Standard Form 85P Form approved:

Revised September 1995 OMB No. 3206-0191

U.S. Office of Personnel Management NSN 7540-01-317-7372

5 CFR Parts 731, 732, and 736 85-1602

# Questionnaire for Public Trust Positions

Follow instructions fully or we cannot process your form. Be sure to
sign and date the certification statement on Page 7 and the release on
Page 8. *If you have any questions,* call the office that gave you the
form.

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­

**Purpose of this Form**

The U.S. Government conducts background investigations and
reinvestigations to establish that applicants or incumbents either
employed by the Government or working for the Government under contract,
are suitable for the job and/or eligible for a public trust or sensitive
position. Information from this form is used primarily as the basis for
this investigation. Complete this form only after a conditional offer of
employment has been made.

Giving us the information we ask for is voluntary. However, we may not
be able to complete your investigation, or complete it in a timely
manner, if you don't give us each item of information we request. This
may affect your placement or employment prospects.

**Authority to Request this Information**

The U.S. Government is authorized to ask for this information under
Executive Orders 10450 and 10577, sections 3301 and 3302 of title 5,
U.S. Code; and parts 5, 731, 732, and 736 of Title 5, Code of Federal
Regulations.

Your Social Security number is needed to keep records accurate, because
other people may have the same name and birth date. Executive Order 9397
also asks Federal agencies to use this number to help identify
individuals in agency records.

**The Investigative Process**

Background investigations are conducted using your responses on this
form and on your Declaration for Federal Employment (OF 306) to develop
information to show whether you are reliable, trustworthy, of good
conduct and character, and loyal to the United States. The information
that you provide on this form is confirmed during the investigation.
Your current employer must be contacted as part of the investigation,
even if you have previously indicated on applications or other forms
that you do not want this.

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

**Your Personal Interview**

Some investigations will include an interview with you as a normal part
of the investigative process. This provides you the opportunity to
update, clarify, and explain information on your form more completely,
which often helps to complete your investigation faster. It is important
that the interview be conducted as soon as possible after you are
contacted. Postponements will delay the processing of your
investigation, and declining to be interviewed may result in your
investigation being delayed or canceled.

You will be asked to bring identification with your picture on it, such
as a valid State driver's license, to the interview. There are other
documents you may be asked to bring to verify your identity as well.

These include documentation of any legal name change, Social Security
card, and/or birth certificate.

You may also be asked to bring documents about information you provided
on the form or other matters requiring specific attention. These matters
include alien registration, delinquent loans or taxes, bankruptcy,
judgments, liens, or other financial obligations, agreements involving
child custody or support, alimony or property settlements, arrests,
convictions, probation, and/or parole.

**Instructions for Completing this Form**

1\. Follow the instructions given to you by the person who gave you the
form and any other clarifying instructions furnished by that person to
assist you in completion of the form. Find out how many copies of the
form you are to turn in. You must sign and date, in black ink, the
original and each copy you submit.

2\. Type or legibly print your answers in black ink (if your form is not
legible, it will not be accepted). You may also be asked to submit your
form in an approved electronic format.

3\. All questions on this form must be answered. If no response is
necessary or applicable, indicate this on the form (for example, enter
\"None\" or \"N/A\"). If you find that you cannot report an exact date,
approximate or estimate the date to the best of your ability and
indicate this by marking \"APPROX.\" or \"EST.\"

4\. Any changes that you make to this form after you sign it must be
initialed and dated by you. Under certain limited circumstances,
agencies may modify the form consistent with your intent.

5\. You must use the State codes (abbreviations) listed on the back of
this page when you fill out this form. Do not abbreviate the names of
cities or foreign countries.

6\. The 5-digit postal ZIP codes are needed to speed the processing of
your investigation. The office that provided the form will assist you in
completing the ZIP codes.

7\. All telephone numbers must include area codes.

8\. All dates provided on this form must be in Month/Day/Year or
Month/Year format. Use numbers (1-12) to indicate months. For example,
June 10, 1978, should be shown as 6/10/78.

9\. Whenever \"City (Country)\" is shown in an address block, also
provide in that block the name of the country when the address is
outside the United States.

10\. If you need additional space to list your residences or
employments/self-employments/unemployments or education, you should use
a continuation sheet, SF 86A. If additional space is needed to answer
other items, use a blank piece of paper. Each blank piece of paper you
use must contain **your name and Social Security Number at the top of
the page.**

## Final Determination on Your Eligibility

Final determination on your eligibility for a public trust or sensitive
position and your being granted a security clearance is the
responsibility of the Office of Personnel Management or the Federal
agency that requested your investigation. You may be provided the
opportunity personally to explain, refute, or clarify any information
before a final decision is made.

**Penalties for Inaccurate or False Statements**

The U.S. Criminal Code (title 18, section 1001) provides that knowingly
falsifying or concealing a material fact is a felony which may result in
fines of up to \$10,000, and/or 5 years imprisonment, or both. In
addition, Federal agencies generally fire, do not grant a security
clearance, or disqualify individuals who have materially and
deliberately falsified these forms, and this remains a part of the
permanent record for future placements. Because the position for which
you are being considered is one of public trust or is sensitive, your
trustworthiness is a very important consideration in deciding your
suitability for placement or retention in the position.

Your prospects of placement are better if you answer all questions
truthfully and completely. You will have adequate opportunity to explain
any information you give us on the form and to make your comments part
of the record.

**Disclosure of Information**

The information you give us is for the purpose of investigating you for
a position; we will protect it from unauthorized disclosure. The
collection, maintenance, and disclosure of background investigative
information is governed by the Privacy Act. The agency which requested
the investigation and the agency which conducted the investigation have
published notices in the Federal Register describing the system of
records in which your records will be maintained. You may obtain copies
of the relevant notices from the person who gave you this form. The
information on this form, and information we collect during an
investigation may be disclosed without your consent as permitted by the
Privacy Act (5 USC 552a(b)) and as follows:

![](media/image1.png){width="7.063194444444444in"
height="0.38333333333333336in"}

1\. To the Department of Justice when: (a) the agency or any component
thereof; or (b) any employee of the agency in his or her official
capacity; or (c) any employee of the agency in his or her individual
capacity where the Department of Justice has agreed to represent the
employee; or (d) the United States Government, is a party to litigation
or has interest in such litigation, and by careful review, the agency
determines that the records are both relevant and necessary to the
litigation and the use of such records by the Department of Justice is
therefore deemed by the agency to be for a purpose that is compatible
with the purpose for which the agency collected the records.

2\. To a court or adjudicative body in a proceeding when: (a) the agency
or any component thereof; or (b) any employee of the agency in his or
her official capacity; or (c) any employee of the agency in his or her
individual capacity where the Department of Justice has agreed to
represent the employee; or (d) the United States Government is a party
to litigation or has interest in such litigation, and by careful review,
the agency determines that the records are both relevant and necessary
to the litigation and the use of such records is therefore deemed by the
agency to be for a purpose that is compatible with the purpose for which
the agency collected the records.

3\. Except as noted in Question 21, when a record on its face, or in
conjunction with other records, indicates a violation or potential
violation of law, whether civil, criminal, or regulatory in nature, and
whether arising by general statute, particular program statute,
regulation, rule, or order issued pursuant thereto, the relevant records
may be disclosed to the appropriate Federal, foreign, State, local,
tribal, or other public authority responsible for enforcing,
investigating or prosecuting such violation or charged with enforcing or
implementing the statute, rule, regulation, or order.

4\. To any source or potential source from which information is
requested in the course of an investigation concerning the hiring or
retention of an employee or other personnel action, or the issuing or
retention of a security clearance, contract, grant, license, or other
benefit, to the extent necessary to identify the individual, inform the
source of the nature and purpose of the investigation, and to identify
the type of information requested.

5\. To a Federal, State, local, foreign, tribal, or other public
authority the fact that this system of records contains information
relevant to the retention of an employee, or the retention of a security
clearance, contract, license, grant, or other benefit. The other agency
or licensing organization may then make a request supported by written
consent of the individual for the entire record if it so chooses. No
disclosure will be made unless the information has been determined to be
sufficiently reliable to support a referral to another office within the
agency or to another Federal agency for criminal, civil, administrative,
personnel, or regulatory action.

6\. To contractors, grantees, experts, consultants, or volunteers when
necessary to perform a function or service related to this record for
which they have been engaged. Such recipients shall be required to
comply with the Privacy Act of 1974, as amended.

7\. To the news media or the general public, factual information the
disclosure of which would be in the public interest and which would not
constitute an unwarranted invasion of personal privacy.

8\. To a Federal, State, or local agency, or other appropriate entities
or individuals, or through established liaison channels to selected
foreign governments, in order to enable an intelligence agency to carry
out its responsibilities under the National Security Act of 1947 as
amended, the CIA Act of 1949 as amended, Executive Order 12333 or any
successor order, applicable national security directives, or classified
implementing procedures approved by the Attorney General and promulgated
pursuant to such statutes, orders or directives.

9\. To a Member of Congress or to a Congressional staff member in
response to an inquiry of the Congressional office made at the written
request of the constituent about whom the record is maintained.

10\. To the National Archives and Records Administration for records
management inspections conducted under 44 USC 2904 and 2906. 11. To the
Office of Management and Budget when necessary to the review of private
relief legislation.

**BBREVIATIONS)**

![](media/image2.png){width="7.097916666666666in"
height="0.2923611111111111in"}

  ------------- ---- ----------- ----- --------------- ---- -------------- ---- ------------ ----
  Alabama       AL   Hawaii      HI    Massachusetts   MA   New Mexico     NM   South Dakota SD

  Alaska        AK   Idaho       ID    Michigan        MI   New York       NY   Tennessee    

  Arizona       AZ   Illinois    IL    Minnesota       MN   North Carolina NC   Texas        

  Arkansas      AR   Indiana     IN    Mississippi     MS   North Dakota   ND   Utah         

  California    CA   Iowa        IA    Missouri        MO   Ohio           OH   Vermont      

  Colorado      CO   Kansas      KS    Montana         MT   Oklahoma            Virginia     

  Connecticut   CT   Kentucky    KY    Nebraska        NE   Oregon              Washington   

  Delaware      DE   Louisiana   LA    Nevada          NV   Pennsylvania        West         
                                                                                Virginia     

  Florida       FL   Maine       ME    New Hampshire   NH   Rhode Island        Wisconsin    

  Georgia       GA   Maryland    MD    New Jersey      NJ   South Carolina      Wyoming      

                                                                                             

  American      AS   District of DC    Guam            GU   Northern            Puerto Rico  
  Samoa              Columbia                               Marianas                         

  Trust         TT   Virgin      VI                                                          
  Territory          Islands                                                                 
  ------------- ---- ----------- ----- --------------- ---- -------------- ---- ------------ ----

**INFORMATION**

Public burden reporting for this collection of information is estimated
to average 60 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 CHP-500,
Washington, D.C. 20415. Do not send your completed form to this address.

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<tbody>
<tr class="odd">
<td colspan="18"><p>Standard Form 85P</p>
<p>Revised September 1995</p>
<p>U.S. Office of Personnel Management</p>
<p>5 CFR Parts 731, 732, and 736</p></td>
<td colspan="21"><h4 id="section"></h4>
<h4 id="section-1"></h4>
<h4 id="questionnair-for">QUESTIONNAIR FOR</h4>
<p><strong>PUBLIC TRUST POSITIONS</strong></p></td>
<td colspan="7"><p>Form approved:</p>
<p>OMB No. 3206-0191</p>
<p>NSN 7540-01-317-7372</p>
<p>85-1602</p></td>
</tr>
<tr class="even">
<td colspan="28" rowspan="2"><p>OPM</p>
<p>USE</p>
<p>ONLY</p></td>
<td colspan="7">Codes</td>
<td colspan="11">Case Number</td>
</tr>
<tr class="odd">
<td colspan="7"></td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="46"><strong>Agency Use Only (<em>Complete items A through P
using instructions provided by USOPM</em>)</strong></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><strong>A</strong> Type of
Investigation</td>
<td></td>
<td colspan="5" rowspan="2"><strong>B</strong> Extra Coverage</td>
<td colspan="8"></td>
<td colspan="4" rowspan="2"><p><strong>C</strong> Sensitivity/</p>
<p>Risk Level</p></td>
<td colspan="5"></td>
<td colspan="5" rowspan="2"><p><strong>D</strong> Compu/</p>
<p>ADP</p></td>
<td></td>
<td colspan="2" rowspan="2"><strong>E</strong> Nature of Action
Code</td>
<td colspan="2"></td>
<td colspan="4" rowspan="2"><strong>F</strong> Date of Action</td>
<td colspan="2">Month</td>
<td colspan="2">Day</td>
<td>Year</td>
</tr>
<tr class="even">
<td></td>
<td colspan="8"></td>
<td colspan="5"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><p><strong>G</strong> Geographic</p>
<p>Location</p></td>
<td colspan="6"></td>
<td colspan="7" rowspan="2"><p><strong>H</strong> position</p>
<p>Code</p></td>
<td></td>
<td colspan="4" rowspan="2"><p><strong>I</strong> Position</p>
<p>Title</p></td>
<td colspan="24"></td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td></td>
<td colspan="24"></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="3"><p><strong>J</strong></p>
<p>SON</p></td>
<td colspan="3"></td>
<td colspan="5" rowspan="3"><p><strong>K</strong> Location</p>
<p>Of Official</p>
<p>Personnel</p>
<p>Folder</p></td>
<td colspan="4"></td>
<td colspan="4">None</td>
<td colspan="25">Other Address</td>
<td colspan="3">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="4">NPRC</td>
<td colspan="25" rowspan="2"></td>
<td colspan="3" rowspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="4">At SON</td>
</tr>
<tr class="even">
<td colspan="2" rowspan="3"><p><strong>L</strong></p>
<p>SOI</p></td>
<td colspan="3"></td>
<td colspan="5" rowspan="3"><p><strong>M</strong> Location</p>
<p>Of Security</p>
<p>Folder</p></td>
<td colspan="4"></td>
<td colspan="4">None</td>
<td colspan="25">Other Address</td>
<td colspan="3">ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="3" rowspan="2"></td>
<td colspan="4"></td>
<td colspan="4">At SOI</td>
<td colspan="25" rowspan="2"></td>
<td colspan="3" rowspan="2"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="4">NPI</td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><p><strong>N</strong> OPAC-ALC</p>
<p>Number</p></td>
<td colspan="6"></td>
<td colspan="11" rowspan="2"><p><strong>O</strong> Accounting Data
and/or</p>
<p>Agency Case Number</p></td>
<td colspan="25"></td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="25"></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><p><strong>P</strong> Requesting</p>
<p>Official</p></td>
<td colspan="17"></td>
<td colspan="14" rowspan="2">Signature</td>
<td colspan="8">Telephone number</td>
<td colspan="3">Date</td>
</tr>
<tr class="even">
<td colspan="17"></td>
<td colspan="8">( )</td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="46"><em><strong>Persons completing this form should begin
with the questions below.</strong></em></td>
</tr>
<tr class="even">
<td rowspan="3">(1)</td>
<td colspan="2"><h5 id="full">FULL</h5>
<h5 id="name">NAME </h5></td>
<td colspan="26"><ul>
<li><p>If you have only initials in your name, use them and state
(IO).</p></li>
<li><p>If you have no middle name, enter “NMN”.</p></li>
</ul></td>
<td colspan="12">– If you are a “Jr.,” “Sr.,” “II,” etc., enter this in
the box after your middle name.</td>
<td colspan="5">(2) <strong>DATE OF BIRTH</strong></td>
</tr>
<tr class="odd">
<td colspan="18">Last Name</td>
<td colspan="14">First Name</td>
<td colspan="4">Middle Name</td>
<td colspan="4">Jr., II, etc.</td>
<td colspan="2" rowspan="2">Month</td>
<td colspan="2" rowspan="2">Day</td>
<td rowspan="2">Year</td>
</tr>
<tr class="even">
<td colspan="18"></td>
<td colspan="14"></td>
<td colspan="4"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td rowspan="3">(3)</td>
<td colspan="36"><strong>PLACE OF BIRTH -</strong> Use the two letter
code for the State.</td>
<td colspan="9">(4) <strong>SOCIAL SECURITY NUMBER</strong></td>
</tr>
<tr class="even">
<td colspan="12" rowspan="2">City</td>
<td colspan="11">County</td>
<td colspan="4">State</td>
<td colspan="9">Country (<em>if not in the United States</em>)</td>
<td colspan="9" rowspan="2"></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
<td colspan="4"></td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td>(5)</td>
<td colspan="45"><h5 id="other-names-used">OTHER NAMES USED</h5></td>
</tr>
<tr class="odd">
<td rowspan="2"><strong>#1</strong></td>
<td colspan="17" rowspan="2">Name</td>
<td colspan="10">Month/Year Month/Year</td>
<td colspan="10" rowspan="2"><p>Name</p>
<p><strong>#3</strong></p></td>
<td colspan="8" rowspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
</tr>
<tr class="even">
<td colspan="10">To</td>
</tr>
<tr class="odd">
<td><strong>#2</strong></td>
<td colspan="17">Name</td>
<td colspan="10">Month/Year Month/Year</td>
<td colspan="10"><p>Name</p>
<p><strong>#4</strong></p></td>
<td colspan="8"><p>Month/Year Month/Year</p>
<p>To</p></td>
</tr>
<tr class="even">
<td rowspan="2">(6)</td>
<td colspan="6" rowspan="2"><h5 id="other">OTHER</h5>
<p><strong>IDENTIFYING</strong></p>
<p><strong>INFORMATION</strong></p></td>
<td colspan="11">Height (<em>feet and inches</em>)</td>
<td colspan="10">Weight (<em>pound</em>s)</td>
<td colspan="5">Hair Color</td>
<td colspan="3">Eye Color</td>
<td colspan="10">Sex (<em>Mark one box</em>)</td>
</tr>
<tr class="odd">
<td colspan="11"></td>
<td colspan="10"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="2">Female</td>
<td colspan="2"></td>
<td colspan="2">Male</td>
</tr>
<tr class="even">
<td rowspan="3">(7)</td>
<td colspan="6" rowspan="3"><h5 id="telephone">TELEPHONE</h5>
<p><strong>NUMBERS</strong></p></td>
<td colspan="21">Work (<em>include Area Code and extension</em>)</td>
<td colspan="18">Home (<em>include Area Code</em>)</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">Day</td>
<td colspan="13" rowspan="2">( )</td>
<td colspan="3"></td>
<td colspan="3">Day</td>
<td colspan="12" rowspan="2">( )</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">Night</td>
<td colspan="3"></td>
<td colspan="3">Night</td>
</tr>
<tr class="odd">
<td rowspan="3"><p>(8)</p>
<p>(a)</p></td>
<td colspan="11" rowspan="3"><h5 id="citizenship">CITIZENSHIP</h5>
<p>Make the box at the right that reflects your current citizenship
status, and follow its instructions.</p></td>
<td colspan="4"></td>
<td colspan="20">I am U.S. Citizen or national by birth in the U.S. or
U.S. territory/possession. <em>Answer items b and d.</em></td>
<td colspan="10" rowspan="3">(b) Your Mother’s Maiden Name</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="20">I am a U.S. citizen, but I was NOT born in the U.S.
<em>Answer items b, c and d.</em></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="20">I am not a U.S. citizen. <em>Answer items b and
e.</em></td>
</tr>
<tr class="even">
<td rowspan="13">(c)</td>
<td colspan="45">UNITED STATES CITIZENSHIP 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 colspan="45">Naturalization Certificate (<em>Where were you
naturalized?</em>)</td>
</tr>
<tr class="even">
<td colspan="17">Court</td>
<td colspan="7">City</td>
<td colspan="4">State</td>
<td colspan="7">Certificate Number</td>
<td colspan="10">Month/Day/Year Issued</td>
</tr>
<tr class="odd">
<td colspan="17"></td>
<td colspan="7"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="45">Citizenship Certificate (<em>Where was the certificate
issued?</em>)</td>
</tr>
<tr class="odd">
<td colspan="24">City</td>
<td colspan="4">State</td>
<td colspan="7">Certificate Number</td>
<td colspan="10">Month/Day/Year Issued</td>
</tr>
<tr class="even">
<td colspan="24"></td>
<td colspan="4"></td>
<td colspan="7"></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="45">State Department Form 240 – Report of Birth Abroad of a
Citizen of the United States</td>
</tr>
<tr class="even">
<td colspan="10" rowspan="2">Give the date the form was prepared and
give an explanation if needed.</td>
<td colspan="8">Month/Day/Year</td>
<td colspan="27">Explanation</td>
</tr>
<tr class="odd">
<td colspan="8"></td>
<td colspan="27"></td>
</tr>
<tr class="even">
<td colspan="45">U.S. Passport</td>
</tr>
<tr class="odd">
<td colspan="24" rowspan="2">This may be either a current or previous
U.S. passport</td>
<td colspan="11">Passport Number</td>
<td colspan="10">Month/Day/Year Issued</td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td rowspan="2">(d)</td>
<td colspan="7" rowspan="2">DUAL CITIZENSHIP</td>
<td colspan="22" rowspan="2">If you are (<em>or were</em>) a dual
citizen of the United States and another country, provide the name of
that country in the space to the right.</td>
<td colspan="16">Country</td>
</tr>
<tr class="even">
<td colspan="16"></td>
</tr>
<tr class="odd">
<td rowspan="3">(e)</td>
<td colspan="45">ALIEN If you are an alien, provide the following
information:</td>
</tr>
<tr class="even">
<td colspan="5" rowspan="2">Place You Entered the United States:</td>
<td colspan="14" rowspan="2">City</td>
<td>State</td>
<td colspan="9">Date You Entered U.S.</td>
<td colspan="6" rowspan="2">Alien Registration Number</td>
<td colspan="10" rowspan="2">Country(ies) of Citizenship</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">Month</td>
<td colspan="3">Day</td>
<td colspan="4">Year</td>
</tr>
</tbody>
</table>

Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA
September 1995. **Page 1**

Designed using Perform Pro, WHS/DIOR, Sep 95

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 18%" />
<col style="width: 5%" />
<col style="width: 23%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 11%" />
</colgroup>
<tbody>
<tr class="odd">
<td>(9)</td>
<td colspan="12"><h5 id="where-you-have-lived">WHERE YOU HAVE LIVED</h5>
<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. 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, former spouses,
or other relatives). Also for addresses in the last 5 years, if the
address 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="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p><strong>#1</strong> To</p></td>
<td colspan="4">Street Address Apt. #</td>
<td colspan="5">City (Country)</td>
<td>State</td>
<td>ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="2">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td colspan="2">City (country)</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
<td colspan="2"><p>Telephone Number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p><strong>#2</strong> To</p></td>
<td colspan="4">Street Address Apt. #</td>
<td colspan="5">City (Country)</td>
<td>State</td>
<td>ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="2">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td colspan="2">City (country)</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
<td colspan="2"><p>Telephone Number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p><strong>#3</strong> To</p></td>
<td colspan="4">Street Address Apt. #</td>
<td colspan="5">City (Country)</td>
<td>State</td>
<td>ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="2">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td colspan="2">City (country)</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
<td colspan="2"><p>Telephone Number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p><strong>#4</strong> To</p></td>
<td colspan="4">Street Address Apt. #</td>
<td colspan="5">City (Country)</td>
<td>State</td>
<td>ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="2">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td colspan="2">City (country)</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
<td colspan="2"><p>Telephone Number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p><strong>#5</strong> To</p></td>
<td colspan="4">Street Address Apt. #</td>
<td colspan="5">City (Country)</td>
<td>State</td>
<td>ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="2">Name of Person Who Knows You</td>
<td colspan="3">Street Address</td>
<td colspan="2">City (country)</td>
<td colspan="2">State</td>
<td colspan="2">ZIP Code</td>
<td colspan="2"><p>Telephone Number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td>(10)</td>
<td colspan="12"><h5 id="where-you-went-to-school">WHERE YOU WENT TO
SCHOOL</h5>
<p>List the schools you have attended, beyond Junior High
School<strong>, beginning with the most recent (#1) and working back 7
years.</strong> List <strong>all</strong> 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.</p>
<ul>
<li><p>Use one of the following codes in the "Code" block:</p></li>
</ul>
<p><strong>1 -</strong> High School <strong>2 -</strong>
College/University/Military College <strong>3 -</strong>
Vocational/Technical/Trade School</p>
<ul>
<li><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 completely outside this 3-year period.</p></li>
<li><p>For correspondence schools and extension classes, provide the
address where the records are maintained.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="2"><p>Month/Year Month/Year</p>
<p><strong>#1</strong> To</p></td>
<td>Code</td>
<td colspan="3">Name of School</td>
<td colspan="5">Degree/Diploma/Other</td>
<td colspan="2">Month/Year Awarded</td>
</tr>
<tr class="even">
<td colspan="10">Street Address and City (Country) of School</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="2">Name of Person Who Knew You</td>
<td colspan="2">Street Address Apt. #</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="2"><p>Telephone Number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p><strong>#2</strong> To</p></td>
<td>Code</td>
<td colspan="3">Name of School</td>
<td colspan="5">Degree/Diploma/Other</td>
<td colspan="2">Month/Year Awarded</td>
</tr>
<tr class="odd">
<td colspan="10">Street Address and City (Country) of School</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2">Name of Person Who Knew You</td>
<td colspan="2">Street Address Apt. #</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="2"><p>Telephone Number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="2"><p>Month/Year Month/Year</p>
<p><strong>#3</strong> To</p></td>
<td>Code</td>
<td colspan="3">Name of School</td>
<td colspan="5">Degree/Diploma/Other</td>
<td colspan="2">Month/Year Awarded</td>
</tr>
<tr class="even">
<td colspan="10">Street Address and City (Country) of School</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="2">Name of Person Who Knew You</td>
<td colspan="2">Street Address Apt. #</td>
<td colspan="3">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="2"><p>Telephone Number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="11" rowspan="2"><h5 id="section-2"></h5>
<h5
id="enter-your-social-security-number-before-going-to-the-next-page">Enter
your Social Security Number before going to the next page </h5></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
</tr>
</tbody>
</table>

**Page 2**

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 15%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 19%" />
<col style="width: 13%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 15%" />
</colgroup>
<tbody>
<tr class="odd">
<td>(11)</td>
<td colspan="11"><h5 id="your-employment-activities">YOUR EMPLOYMENT
ACTIVITIES</h5>
<p><strong>List your employment activities, beginning with the present
(#1)</strong> and working back 7 years. 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 16th
birthday.</p>
<ul>
<li><p><strong>Code.</strong> Use one of the codes listed below to
identify the type of employment:</p></li>
</ul>
<p><strong>1</strong> - Active military duty stations <strong>5</strong>
- State Government (Non-Federal <strong>7</strong> - Unemployment
(Include name of <strong>9</strong> - Other</p>
<p><strong>2</strong> - National Guard/Reserve employment) person who
can verify)</p>
<p><strong>3</strong> - U.S.P.H.S. Commissioned Corps <strong>6</strong>
- Self-employment (Include business <strong>8</strong> - Federal
Contractor (List Contractor,</p>
<p><strong>4</strong> - Other Federal employment and/or name of person
who can verify) not Federal agency)</p>
<ul>
<li><p><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.</p></li>
<li><p><strong>Previous Periods of Activity.</strong> Complete these
lines if you worked for an employer on 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.</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="3"><p>Month/Year Month/Year</p>
<p><strong>#1</strong> To Present</p></td>
<td colspan="2">Code</td>
<td colspan="3">Employer/Varifier Name/Military Duty Location</td>
<td colspan="4">Your Position Title/Military Rank</td>
</tr>
<tr class="odd">
<td colspan="6">Employer’s/Verifier’s Street Address</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="6">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="6">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="3"><h5 id="previous">PREVIOUS</h5>
<p><strong>PERIODS</strong></p>
<p><strong>OF</strong></p>
<h5 id="activity">ACTIVITY</h5>
<p>(<em>Block #1</em>)</p></td>
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"><p>Month/Year Month/Year</p>
<p><strong>#2</strong> To Present</p></td>
<td colspan="2">Code</td>
<td colspan="3">Employer/Varifier Name/Military Duty Location</td>
<td colspan="4">Your Position Title/Military Rank</td>
</tr>
<tr class="even">
<td colspan="6">Employer’s/Verifier’s Street Address</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="6">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="6">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="3"><h5 id="previous-1">PREVIOUS</h5>
<p><strong>PERIODS</strong></p>
<p><strong>OF</strong></p>
<h5 id="activity-1">ACTIVITY</h5>
<p>(<em>Block #2</em>)</p></td>
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="even">
<td colspan="3"><p>Month/Year Month/Year</p>
<p><strong>#3</strong> To Present</p></td>
<td colspan="2">Code</td>
<td colspan="3">Employer/Varifier Name/Military Duty Location</td>
<td colspan="4">Your Position Title/Military Rank</td>
</tr>
<tr class="odd">
<td colspan="6">Employer’s/Verifier’s Street Address</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="6">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="6">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
<td><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="3"><h5 id="previous-2">PREVIOUS</h5>
<p><strong>PERIODS</strong></p>
<p><strong>OF</strong></p>
<h5 id="activity-2">ACTIVITY</h5>
<p>(<em>Block #3</em>)</p></td>
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="even">
<td colspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="5">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="10"><h5 id="section-3"></h5>
<h5
id="enter-your-social-security-number-before-going-to-the-next-page-1">Enter
your Social Security Number before going to the next page </h5></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

**Page 3**

**YOUR EMPLOYMENT ACTIVITIES** (CONTINUED)

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 19%" />
<col style="width: 13%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 6%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="4"><p>Month/Year Month/Year</p>
<p><strong>#4</strong> To Present</p></td>
<td colspan="2">Code</td>
<td colspan="3">Employer/Varifier Name/Military Duty Location</td>
<td colspan="7">Your Position Title/Military Rank</td>
</tr>
<tr class="even">
<td colspan="7">Employer’s/Verifier’s Street Address</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="7">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="7">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="3"><h5 id="previous-3">PREVIOUS</h5>
<p><strong>PERIODS</strong></p>
<p><strong>OF</strong></p>
<h5 id="activity-3">ACTIVITY</h5>
<p>(<em>Block #4</em>)</p></td>
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="4"><p>Month/Year Month/Year</p>
<p><strong>#5</strong> To Present</p></td>
<td colspan="2">Code</td>
<td colspan="3">Employer/Varifier Name/Military Duty Location</td>
<td colspan="7">Your Position Title/Military Rank</td>
</tr>
<tr class="odd">
<td colspan="7">Employer’s/Verifier’s Street Address</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="7">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="7">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="2" rowspan="3"><h5 id="previous-4">PREVIOUS</h5>
<p><strong>PERIODS</strong></p>
<p><strong>OF</strong></p>
<h5 id="activity-4">ACTIVITY</h5>
<p>(<em>Block #5</em>)</p></td>
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="4"><p>Month/Year Month/Year</p>
<p><strong>#6</strong> To Present</p></td>
<td colspan="2">Code</td>
<td colspan="3">Employer/Varifier Name/Military Duty Location</td>
<td colspan="7">Your Position Title/Military Rank</td>
</tr>
<tr class="even">
<td colspan="7">Employer’s/Verifier’s Street Address</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="7">Street Address of Job Location (if different than
Employer’s Address)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="even">
<td colspan="7">Supervisor’s Name &amp; Street Address (if different
than Job Location)</td>
<td colspan="2">City (Country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
<td colspan="3"><p>Telephone number</p>
<p>( )</p></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="3"><h5 id="previous-5">PREVIOUS</h5>
<p><strong>PERIODS</strong></p>
<p><strong>OF</strong></p>
<h5 id="activity-5">ACTIVITY</h5>
<p>(<em>Block #6</em>)</p></td>
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="odd">
<td colspan="3"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="3">Position Title</td>
<td colspan="8">Supervisor</td>
</tr>
<tr class="even">
<td rowspan="3">(12)</td>
<td colspan="13" rowspan="2"><h5 id="your-employment-record">YOUR
EMPLOYMENT RECORD</h5>
<p>Has any of the following happened to you in the last 7 years? If
"Yes," begin with the most recent occurrence and go backward, providing
date fired, quit, or left, and other information requested.</p></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="15"><p>Use the following codes and explain the reason your
employment was ended:</p>
<p><strong>1 -</strong> Fired from a job <strong>3</strong> - Left a job
by mutual agreement following allegations of misconduct
<strong>5</strong> - Left a job for other reasons</p>
<p>under unfavorable circumstances</p>
<p><strong>2</strong> - Quit a job after being told <strong>4</strong> -
Left a job by mutual agreement following allegations of</p>
<p>you’d be fired unsatisfactory performance</p></td>
</tr>
<tr class="odd">
<td colspan="2">Month/Year</td>
<td>Code</td>
<td colspan="3">Specify Reason</td>
<td colspan="5">Employer’s Name and Address (<em>Include city/Country if
outside U.S.</em>)</td>
<td colspan="3">State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="12"><h5 id="section-4"></h5>
<h5
id="enter-your-social-security-number-before-going-to-the-next-page-2">Enter
your Social Security Number before going to the next page </h5></td>
<td colspan="4"></td>
</tr>
</tbody>
</table>

**Page 4**

<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 17%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3"><strong>(13)</strong></td>
<td colspan="22"><p id="people-who-know-you-well" class="heading">PEOPLE
WHO KNOW YOU WELL</p>
<p>List three people 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.</p></td>
</tr>
<tr class="even">
<td colspan="11" rowspan="3"><p>Name</p>
<p><strong>#1</strong></p></td>
<td colspan="5" rowspan="3"><p>Dates Known</p>
<p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="9">Telephone Number</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">Day</td>
<td colspan="5" rowspan="2">( )</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">Night</td>
</tr>
<tr class="odd">
<td colspan="14">Home or Work Address</td>
<td colspan="7">City (country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="11" rowspan="3"><p>Name</p>
<p><strong>#2</strong></p></td>
<td colspan="5" rowspan="3"><p>Dates Known</p>
<p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="9">Telephone Number</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">Day</td>
<td colspan="5" rowspan="2">( )</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">Night</td>
</tr>
<tr class="odd">
<td colspan="14">Home or Work Address</td>
<td colspan="7">City (country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="11" rowspan="3"><p>Name</p>
<p><strong>#3</strong></p></td>
<td colspan="5" rowspan="3"><p>Dates Known</p>
<p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="9">Telephone Number</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">Day</td>
<td colspan="5" rowspan="2">( )</td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">Night</td>
</tr>
<tr class="odd">
<td colspan="14">Home or Work Address</td>
<td colspan="7">City (country)</td>
<td>State</td>
<td colspan="3">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2" rowspan="4"><strong>(14)</strong></td>
<td colspan="23"><h5 id="your-marital-status">YOUR MARITAL
STATUS</h5></td>
</tr>
<tr class="odd">
<td colspan="23">Mark one of the following boxes to show your current
marital status:</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="4">1 – Never married (<em>go to question 15</em>)</td>
<td></td>
<td colspan="5">3 – Separated</td>
<td></td>
<td colspan="10">5 – Divorced</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="4">2 – Married</td>
<td></td>
<td colspan="5">4 – Legally Separated</td>
<td></td>
<td colspan="10">6 - Widowed</td>
</tr>
<tr class="even">
<td colspan="25">Current Spouse Complete the following about your
current spouse.</td>
</tr>
<tr class="odd">
<td colspan="7">Full Name</td>
<td colspan="5">Date of Birth (<em>Mo./Day/Yr.)</em></td>
<td colspan="9">Place of Birth (<em>Include country if outside the
U.S.</em>)</td>
<td colspan="4">Social Security Number</td>
</tr>
<tr class="even">
<td colspan="25">Other Names Used (<em>Specify maiden name, names by
other marriages, etc., and show dates used for each name</em>)</td>
</tr>
<tr class="odd">
<td colspan="7">Country of Citizenship</td>
<td colspan="5">Date Married (<em>Mo./Day/Yr.)</em></td>
<td colspan="11">Place Married (<em>Include country if outside the
U.S.</em>)</td>
<td colspan="2">State</td>
</tr>
<tr class="even">
<td colspan="7">If Separated, Date of Separation
(<em>Mo./Day/Yr.</em>)</td>
<td colspan="16">If Legally Separated, Where is the Record Located? City
(<em>Country</em>)</td>
<td colspan="2">State</td>
</tr>
<tr class="odd">
<td colspan="18">Address of Current Spouse (<em>Street, City, and
country if outside the U.S.</em>)</td>
<td colspan="3">State</td>
<td colspan="4">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2"><strong>(15)</strong></td>
<td colspan="23"><p><strong>YOUR RELATIVES</strong></p>
<p>Give the full name, correct code, and other requested information for
each of your relatives, living or dead, specified below.</p>
<p><strong>1</strong> - Mother <em>(first)</em> <strong>3</strong> -
Stepmother <strong>5</strong> - Foster Parent <strong>7</strong> -
Stepchild</p>
<p><strong>2</strong> - Father <em>(second)</em> <strong>4</strong> -
Stepfather <strong>6</strong> - Child <em>(adopted also)</em></p></td>
</tr>
<tr class="odd">
<td colspan="5">Full Name (<em>If deceased, check box on the left before
entering name</em>)</td>
<td>Code</td>
<td colspan="4"><p>Date of Birth</p>
<p>Month/Day/Year</p></td>
<td colspan="3">Country of Birth</td>
<td colspan="2">Country(ies) of Citizenship</td>
<td colspan="9">Current Street Address and City (<em>country</em>) of
Living Relatives</td>
<td>State</td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"></td>
<td>1</td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4"></td>
<td>2</td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"></td>
<td></td>
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="19"><h5 id="section-5"></h5>
<h5
id="enter-your-social-security-number-before-going-to-the-next-page-3">Enter
your Social Security Number before going to the next page </h5></td>
<td colspan="6"></td>
</tr>
</tbody>
</table>

**Page 5**

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 9%" />
<col style="width: 4%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="7"><strong>(16)</strong></td>
<td colspan="20"><h5 id="your-military-history">YOUR MILITARY
HISTORY</h5></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="even">
<td>(a)</td>
<td colspan="19">Have you served in the United States military?</td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>(b)</td>
<td colspan="19">Have you served in the United States Merchant
Marine?</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="22"><p>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.</p>
<p><strong>Code.</strong> Use one of the codes listed below to identify
your branch of service:</p>
<p><strong>1</strong> - Air Force <strong>2</strong> - Army
<strong>3</strong> - Navy <strong>4</strong> - Marine Corps
<strong>5</strong> - Coast Guard <strong>6</strong> - Merchant Marine
<strong>7</strong> - National Guard</p>
<p><strong>O/E.</strong> Mark "O" block for Officer or "E" block for
Enlisted.</p>
<p><strong>Status.</strong> "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 not use</p>
<p>an "X": use the two-letter code for the state to mark the block.</p>
<p><strong>Country.</strong> If your service was with other than the
U.S. Armed Forces, identify the country for which you served.</p></td>
</tr>
<tr class="odd">
<td colspan="4" rowspan="2"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="2" rowspan="2">Code</td>
<td colspan="3" rowspan="2">Service/Certificate No.</td>
<td>O</td>
<td>E</td>
<td colspan="8">Status</td>
<td colspan="3" rowspan="2">Country</td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td>Active</td>
<td colspan="2"><p>Active</p>
<p>Reserve</p></td>
<td colspan="2"><p>Inactive</p>
<p>Reserve</p></td>
<td colspan="3"><p>National</p>
<p>Guard</p>
<p>(<em>State</em>)</p></td>
</tr>
<tr class="odd">
<td colspan="4">To</td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td rowspan="5"><strong>(17)</strong></td>
<td colspan="20"><h5 id="your-selective-service-record">YOUR SELECTIVE
SERVICE RECORD</h5></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="odd">
<td>(a)</td>
<td colspan="19">Are A MALE BORN AFTER December 31, 1959? If
“<strong>No</strong>,” go to <strong>18</strong>. If
“<strong>Yes</strong>,” go to b.</td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>(b)</td>
<td colspan="19"><p>Have you registered with the Selective Service
System? If "Yes," provide your registration number. If
"<strong>No</strong>," show the reason for your legal</p>
<p>exemption below.</p></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6">Registration Number</td>
<td colspan="16">Legal Exemption Explanation</td>
</tr>
<tr class="even">
<td colspan="6"></td>
<td colspan="16"></td>
</tr>
<tr class="odd">
<td rowspan="9"><strong>(18)</strong></td>
<td colspan="20"><h5 id="your-investigations-record">YOUR INVESTIGATIONS
RECORD</h5></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="even">
<td>(a)</td>
<td colspan="19"><p>Has the United States Government ever investigated
your background and/or granted you a security clearance? If
"<strong>Yes</strong>," use the codes that</p>
<p>follow to provide the requested information below. If
"<strong>Yes</strong>," but you can’t recall the investigating agency
and/or the security clearance</p>
<p>received, enter "<strong>Other</strong>" agency code or clearance
code, as appropriate, and "<strong>Don’t know</strong>" or
"<strong>Don’t recall</strong>" under the "<strong>Other
Agency</strong>"</p>
<p>heading, below. If your response is "<strong>No</strong>," or you
don’t know or can’t recall if you were investigated and cleared, check
the "<strong>No</strong>" box.</p></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10"><p>Codes for Investigating Agency</p>
<p><strong>1</strong> - Defense Department <strong>4</strong> - FBI</p>
<p><strong>2</strong> - State Department <strong>5</strong> - Treasury
Department</p>
<p><strong>3</strong> - Office of Personnel Management
<strong>6</strong> - Other <em>(Specify)</em></p></td>
<td colspan="12"><p>Codes for Security Clearance Received</p>
<p><strong>0</strong> - Not Required <strong>3</strong> - Top Secret
<strong>6</strong> - L</p>
<p><strong>1</strong> - Confidential <strong>4</strong> - Sensitive
Compartmented Information <strong>7</strong> - Other</p>
<p><strong>2</strong> - Secret <strong>5</strong> - Q</p></td>
</tr>
<tr class="even">
<td colspan="2">Month/Year</td>
<td><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><p>Agency</p>
<p>Code</p></td>
<td colspan="7">Other Agency</td>
<td colspan="2"><p>Clearance</p>
<p>Code</p></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="7"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td rowspan="2">(b)</td>
<td colspan="19" rowspan="2"><p>To your knowledge, have you ever had a
clearance or access authorization denied, suspended, or revoked, or have
you ever been debarred</p>
<p>from government employment? If "<strong>Yes</strong>," give date of
action and agency. <strong>Note:</strong> An administrative downgrade or
termination of a security</p>
<p>clearance is not a revocation.</p></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Month/Year</td>
<td colspan="8">Department or Agency Taking Action</td>
<td colspan="2">Month/Year</td>
<td colspan="10">Department or Agency Taking Action</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="8"></td>
<td colspan="2"></td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td><strong>(19)</strong></td>
<td colspan="22"><p><strong>FOREIGN COUNTRIES YOU HAVE
VISITED</strong></p>
<p>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</p>
<p>dependent or contractor must be listed.)</p>
<p>Use one of these codes to indicate the purpose of your visit:
<strong>1</strong> - Business <strong>2</strong> - Pleasure
<strong>3</strong> - Education <strong>4</strong> - Other</p>
<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>
<p>Do not repeat travel covered in items 9, 10, or 11.</p></td>
</tr>
<tr class="odd">
<td colspan="6"><p>Month/Year Month/Year</p>
<p><strong>#1</strong> To</p></td>
<td colspan="2">Code</td>
<td colspan="3">Country</td>
<td colspan="5"><p>Month/Year Month/Year</p>
<p><strong>#5</strong> To</p></td>
<td colspan="2">Code</td>
<td colspan="5">Country</td>
</tr>
<tr class="even">
<td colspan="6"><strong>#2</strong></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"><strong>#6</strong></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="6"><strong>#3</strong></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"><strong>#7</strong></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="6"><strong>#4</strong></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"><strong>#8</strong></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="19"><h5 id="section-6"></h5>
<h5
id="enter-your-social-security-number-before-going-to-the-next-page-4">Enter
your Social Security Number before going to the next page </h5></td>
<td colspan="4"></td>
</tr>
</tbody>
</table>

**Page 6**

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 22%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="2"><strong>(20)</strong></td>
<td colspan="13"><h5
id="your-police-record-do-not-include-anything-that-happened-before-your-16th-birthday.">YOUR
POLICE RECORD (<em>Do not include anything that happened before your
16<sup>th</sup> birthday.</em>)</h5></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="even">
<td colspan="13"><p>In the last 7 years, have you been arrested for,
charged with, or convicted of any offense(s)? (Leave out traffic fines
of less than $150.)</p>
<p>If you answered "Yes," explain your answer(s) in the space
provided.</p></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Month/Year</td>
<td colspan="3">Offense</td>
<td colspan="3">Action Taken</td>
<td colspan="5">Law Enforcement Authority or Court (<em>City and
county/country if outside the U.S.</em>)</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td rowspan="4"><strong>(21)</strong></td>
<td colspan="13"><h5 id="illegal-drugs">ILLEGAL DRUGS</h5>
<p>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</p>
<p>failure to do so could be grounds for an adverse employment decision
or action against you, but neither your truthful responses nor
information</p>
<p>derived from your responses will be used as evidence against you in
any subsequent criminal proceeding.</p></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="odd">
<td colspan="13"><p>(a) In the last year, have you illegally used any
controlled substance, for example, marijuana, cocaine, crack cocaine,
hashish, narcotics (opium,</p>
<p>morphine, codeine, heroin, etc.), amphetamines, depressants
(barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD,
PCP, etc.), or</p>
<p>prescription drugs?</p></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="13"><p>(b) In the last 7 years, have you been involved in
the illegal purchase, manufacture, trafficking, production, transfer,
shipping, receiving, or sale of any</p>
<p>narcotic, depressant, stimulant, hallucinogen, or cannabis, for your
own intended profit or that of another?</p></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="13"><p>If you answered "Yes" to "a" above, provide
information relating to the types of substance(s), the nature of the
activity, and any other details relating</p>
<p>to your involvement with illegal drugs. Include any treatment or
counseling received.</p></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><p>Month/Year Month/Year</p>
<p>To</p></td>
<td colspan="6">Controlled Substance/Prescription Drug Used</td>
<td colspan="6">Number of Times Used</td>
</tr>
<tr class="odd">
<td colspan="4">To</td>
<td colspan="6"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="4">To</td>
<td colspan="6"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td rowspan="10"><strong>(22)</strong></td>
<td colspan="13"><h5 id="your-financial-record">YOUR FINANCIAL RECORD
</h5></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="even">
<td colspan="13"><p>(a) In the last 7 years, have you, or a company over
which you exercised some control, filed for bankruptcy, been declared
bankrupt, been subject to a</p>
<p>tax lien, or had legal judgment rendered against you for a debt? If
you answered "Yes," provide date of initial action and other information
requested</p>
<p>below.</p></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Month/Year</td>
<td colspan="3">Type of Action</td>
<td colspan="3">Name Action Occurred Under</td>
<td colspan="4">Name/Address of Court or Agency Handling Case</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="13" rowspan="2"><p>(b) Are you now over 180 days delinquent
on any loan or financial obligation? Include loans or obligations funded
or guaranteed by the Federal</p>
<p>Government.</p>
<p>If you answered "<strong>Yes</strong>," provide the information
requested below:</p></td>
<td>Yes</td>
<td>No</td>
</tr>
<tr class="odd">
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Month/Year</td>
<td colspan="4"><p>Type of Loan or Obligation</p>
<p>and Account #</p></td>
<td colspan="6">Name/Address of Creditor or Obligee</td>
<td>State</td>
<td colspan="2">ZIP Code</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="6"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="6"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="16"><p>After completing 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</p>
<p>following certification and sign and date the release on Page
8.</p></td>
</tr>
<tr class="even">
<td colspan="16"><p id="certification-that-my-answers-are-true"
class="heading">Certification That My Answers Are True</p>
<p>My statements on this form, and any attachments to it, are true,
complete, and correct to the best of my knowledge and belief and are
made in good faith. I understand that a knowing and willful false
statement on this form can be punished by fine or imprisonment or both.
(See section 1001 of title 18, United States Code).</p></td>
</tr>
<tr class="odd">
<td colspan="11">Signature (<em>Sign in ink</em>)</td>
<td colspan="5">Date</td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="12"><h5 id="section-7"></h5>
<h5
id="enter-your-social-security-number-before-going-to-the-next-page-5">Enter
your Social Security Number before going to the next page </h5></td>
<td colspan="4"></td>
</tr>
</tbody>
</table>

**Page 7**

Standard Form 85P Form approved:

Revised September 1995 OMB No. 3206-0191

U.S. Office of Personnel Management NSN 7540-01-317-7372

5 CFR Parts 731, 732, and 736 85-1602

**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 questions,
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 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 85P, 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.

+-----------------------+------------+-----+-------+------------------+
| Signature (*Sign in   | Full Name  |     |       | Date Signed      |
| ink*)                 | (*Type or  |     |       |                  |
|                       | Print      |     |       |                  |
|                       | Legibly*)  |     |       |                  |
+-----------------------+------------+-----+-------+------------------+
| Other Names Used      |            |     |       | Social Security  |
|                       |            |     |       | Number           |
+-----------------------+------------+-----+-------+------------------+
| Current Address       |            | St  | ZIP   | Home Telephone   |
| (*Street, City*)      |            | ate | Code  | Number           |
|                       |            |     |       |                  |
|                       |            |     |       | (*include Area   |
|                       |            |     |       | Code*)           |
|                       |            |     |       |                  |
|                       |            |     |       | ( )              |
+-----------------------+------------+-----+-------+------------------+

**Page 8**

Standard Form 85P Form approved:

Revised September 1995 OMB No. 3206-0191

U.S. Office of Personnel Management NSN 7540-01-317-7372

5 CFR Parts 731, 732, and 736 85-1602

### 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 black 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 am seeking assignment to or retention in a position of public trust
with the Federal Government as a(n)

(Investigator instructed to write in position title.)

As part of the investigative process, **I hereby authorize** the
investigator, special agent, or duly accredited representative of the
authorized Federal agency conducting my background investigation, to
obtain the following information relating to my mental health
consultations:

Does the person under investigation have a condition or treatment that
could impair his/her judgment or reliability?

If so, please describe the nature of the condition and the extent and
duration of the impairment or treatment.

What is the prognosis?

I understand that the information released pursuant to this release is
for use by the Federal Government only for purposes provided in the
Standard Form 85P 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 1 year
from the date signed or upon termination of my affiliation with the
Federal Government, whichever is sooner.

+-----------------------+------------+-----+-------+------------------+
| Signature (*Sign in   | Full Name  |     |       | Date Signed      |
| ink*)                 | (*Type or  |     |       |                  |
|                       | Print      |     |       |                  |
|                       | Legibly*)  |     |       |                  |
+-----------------------+------------+-----+-------+------------------+
| Other Names Used      |            |     |       | Social Security  |
|                       |            |     |       | Number           |
+-----------------------+------------+-----+-------+------------------+
| Current Address       |            | St  | ZIP   | Home Telephone   |
| (*Street, City*)      |            | ate | Code  | Number           |
|                       |            |     |       |                  |
|                       |            |     |       | (*include Area   |
|                       |            |     |       | Code*)           |
|                       |            |     |       |                  |
|                       |            |     |       | ( )              |
+-----------------------+------------+-----+-------+------------------+