<td>ZIP Code</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>     </strong></p>
<p><strong>#1</strong></p></td>
<td>To</td>
<td><strong>Present</strong></td>
<td colspan="6"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td>Apt. #</td>
<td colspan="3">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="6">Street Address</td>
<td>Apt. #</td>
<td colspan="6">City (County)</td>
<td colspan="2">State</td>
<td>ZIP Code</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>     </strong></p>
<p><strong>#2</strong></p></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td>Apt. #</td>
<td colspan="3">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="6">Street Address</td>
<td>Apt. #</td>
<td colspan="6">City (County)</td>
<td colspan="2">State</td>
<td>ZIP Code</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>     </strong></p>
<p><strong>#3</strong></p></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td>Apt. #</td>
<td colspan="3">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="6">Street Address</td>
<td>Apt. #</td>
<td colspan="6">City (County)</td>
<td colspan="2">State</td>
<td>ZIP Code</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>     </strong></p>
<p><strong>#4</strong></p></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td>Apt. #</td>
<td colspan="3">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="6">Street Address</td>
<td>Apt. #</td>
<td colspan="6">City (County)</td>
<td colspan="2">State</td>
<td>ZIP Code</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>     </strong></p>
<p><strong>#5</strong></p></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td>Apt. #</td>
<td colspan="3">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td><strong>10</strong></td>
<td colspan="20"><strong>WHERE YOU WENT TO SCHOOL</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="20">List the schools you have attended, beyond Junior High
School, <strong>beginning with the most recent (#1) and working back 7
years.</strong> List College or University degrees and the dates they
were received. If all of your education occurred more than 7 years ago,
list your most recent education beyond high school, no matter when that
education occurred.</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="19">- Use one of the following codes in the “Code”
block:</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="4">1 - High School</td>
<td colspan="6">2 - College/University/Military College</td>
<td colspan="7">3 - Vocational/Technical/Trade School</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="19"><p>- For schools you attended in the past 3 years, list
a person who knew you at school (an instructor, student, etc.). Do not
list people for education</p>
<p>completely outside this 3-year period.</p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="19">- For correspondence schools and extension classes,
provide the address where the records are maintained.</td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="2">Code</td>
<td colspan="5">Name of School</td>
<td colspan="7">Degree/Diploma/Other</td>
<td colspan="2">Month/Year Awarded</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>     </strong></p>
<p><strong>#1</strong></p></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="17">Street Address and City (Country) of School</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="17"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6">Name of Person Who Knew You</td>
<td colspan="3">Street Address</td>
<td>Apt. #</td>
<td colspan="3">City (Country)</td>
<td colspan="2">State</td>
<td colspan="4">ZIP Code</td>
<td colspan="2">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="2"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="2">Code</td>
<td colspan="5">Name of School</td>
<td colspan="7">Degree/Diploma/Other</td>
<td colspan="2">Month/Year Awarded</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>     </strong></p>
<p><strong>#2</strong></p></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="17">Street Address and City (Country) of School</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="17"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6">Name of Person Who Knew You</td>
<td colspan="3">Street Address</td>
<td>Apt. #</td>
<td colspan="3">City (Country)</td>
<td colspan="2">State</td>
<td colspan="4">ZIP Code</td>
<td colspan="2">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="2"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="2">Code</td>
<td colspan="5">Name of School</td>
<td colspan="7">Degree/Diploma/Other</td>
<td colspan="2">Month/Year Awarded</td>
</tr>
<tr class="even">
<td colspan="3"><p><strong>     </strong></p>
<p><strong>#3</strong></p></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="17">Street Address and City (Country) of School</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="17"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6">Name of Person Who Knew You</td>
<td colspan="3">Street Address</td>
<td>Apt. #</td>
<td colspan="3">City (Country)</td>
<td colspan="2">State</td>
<td colspan="4">ZIP Code</td>
<td colspan="2">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="6"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>    </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="2"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="16">Enter your Social Security Number before going to the
next page →</td>
<td colspan="5"><strong>     </strong></td>
</tr>
</tbody>
</table>

**Page 2**

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
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<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 13%" />
<col style="width: 13%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 8%" />
<col style="width: 3%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>11</strong></td>
<td colspan="21"><strong>YOUR EMPLOYMENT ACTIVITIES</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="21"><strong>List your employment activities, beginning with
the present (#1) and working back 7 years.</strong> You should list all
full-time work, part-time work, military service, temporary military
duty locations over 90 days, self-employment, other paid work, and all
periods of unemployment. The entire 7-year period must be accounted for
without breaks, but you need not list employments before your
16<sup>th</sup> birthday. EXCEPTION: Show all Federal civilian service,
whether it occurred within the last 7 years or not.</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="20"><strong>- Code.</strong> Use one of the codes listed
below to identify the type of employment:</td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"><p>1-</p>
<p>2-</p>
<p>3-</p>
<p>4-</p></td>
<td colspan="6"><p>Active military duty stations</p>
<p>National Guard/Reserve</p>
<p>U.S.P.H.S. Commissioned Corps</p>
<p>Other Federal employment</p></td>
<td><p>5-</p>
<p>6-</p></td>
<td colspan="2"><p>State Government (Non-Federal employment)</p>
<p>Self-employment (Include business name and/or name of person who can
verify)</p></td>
<td><p>7-</p>
<p>8-</p></td>
<td colspan="5"><p>Unemployment (Include name of person who can
verify)</p>
<p>Federal Contractor (List Contractor, not Federal Agency</p></td>
<td>9-</td>
<td>Other</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="20"><strong>- Employer/Verifier Name.</strong> List the
business name of your employer or the name of the person who can verify
your self-employment or unemployment in this block. If military service
is being listed, include your duty location or home port here as well as
your branch of service. You should provide separate listings to reflect
changes in your military duty locations or home ports.</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="20"><strong>- Previous Periods of Activity.</strong>
Complete these lines if you worked for an employer in more than one
occasion at the same location. After entering the most recent period of
employment in the initial numbered block, provide previous periods of
employment at the same location on the additional lines provided. For
example, if you worked at XY Plumbing in Denver, CO, during 3 separate
periods of time, you would enter dates and information concerning the
most recent period of employment first, and provide dates, position
titles, and supervisors for the two previous periods of employment on
the lines below that information.</td>
</tr>
<tr class="odd">
<td colspan="5">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td>Code</td>
<td colspan="6">Employer/Verifier Name/Military Duty Location</td>
<td colspan="6">Your Position Title/Military Rank</td>
</tr>
<tr class="even">
<td colspan="5"><p><strong>     </strong></p>
<p><strong>#1</strong></p></td>
<td>To</td>
<td colspan="3"><strong>Present</strong></td>
<td><strong> </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Employer’s/Verifier’s Street Address</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td>Code</td>
<td colspan="6">Employer/Verifier Name/Military Duty Location</td>
<td colspan="6">Your Position Title/Military Rank</td>
</tr>
<tr class="even">
<td colspan="5"><p><strong>     </strong></p>
<p><strong>#2</strong></p></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td><strong> </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Employer’s/Verifier’s Street Address</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="5">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td>Code</td>
<td colspan="6">Employer/Verifier Name/Military Duty Location</td>
<td colspan="6">Your Position Title/Military Rank</td>
</tr>
<tr class="even">
<td colspan="5"><p><strong>     </strong></p>
<p><strong>#3</strong></p></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td><strong> </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Employer’s/Verifier’s Street Address</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="13">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td colspan="13"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="18">Enter your Social Security Number before going to the
next page →</td>
<td colspan="4"><strong>     </strong></td>
</tr>
</tbody>
</table>

**Page 3**

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 21%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="22"><strong>YOUR EMPLOYMENT ACTIVITIES
(CONTINUED)</strong></td>
</tr>
<tr class="even">
<td colspan="4">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td>Code</td>
<td colspan="6">Employer/Verifier Name/Military Duty Location</td>
<td colspan="8">Your Position Title/Military Rank</td>
</tr>
<tr class="odd">
<td colspan="4"><p><strong>     </strong></p>
<p><strong>#4</strong></p></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td><strong> </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="10">Employer’s/Verifier’s Street Address</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="10">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="10">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="4">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td>Code</td>
<td colspan="6">Employer/Verifier Name/Military Duty Location</td>
<td colspan="8">Your Position Title/Military Rank</td>
</tr>
<tr class="odd">
<td colspan="4"><p><strong>     </strong></p>
<p><strong>#5</strong></p></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td><strong> </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="10">Employer’s/Verifier’s Street Address</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="10">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="10">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="4">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td>Code</td>
<td colspan="6">Employer/Verifier Name/Military Duty Location</td>
<td colspan="8">Your Position Title/Military Rank</td>
</tr>
<tr class="odd">
<td colspan="4"><p><strong>     </strong></p>
<p><strong>#6</strong></p></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td><strong> </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="10">Employer’s/Verifier’s Street Address</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="10">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="10">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="5">City (Country)</td>
<td colspan="2">State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="10"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="4">Position Title</td>
<td colspan="10">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>12</strong></td>
<td colspan="22"><strong>PEOPLE WHO KNOW YOU WELL</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="22"><strong>List three people</strong> who know you well
and live in the United States. They should be good friends, peers,
colleagues, college roommates, etc., whose combined association with you
covers as well as possible the last 7 years. Do not list your spouse,
former spouses, or other relatives, and try not to list anyone who is
listed elsewhere on this form.</td>
</tr>
<tr class="even">
<td colspan="2">Name</td>
<td colspan="9"></td>
<td colspan="8">Dates Known</td>
<td colspan="4">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="11"><strong>#1      </strong></td>
<td colspan="3"><p>Month/Year</p>
<p><strong>     </strong></p></td>
<td colspan="2">To</td>
<td colspan="3"><p>Month/Year</p>
<p><strong>     </strong></p></td>
<td colspan="4"><p>Day</p>
<p>Night <strong>(   )      </strong></p></td>
</tr>
<tr class="even">
<td colspan="12">Home or Work Address</td>
<td colspan="9">City (Country)</td>
<td>State</td>
<td>ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
<td><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2">Name</td>
<td colspan="9"></td>
<td colspan="8">Dates Known</td>
<td colspan="4">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="11"><strong>#2      </strong></td>
<td colspan="3"><p>Month/Year</p>
<p><strong>     </strong></p></td>
<td colspan="2">To</td>
<td colspan="3"><p>Month/Year</p>
<p><strong>     </strong></p></td>
<td colspan="4"><p>Day</p>
<p>Night <strong>(   )      </strong></p></td>
</tr>
<tr class="even">
<td colspan="12">Home or Work Address</td>
<td colspan="9">City (Country)</td>
<td>State</td>
<td>ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
<td><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2">Name</td>
<td colspan="9"></td>
<td colspan="8">Dates Known</td>
<td colspan="4">Telephone Number</td>
</tr>
<tr class="odd">
<td colspan="11"><strong>#3      </strong></td>
<td colspan="3"><p>Month/Year</p>
<p><strong>     </strong></p></td>
<td colspan="2">To</td>
<td colspan="3"><p>Month/Year</p>
<p><strong>     </strong></p></td>
<td colspan="4"><p>Day</p>
<p>Night <strong>(   )      </strong></p></td>
</tr>
<tr class="even">
<td colspan="12">Home or Work Address</td>
<td colspan="9">City (Country)</td>
<td>State</td>
<td>ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>     </strong></td>
<td colspan="9"><strong>     </strong></td>
<td><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="18">Enter your Social Security Number before going to the
next page →</td>
<td colspan="5"><strong>     </strong></td>
</tr>
</tbody>
</table>

**Page 4**

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 14%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>13</strong></td>
<td colspan="27"><strong>YOUR SPOUSE</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="27">Mark one box to show your current marital status and
provide information about your spouse(s) in items a, and/or b.</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="7"> 1 - Never married</td>
<td colspan="7"> 3 - Separated</td>
<td colspan="12"> 5 - Divorced</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="7"> 2 - Married</td>
<td colspan="7"> 4 - Legally Separated</td>
<td colspan="12"> 6 - Widowed</td>
</tr>
<tr class="odd">
<td><strong>a</strong></td>
<td colspan="27"><strong>CURRENT SPOUSE</strong> Complete the following
about your current spouse only.</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7">Full Name</td>
<td colspan="4">Date of Birth</td>
<td colspan="10">Place of Birth <em>(Include country if outside the
U.S.)</em></td>
<td colspan="6">Social Security Number</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="22">Other Names Used <em>(Specify maiden name, names by
other marriages, etc., and show dates used for each name)</em></td>
<td colspan="5">Country(ies) of Citizenship</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="22"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="6">Date Married</td>
<td colspan="20">Place Married <em>(include country if outside the
U.S.)</em></td>
<td>State</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="20"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="6">If Separated, Date of Separation</td>
<td colspan="20">If Legally Separated, Where is the Record Located? City
<em>(Country)</em></td>
<td>State</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="20"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="23">Address of Current Spouse, if different than your
current address <em>(Street, city, and country if outside the
U.S.)</em></td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="23"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>b</strong></td>
<td colspan="27"><strong>Former Spouse(s)</strong> Complete the
following about your former spouse(s), use blank sheets if needed.</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Full Name</td>
<td colspan="4">Date of Birth</td>
<td colspan="15">Place of Birth <em>(Include country if outside the
U.S.)</em></td>
<td>State</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="15"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Country(ies) of Citizenship</td>
<td colspan="4">Date Married</td>
<td colspan="15">Place Married <em>(Include country if outside the
U.S.)</em></td>
<td>State</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="15"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Check One, Then Give Date</td>
<td colspan="4">Month/Year</td>
<td colspan="15">If Divorced, Where is the Record Located? City
<em>(Country)</em></td>
<td>State</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"> Divorced Widowed</td>
<td colspan="4"><strong>     </strong></td>
<td colspan="15"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="18">Address of Former Spouse <em>(Street, city, and country
if outside the U.S.)</em></td>
<td colspan="2">State</td>
<td colspan="4">ZIP Code</td>
<td colspan="3">Telephone Number</td>
</tr>
<tr class="even">
<td></td>
<td colspan="18"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="3"><strong>(   )      </strong></td>
</tr>
<tr class="odd">
<td><strong>14</strong></td>
<td colspan="27"><strong>YOUR RELATIVES AND ASSOCIATES</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="27">Give the full name, correct code, and other requested
information for each of your relatives and associates, living or dead,
specified below.</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"><p>1-</p>
<p>2-</p>
<p>3-</p>
<p>4-</p></td>
<td><p>Mother <em>(first)</em></p>
<p><em>Father (second)</em></p>
<p><em>Stepmother</em></p>
<p><em>Stepfather</em></p></td>
<td><p>5-</p>
<p>6-</p>
<p>7-</p>
<p>8-</p></td>
<td colspan="5"><p>Foster parent</p>
<p>Child <em>(adopted also)</em></p>
<p><em>Stepchild</em></p>
<p><em>Brother</em></p></td>
<td><p>9-</p>
<p>10-</p>
<p>11-</p>
<p>12-</p></td>
<td colspan="3"><p>Sister</p>
<p>Stepbrother</p>
<p>Stepsister</p>
<p>Half-brother</p></td>
<td><p>13-</p>
<p>14-</p>
<p>15-</p>
<p>16-</p></td>
<td colspan="3"><p>Half-sister</p>
<p>Father-in-law</p>
<p>Mother-in-law</p>
<p>Guardian</p></td>
<td colspan="2"><p>17-</p>
<p>18-</p>
<p>19-</p></td>
<td colspan="8"><p>Other Relative*</p>
<p>Associate*</p>
<p>Adult Currently Living With You</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="27">*Code 17 (Other Relative)-include only foreign national
relatives not listed in 1-16 with whom you or your spouse are bound by
affection, obligation, or close and continuing contact. Code 18
(Associates) - include only foreign national associates with whom you or
your spouse are bound by affection, obligation, or close and continuing
contact.</td>
</tr>
<tr class="odd">
<td colspan="6"><p>Full Name (if deceased, check box on the</p>
<p>left before entering name)</p></td>
<td colspan="2">Code</td>
<td colspan="5"><p>Date of Birth</p>
<p>Month/Day/Year</p></td>
<td colspan="2">Country of Birth</td>
<td colspan="2">Country(ies) of Citizenship</td>
<td colspan="10"><p>Current Street Address and City</p>
<p><em>(country)</em> of Living Relatives</p></td>
<td>State</td>
</tr>
<tr class="even">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>1</strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>2</strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="even">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="even">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="even">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="even">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="even">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="odd">
<td colspan="6"> <strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td><strong>  </strong></td>
</tr>
<tr class="even">
<td colspan="21">Enter your Social Security Number before going to the
next page →</td>
<td colspan="7"><strong>     </strong></td>
</tr>
</tbody>
</table>

**Page 5**

<table style="width:100%;">
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<col style="width: 4%" />
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<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 1%" />
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<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 2%" />
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<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 0%" />
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<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>15</strong></td>
<td colspan="24"><strong>CITIZENSHIP OF YOUR RELATIVES AND
ASSOCIATES</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="24">If your mother, father, sister, brother, child, or
current spouse or person with whom you have a spouse-like relationship
is a U.S. citizen by other than birth, or an alien residing in the U.S.,
provide the nature of the individual’s relationship to you (Spouse,
Spouse-like, Mother, etc.), and the individual’s name and date of birth
on the first line <em>(this information is needed to pair it accurately
with information in items 13 and 14).</em></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="24">On the second line, provide the individual’s
naturalization certificate or alien registration number and use one of
the document codes below to identify proof of citizenship status.
Provide additional information on that line as requested.</td>
</tr>
<tr class="even">
<td colspan="6"><p><strong>1.</strong></p>
<p><strong>2.</strong></p></td>
<td colspan="9"><p><strong>Naturalization Certificate:</strong> Provide
the date issued and the location where the person was naturalized
(Court, City, and State).</p>
<p><strong>Citizenship Certificate:</strong> Provide the date and
location issued (City and State).</p></td>
<td colspan="2"><p><strong>3.</strong></p>
<p><strong>4.</strong></p></td>
<td colspan="7"><p><strong>Alien Registration:</strong> Provide the date
and place where the person entered the U.S. (City and State).</p>
<p><strong>Other:</strong> Provide an explanation in the “Additional
Information” block.</p></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Association</td>
<td colspan="13">Name</td>
<td colspan="4">Date of Birth (Month/Day/Year)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"><strong>#1      </strong></td>
<td colspan="13"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Certificate/Registration #</td>
<td colspan="3">Document Code</td>
<td colspan="14">Additional Information</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="14"><strong>     </strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Association</td>
<td colspan="13">Name</td>
<td colspan="4">Date of Birth (Month/Day/Year)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"><strong>#2      </strong></td>
<td colspan="13"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Certificate/Registration #</td>
<td colspan="3">Document Code</td>
<td colspan="14">Additional Information</td>
</tr>
<tr class="even">
<td></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="14"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>16</strong></td>
<td colspan="24"><strong>YOUR MILITARY HISTORY</strong></td>
</tr>
<tr class="even">
<td><strong>a</strong></td>
<td colspan="22">Have you served in the United States military?</td>
<td colspan="2"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>b</strong></td>
<td colspan="22">Have you served in the United States Merchant
Marine?</td>
<td colspan="2"> Yes No</td>
</tr>
<tr class="even">
<td colspan="25">List all of your military service below, including
service in Reserve, National Guard, and U.S. Merchant Marine. Start with
the most recent period of service (#1) and work backward. If you had a
break in service, each separate period should be listed.</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="22"><strong>-</strong> <strong>Code.</strong> Use one of
the codes listed below to identify your branch of service:</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"><strong>1 - Air Force</strong></td>
<td colspan="3"><strong>2 - Army</strong></td>
<td colspan="2"><strong>3 - Navy</strong></td>
<td colspan="4"><strong>4 - Marine Corps</strong></td>
<td colspan="4"><strong>5 - Coast Guard</strong></td>
<td colspan="3"><strong>6 - Merchant Marine</strong></td>
<td colspan="4"><strong>7 - National Guard</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="22"><strong>-</strong> <strong>O/E.</strong> Mark “O” block
for Officer or “E” block for Enlisted.</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="24"><strong>-</strong> <strong>Status. “X” the appropriate
block for the status of your service during the time that you served. If
your service was in the National Guard, do</strong></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="23">not use an “X”: use the two letter code for the state
to mark the block.</td>
</tr>
<tr class="even">
<td></td>
<td colspan="24"><strong>-</strong> <strong>Country.</strong> If your
service was with other than the U.S. Armed Forces, identify the country
for which you served.</td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td colspan="2">Code</td>
<td colspan="3">Service/Certificate #</td>
<td>O</td>
<td>E</td>
<td colspan="8">Status</td>
<td colspan="3">Country</td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td colspan="2"><p>Active</p>
<p><strong>     </strong></p></td>
<td colspan="3"><p>Active</p>
<p>Reserve</p>
<p><strong>     </strong></p></td>
<td><p>Inactive Reserve</p>
<p><strong>     </strong></p></td>
<td colspan="2"><p>National Guard (State)</p>
<p><strong>     </strong></p></td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="3"><strong>     </strong></td>
<td></td>
<td></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>17</strong></td>
<td colspan="24"><strong>YOUR FOREIGN ACTIVITIES</strong></td>
</tr>
<tr class="odd">
<td><strong>a</strong></td>
<td colspan="22">Do you have any foreign property, business connections,
or financial interests?</td>
<td colspan="2"> Yes No</td>
</tr>
<tr class="even">
<td><strong>b</strong></td>
<td colspan="22">Are you now or have you ever been employed by or acted
as a consultant for a foreign government, firm, or agency?</td>
<td colspan="2"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>c</strong></td>
<td colspan="22">Have you ever had any contact with a foreign
government, its establishments (embassies or consulates), or its
representatives, whether inside or outside the U.S., other than on
official U.S. Government business? (Does not include routine visa
applications and border crossing contacts.)</td>
<td colspan="2"> Yes No</td>
</tr>
<tr class="even">
<td><strong>d</strong></td>
<td colspan="22">In the last 7 years, have you had an active passport
that was issued by a foreign government?</td>
<td colspan="2"> Yes No</td>
</tr>
</tbody>
</table>

If you answered "Yes" to a, b, c, or d above, explain in the space
below: provide inclusive dates, names of firms and/or governments
involved, and an explanation of your involvement.

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 10%" />
<col style="width: 4%" />
<col style="width: 15%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 21%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="2">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td colspan="3">Firm and/or Government</td>
<td colspan="10">Explanation</td>
</tr>
<tr class="even">
<td colspan="2"><strong>     </strong></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>     </strong></td>
<td>To</td>
<td><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>18</strong></td>
<td colspan="16"><strong>FOREIGN COUNTRIES YOU HAVE
VISITED</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="16">List foreign countries you have visited, except on
travel under official Government orders, beginning with the most current
(#1) and working back 7 years. (Travel as a dependent or contractor must
be listed.)</td>
</tr>
<tr class="even">
<td></td>
<td colspan="5">- Use one of these codes to indicate the purpose of your
visit:</td>
<td colspan="3">1 - Business</td>
<td colspan="3">2 - Pleasure</td>
<td colspan="3">3 - Education</td>
<td colspan="2">4 - Other</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="16"><p>- Include short trips to Canada or Mexico. If you
have lived near a border and have made short (one day or less) trips to
the neighboring country, you do</p>
<p>not need to list each trip. Instead, provide the time period, the
code, the country, and a note (“Many Short Trips”).</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="16">- Do not repeat travel covered in items 9, 10, or
11.</td>
</tr>
<tr class="odd">
<td colspan="2">Month/Year</td>
<td></td>
<td>Month/Year</td>
<td>Code</td>
<td colspan="3">Country</td>
<td colspan="2">Month/Year</td>
<td></td>
<td colspan="2">Month/Year</td>
<td colspan="2">Code</td>
<td colspan="2">Country</td>
</tr>
<tr class="even">
<td colspan="2"><strong>#1     </strong></td>
<td>To</td>
<td><strong>     </strong></td>
<td><strong> </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>#3     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>#2     </strong></td>
<td>To</td>
<td><strong>     </strong></td>
<td><strong> </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong>#4     </strong></td>
<td>To</td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="14"><strong>This concludes Part 1 of this form. If you have
used Page 9, continuation sheets, or blank sheets to complete any of the
questions in Part 1, give the number for those questions in the space to
the right.</strong></td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="16">Enter your Social Security Number before going to the
next page →</td>
<td><strong>     </strong></td>
</tr>
</tbody>
</table>

**Page 6**

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 9%" />
<col style="width: 25%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 6%" />
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</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><p>Standard Form 86</p>
<p>Revised September 1995</p>
<p><strong>U.S. Office of Personnel Management</strong></p>
<p><strong>5 CFR</strong> Parts 731, <strong>732. and
736</strong></p></td>
<td colspan="3"><p><strong>QUESTIONNAIRE FOR</strong></p>
<p><strong>NATIONAL SECURITY POSITIONS</strong></p></td>
<td colspan="3"></td>
<td colspan="5"><p>Form approved:</p>
<p>O.M.B. No 3206 0007</p>
<p>NSN 7540-00-634-4036</p>
<p>86‑111</p></td>
<td></td>
</tr>
<tr class="even">
<td colspan="6"><strong>Part 2</strong></td>
<td colspan="16"><p>OFFICIAL</p>
<p>USE</p>
<p>ONLY</p></td>
<td></td>
</tr>
<tr class="odd">
<td><strong>19</strong></td>
<td colspan="22"><strong>YOUR MILITARY RECORD</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="18"><p>Have you ever received other than an honorable
discharge from the military?</p>
<p>If “Yes,” provide the date of discharge and type of discharge
below.</p></td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td colspan="20">Type of Discharge</td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td colspan="20"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>20</strong></td>
<td colspan="22"><strong>YOUR SELECTIVE SERVICE RECORD</strong></td>
</tr>
<tr class="even">
<td><strong>a</strong></td>
<td colspan="18">Are you a male born after December 31, 1959? If “No,”
go to 21. If “Yes,” go to <strong>b</strong>.</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>b</strong></td>
<td colspan="18">Have you registered with the Selective Service System?
If “Yes,” provide your registration number. If “No,” show the reason for
your legal exemption below.</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td colspan="7">Registration Number</td>
<td colspan="16">Legal Exemption Explanation</td>
</tr>
<tr class="odd">
<td colspan="7"><strong>     </strong></td>
<td colspan="16"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>21</strong></td>
<td colspan="22"><strong>YOUR MEDICAL RECORD</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="18">In the last 7 years, have you consulted with a mental
health professional (psychiatrist, psychologist, counselor, etc.) or
have you consulted with another health care provider about a mental
health related condition?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td></td>
<td colspan="18">If you answered “Yes,” provide the dates of treatment
and the name and address of the therapist or doctor below, unless the
consultation(s) involved only marital, family, or grief counseling, not
related to violence by you.</td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="4">Month/Year</td>
<td colspan="12">Name/Address of Therapist or Doctor</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="4"><strong>     </strong></td>
<td colspan="12"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="4"><strong>     </strong></td>
<td colspan="12"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>22</strong></td>
<td colspan="22"><strong>YOUR EMPLOYMENT RECORD</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="18">Has any of the following happened to you <strong>in the
last 7 years</strong>? If “Yes,” begin with the most recent occurrence
and go backward, providing date fired, quit, or left, and other
information requested.</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td></td>
<td colspan="18">Use the following codes and explain the reason your
employment was ended:</td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td></td>
<td><p><strong>1 -</strong></p>
<p><strong>2 -</strong></p></td>
<td colspan="8"><p>Fired from a job</p>
<p>Quit a job after being told you’d be fired</p></td>
<td colspan="2"><p><strong>3 -</strong></p>
<p><strong>4 -</strong></p></td>
<td colspan="3"><p>Left a job by mutual agreement following allegations
of misconduct</p>
<p>Left a job by mutual agreement following allegations of
unsatisfactory performance</p></td>
<td colspan="3"><strong>5 -</strong></td>
<td colspan="5">Left a job for other reasons under unfavorable
circumstances</td>
</tr>
<tr class="even">
<td colspan="3">Month/Year</td>
<td colspan="2">Code</td>
<td colspan="8">Specify Reason</td>
<td colspan="7">Employer’s Name and Address <em>(Include city/Country if
outside U.S.)</em></td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="8"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td colspan="2"><strong> </strong></td>
<td colspan="8"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>23</strong></td>
<td colspan="22"><strong>YOUR POLICE RECORD</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="18">For this item, report information regardless of whether
the record in your case has been “sealed” or otherwise stricken from the
court record. The single exception to this requirement is for certain
convictions under the Federal Controlled Substances Act for which the
court issued an expungement order under the authority of 21 U.S.C. 844
or 18 U.S.C. 3607.</td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td><strong>a</strong></td>
<td colspan="18">Have you ever been charged with or convicted of any
felony offense? (Include those under Uniform Code of Military
Justice)</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td><strong>b</strong></td>
<td colspan="18">Have you ever been charged with or convicted of a
firearms or explosives offense?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>c</strong></td>
<td colspan="18">Are there currently any charges pending against you for
any criminal offense?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td><strong>d</strong></td>
<td colspan="18">Have you ever been charged with or convicted of any
offense(s) related to alcohol or drugs?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>e</strong></td>
<td colspan="18">In the last 7 years, have you been subject to court
martial or other disciplinary proceedings under the Uniform Code of
Military Justice? (Include non-judicial, Captain’s mast, etc.)</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td><strong>f</strong></td>
<td colspan="18">In the last 7 years, have you been arrested for,
charged with, or convicted of any offense(s) not listed in response to
a, b, c, d, or e above? (Leave out traffic fines of less than $150
unless the violation was alcohol or drug related.)</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="22"><p>If you answered “Yes” to a, b, c, d, e, or f above,
explain below. Under “Offense,” do not list specific penalty codes, list
the actual offense or violation</p>
<p>(for example, arson, theft, etc.)</p></td>
</tr>
<tr class="even">
<td colspan="3">Month/Year</td>
<td colspan="6">Offense</td>
<td colspan="4">Action Taken</td>
<td colspan="7">Law Enforcement Authority/Court <em>(Include City and
county/country if outside U.S.)</em></td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td colspan="6"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="16">Enter your Social Security Number before going to the
next page →</td>
<td colspan="7"><strong>     </strong></td>
</tr>
</tbody>
</table>

**Page 7**

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 12%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 12%" />
<col style="width: 7%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>24</strong></td>
<td colspan="24"><strong>YOUR USE OF ILLEGAL DRUGS AND DRUG
ACTIVITY</strong></td>
</tr>
<tr class="even">
<td></td>
<td colspan="19">The following questions pertain to the illegal use of
drugs or drug activity. You are required to answer the questions fully
and truthfully, and your failure to do so could be grounds for an
adverse employment decision or action against you, but neither your
truthful responses nor information derived from your responses will be
used as evidence against you in any subsequent criminal proceeding.</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td><strong>a</strong></td>
<td colspan="19">Since the age of 16 or in the last 7 years, whichever
is shorter, have you <u>illegally</u> used any controlled substance, for
example, marijuana, cocaine, crack cocaine, hashish, narcotics (opium,
morphine, codeine, heroin, etc.), amphetamines, depressants
(barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD,
PCP, etc.), or prescription drugs?</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="even">
<td><strong>b</strong></td>
<td colspan="19">Have you <u>ever</u> illegally used a controlled
substance while employed as a law enforcement officer, prosecutor, or
courtroom official; while possessing a security clearance; or while in a
position directly and immediately affecting the public safety?</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>c</strong></td>
<td colspan="19">In the last 7 years, have you been involved in the
illegal purchase, manufacture, trafficking, production, transfer,
shipping, receiving, or sale of any narcotic, depressant, stimulant,
hallucinogen, or cannabis for your own intended profit or that of
another?</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="even">
<td></td>
<td colspan="24">If you answered “Yes” to a or b above, provide the
date(s), identify the controlled substance(s) and/or prescription drugs
used, and the number of times each was used.</td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td colspan="10">Controlled Substance/Prescription Drug Used</td>
<td colspan="8">Number of Times Used</td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td colspan="8"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>25</strong></td>
<td colspan="24"><strong>YOUR USE OF ALCOHOL</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="19">In the last 7 years, has your use of alcoholic
beverages (such as liquor, beer, wine) resulted in any alcohol-related
treatment or counseling (such as for alcohol abuse or alcoholism)?</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="even">
<td></td>
<td colspan="24">If you answered “Yes,” provide the dates of treatment
and the name and address of the counselor or doctor below. Do not repeat
information reported in response to item 21 above.</td>
</tr>
<tr class="odd">
<td colspan="3">Month/Year</td>
<td></td>
<td colspan="3">Month/Year</td>
<td colspan="14">Name/Address of Counselor or Doctor</td>
<td colspan="3">State</td>
<td>ZIP Code</td>
</tr>
<tr class="even">
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="14"><strong>     </strong></td>
<td colspan="3"><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>     </strong></td>
<td>To</td>
<td colspan="3"><strong>     </strong></td>
<td colspan="14"><strong>     </strong></td>
<td colspan="3"><strong>  </strong></td>
<td><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>26</strong></td>
<td colspan="24"><strong>YOUR INVESTIGATIONS RECORD</strong></td>
</tr>
<tr class="odd">
<td><strong>a</strong></td>
<td colspan="19">Has the United States Government ever investigated your
background and/or granted you a security clearance? If “Yes,” use the
codes that follow to provide the requested information below. If “Yes,”
but you can’t recall the investigating agency and/or the security
clearance received, enter “Other” agency code or clearance code, as
appropriate, and “Don’t know” or Don’t recall” under the “Other Agency”
heading, below. If your response is “No,” or you don’t know or can’t
recall if you were investigated and cleared, check the “No” box.</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="even">
<td></td>
<td colspan="10">Codes for Investigating Agency</td>
<td colspan="14">Codes for Security Clearance Received</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7"><p>1 - Defense Department</p>
<p>2 - State Department</p>
<p>3 - Office of Personnel Management</p></td>
<td colspan="3"><p>4 - FBI</p>
<p>5 - Treasury Department</p>
<p>6 - Other <em>(Specify</em></p></td>
<td colspan="5"><p>0 - Not Required</p>
<p>1 - Confidential</p>
<p>2 - Secret</p></td>
<td colspan="6"><p>3 - Top Secret</p>
<p>4 - Sensitive Compartmented Information</p>
<p>5 - Q</p></td>
<td colspan="3"><p>6 - L</p>
<p>7 - Other</p></td>
</tr>
<tr class="even">
<td colspan="2">Month/Year</td>
<td colspan="3"><p>Agency</p>
<p>Code</p></td>
<td colspan="5">Other Agency</td>
<td colspan="2"><p>Clearance</p>
<p>Code</p></td>
<td colspan="2">Month/Year</td>
<td colspan="4"><p>Agency</p>
<p>Code</p></td>
<td colspan="5">Other Agency</td>
<td colspan="2"><p>Clearance</p>
<p>Code</p></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="5"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>b</strong></td>
<td colspan="19">To your knowledge, have you ever had a clearance or
access authorization denied, suspended, or revoked, or have you ever
been debarred from government employment? If “Yes,” give date of action
and agency. <strong>Note:</strong> An administrative downgrade or
termination of a security clearance is not a revocation.</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="even">
<td colspan="2">Month/Year</td>
<td colspan="10">Department or Agency Taking Action</td>
<td colspan="3">Month/Year</td>
<td colspan="10">Department or Agency Taking Action</td>
</tr>
<tr class="odd">
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="2"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="10"><strong>     </strong></td>
</tr>
<tr class="odd">
<td><strong>27</strong></td>
<td colspan="24"><strong>YOUR FINANCIAL RECORD</strong></td>
</tr>
<tr class="even">
<td><strong>a</strong></td>
<td colspan="19">In the last 7 years, have you filed a petition under
any chapter of the bankruptcy code (to include Chapter 13)?</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>b</strong></td>
<td colspan="19">In the last 7 years, have you had your wages garnished
or had any property repossessed for any reason?</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="even">
<td><strong>c</strong></td>
<td colspan="19">In the last 7 years, have you had a lien placed against
your property for failing to pay taxes or other debts?</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>d</strong></td>
<td colspan="19">In the last 7 years, have you had any judgments against
you that have not been paid?</td>
<td colspan="5"> Yes No</td>
</tr>
<tr class="even">
<td></td>
<td colspan="19">If you answered “Yes” to a, b, c, or d, provide the
information requested below:</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="2">Month/Year</td>
<td colspan="4">Type of Action</td>
<td colspan="3">Amount</td>
<td colspan="4">Name Action Occurred Under</td>
<td colspan="7">Name/Address of Court or Agency Handling Case</td>
<td colspan="3">Sate</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="3"><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="3"><strong>     </strong></td>
<td colspan="4"><strong>     </strong></td>
<td colspan="7"><strong>     </strong></td>
<td colspan="3"><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="19">Enter your Social Security Number before going to the
next page →</td>
<td colspan="6"><strong>     </strong></td>
</tr>
</tbody>
</table>

**Page 8**

<table style="width:100%;">
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 9%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 12%" />
<col style="width: 5%" />
<col style="width: 34%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td><strong>28</strong></td>
<td colspan="12"><strong>YOUR FINANCIAL DELINQUENCIES</strong></td>
</tr>
<tr class="even">
<td><strong>a</strong></td>
<td colspan="8">In the last 7 years, have you been over 180 days
delinquent on any debt(s)?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="odd">
<td><strong>b</strong></td>
<td colspan="8">Are you currently over 90 days delinquent on any
debt(s)?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">If you answered “Yes” to a or b, provide the information
requested below:</td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="2"><p>Incurred</p>
<p>Month/Year</p></td>
<td><p>Satisfied</p>
<p>Month/Year</p></td>
<td colspan="2">Amount</td>
<td colspan="2"><p>Type of Loan or Obligation</p>
<p>and Account Number</p></td>
<td colspan="2">Name/Address of Creditor or Obligee</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>  </strong></td>
<td colspan="2"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>29</strong></td>
<td colspan="12"><strong>PUBLIC RECORD CIVIL COURT ACTIONS</strong></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8">In the last 7 years, have you been a party to any public
record civil court actions not listed elsewhere on this form?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8">If you answered “Yes,” provide the information about the
public record civil court action requested below:</td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="2">Month/Year</td>
<td colspan="2">Nature of Action</td>
<td colspan="2">Result of Action</td>
<td colspan="2">Name of Parties Involved</td>
<td>Court <em>(Include City and county/country if outside
U.S.)</em></td>
<td>State</td>
<td colspan="3">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td colspan="2"><strong>     </strong></td>
<td><strong>     </strong></td>
<td><strong>  </strong></td>
<td colspan="3"><strong>     </strong></td>
</tr>
<tr class="even">
<td><strong>30</strong></td>
<td colspan="12"><strong>YOUR ASSOCIATION RECORD</strong></td>
</tr>
<tr class="odd">
<td><strong>a</strong></td>
<td colspan="8">Have you been an officer or a member or made a
contribution to an organization dedicated to the violent overthrow of
the United States Government and which engages in illegal activities to
that end, knowing that the organization engages in such activities with
the specific intent to further such activities?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="even">
<td><strong>b</strong></td>
<td colspan="8">Have you ever knowingly engaged in any acts or
activities designed to overthrow the United States Government by
force?</td>
<td colspan="4"> Yes No</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8">If you answered “Yes” to a or b, explain in the space
below:</td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="12"><strong>Continuation Space</strong></td>
<td></td>
</tr>
</tbody>
</table>

Use the continuation sheet(s) (SF 86A) for additional answers to items
9, 10, and 11. Use the space below to continue answers to all other
items and any information you would like to add. If more space is needed
than is provided below, use a blank sheet(s) of paper. Start each sheet
with your name and Social Security Number. Before each answer, identify
the number of the item.

+---+--------------------------------------------------+---+----------+
| * |                                                  |   |          |
| * |                                                  |   |          |
|   |                                                  |   |          |
|   |                                                  |   |          |
|   |                                                  |   |          |
|   |                                                  |   |          |
|   |                                                  |   |          |
| * |                                                  |   |          |
| * |                                                  |   |          |
+---+--------------------------------------------------+---+----------+
|   | **After completing Parts 1 and 2 of this form    |   |          |
|   | and any attachments, you should review your      |   |          |
|   | answers to all questions to make sure**          |   |          |
|   |                                                  |   |          |
|   | **the form is complete and accurate, and then    |   |          |
|   | sign and date the following certification and    |   |          |
|   | sign and date the release on page 10.**          |   |          |
+---+--------------------------------------------------+---+----------+
| * |                                                  |   |          |
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+---+--------------------------------------------------+---+----------+
| * |                                                  |   | **Date** |
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+---+--------------------------------------------------+---+----------+
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| → |                                                  |   |          |
+---+--------------------------------------------------+---+----------+

**Page 9**

+---------------------+--------------------------+-------+------------+
| Standard Form 86    |                          |       | Form       |
|                     |                          |       | approved:  |
| Revised September   |                          |       |            |
| 1995                |                          |       | O.M.B. No  |
|                     |                          |       | 3206 0007  |
| **U.S. Office of    |                          |       |            |
| Personnel           |                          |       | NSN        |
| Management**        |                          |       | 7540-0     |
|                     |                          |       | 0-634-4036 |
| **5 CFR** Parts     |                          |       |            |
| 731, **732. and     |                          |       | 86‑111     |
| 736**               |                          |       |            |
+---------------------+--------------------------+-------+------------+

**UNITED STATES OF AMERICA**

**AUTHORIZATION FOR RELEASE OF INFORMATION**

Carefully read this authorization to release information about you, then
sign and date it in ink.

**I Authorize** any investigator, special agent, or other duly
accredited representative of the authorized Federal agency conducting my
background investigation, to obtain any information relating to my
activities from individuals, schools, residential management agents,
employers, criminal justice agencies, credit bureaus, consumer reporting
agencies, collection agencies, retail business establishments, or other
sources of information. This information may include, but is not limited
to, my academic, residential, achievement, performance, attendance,
disciplinary, employment history, criminal history record information,
and financial and credit information. I authorize the Federal agency
conducting my investigation to disclose the record of my background
investigation to the requesting agency for the purpose of making a
determination of suitability or eligibility for a security clearance.

**I Understand** that, for financial or lending institutions, medical
institutions, hospitals, health care professionals, and other sources of
information, a separate specific release will be needed, and I may be
contacted for such a release at a later date. Where a separate release
is requested for information relating to mental health treatment or
counseling, the release will contain a list of the specific question,
relevant to the job description, which the doctor or therapist will be
asked.

**I Further Authorize** any investigator, special agent, or other duly
accredited representative of the U.S. Office of Personnel Management,
the Federal Bureau of Investigation, the Department of Defense, the
Defense Investigative Service, and any other authorized Federal agency,
to request criminal record information about me from criminal justice
agencies for the purpose of determining my eligibility for access to
classified information and/or for assignment to, or retention in, a
sensitive National Security position, in accordance with 5 U.S.C. 9101.
I understand that I may request a copy of such records as may be
available to me under the law.

**I Authorize** custodians of records and other sources of information
pertaining to me to release such information upon request of the
investigator, special agent, or other duly accredited representative of
any Federal agency authorized above regardless of any previous agreement
to the contrary.

**I Understand** that the information released by records custodians and
sources of information is for official use by the Federal Government
only for the purposes provided in this Standard Form 86, and that it may
be redisclosed by the Government only as authorized by law.

Copies of this authorization that show my signature are as valid as the
original release signed by me. This authorization is valid for five (5)
years from the date signed or upon the termination of my affiliation
with the Federal Government, whichever is sooner. Read, sign and date
the release on the next page if you answered "Yes" to question 21.

+-----------------------------+-----------+----+-----+----+----------+
| **Signature *(Sign in       | **Full    |    |     |    | **Date   |
| Ink)***                     | Name      |    |     |    | Signed** |
|                             | *(Type or |    |     |    |          |
|                             | Print     |    |     |    | *        |
|                             | Le        |    |     |    | *     ** |
|                             | gibly)*** |    |     |    |          |
|                             |           |    |     |    |          |
|                             | **     ** |    |     |    |          |
+-----------------------------+-----------+----+-----+----+----------+
| **Other Names Used**        |           |    |     | ** |          |
|                             |           |    |     | So |          |
| **     **                   |           |    |     | ci |          |
|                             |           |    |     | al |          |
|                             |           |    |     | Se |          |
|                             |           |    |     | cu |          |
|                             |           |    |     | ri |          |
|                             |           |    |     | ty |          |
|                             |           |    |     | Nu |          |
|                             |           |    |     | mb |          |
|                             |           |    |     | er |          |
|                             |           |    |     | ** |          |
|                             |           |    |     |    |          |
|                             |           |    |     | *  |          |
|                             |           |    |     | *  |          |
|                             |           |    |     |    |          |
|                             |           |    |     |    |          |
|                             |           |    |     | ** |          |
+-----------------------------+-----------+----+-----+----+----------+
| **Current Address *(Street, |           | *  | **  | ** |          |
| City)***                    |           | *S | Zip | Ho |          |
|                             |           | ta | Cod | me |          |
| **     **                   |           | te | e** | T  |          |
|                             |           | ** |     | el |          |
|                             |           |    | **  | ep |          |
|                             |           | ** |     | ho |          |
|                             |           |    |  ** | ne |          |
|                             |           | ** |     | Nu |          |
|                             |           |    |     | mb |          |
|                             |           |    |     | er |          |
|                             |           |    |     | ** |          |
|                             |           |    |     |    |          |
|                             |           |    |     | *  |          |
|                             |           |    |     | ** |          |
|                             |           |    |     | (I |          |
|                             |           |    |     | nc |          |
|                             |           |    |     | lu |          |
|                             |           |    |     | de |          |
|                             |           |    |     | Ar |          |
|                             |           |    |     | ea |          |
|                             |           |    |     | Co |          |
|                             |           |    |     | de |          |
|                             |           |    |     | )* |          |
|                             |           |    |     | ** |          |
|                             |           |    |     |    |          |
|                             |           |    |     | *  |          |
|                             |           |    |     | *( |          |
|                             |           |    |     |    |          |
|                             |           |    |     |  ) |          |
|                             |           |    |     |    |          |
|                             |           |    |     |    |          |
|                             |           |    |     |    |          |
|                             |           |    |     | ** |          |
+-----------------------------+-----------+----+-----+----+----------+

**Page 10**

+---------------------+--------------------------+-------+------------+
| Standard Form 86    |                          |       | Form       |
|                     |                          |       | approved:  |
| Revised September   |                          |       |            |
| 1995                |                          |       | O.M.B. No  |
|                     |                          |       | 3206 0007  |
| **U.S. Office of    |                          |       |            |
| Personnel           |                          |       | NSN        |
| Management**        |                          |       | 7540-0     |
|                     |                          |       | 0-634-4036 |
| **5 CFR** Parts     |                          |       |            |
| 731, **732. and     |                          |       | 86‑111     |
| 736**               |                          |       |            |
+---------------------+--------------------------+-------+------------+

**UNITED STATES OF AMERICA**

**AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION**

Carefully read this authorization to release information about you, then
sign and date it in ink.

**Instructions for Completing this Release**

This is a release for the investigator to ask your health
practitioner(s) the three questions below concerning your mental health
consultations. Your signature will allow the practitioner(s) to answer
only these questions.

+---+----------------------+-------------+----+-----+----------------+
| I |                      |             |    |     |                |
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| l |                      |             |    |     |                |
| t |                      |             |    |     |                |
| a |                      |             |    |     |                |
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| n |                      |             |    |     |                |
| s |                      |             |    |     |                |
| : |                      |             |    |     |                |
+---+----------------------+-------------+----+-----+----------------+
|   | Does the person      |             |    |     |                |
|   | under investigation  |             |    |     |                |
|   | have a condition or  |             |    |     |                |
|   | treatment that could |             |    |     |                |
|   | impair his/her       |             |    |     |                |
|   | judgment or          |             |    |     |                |
|   | reliability,         |             |    |     |                |
|   | particularly in the  |             |    |     |                |
|   | context of           |             |    |     |                |
|   | safeguarding         |             |    |     |                |
|   | classified national  |             |    |     |                |
|   | security information |             |    |     |                |
|   | or special nuclear   |             |    |     |                |
|   | information or       |             |    |     |                |
|   | material? **     **  |             |    |     |                |
|   |                      |             |    |     |                |
|   | If so, please        |             |    |     |                |
|   | describe the nature  |             |    |     |                |
|   | of the condition and |             |    |     |                |
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