Depending upon the purpose of your investigation, the U.S. Government is 

authorized to ask for this information under Executive Orders 10450, 10865, 

12333, and 12968; sections 3301, 3302, and 9101 of title 5, United States 

Code (U.S.C.); sections 2165 and 2201 of title 42, U.S.C.; chapter 23 of title 

50, U.S.C.; and parts 2, 5, 731, 732, and 736 of title 5, Code of Federal 

Regulations (CFR). 

 

Your Social Security Number (SSN) is needed to identify records unique to 

you. Although disclosure of your SSN is not mandatory, failure to disclose 

your SSN may prevent or delay the processing of your background 

investigation. The authority for soliciting and verifying your SSN is Executive 

Order 9397.

This form will be used by the United States (U.S.) Government in conducting 

background investigations, reinvestigations, and continuous evaluations of 

persons under consideration for, or retention of, national security positions as 

defined in 5 CFR 732, and for individuals requiring eligibility for access to 

classified information under Executive Order 12968. This form may also be 

used by agencies in determining whether a subject performing work for, or on 

behalf of, the Government under a contract should be deemed eligible for 

logical or physical access when the nature of the work to be performed is 

sensitive and could bring about an adverse effect on the national security .

This form is a permanent document that may be used as the basis for future 

investigations, eligibility determinations for access to classified information, or 

to hold a sensitive position, suitability or fitness for Federal employment, 

fitness for contract employment, or eligibility for physical and logical access to 

federally controlled facilities or information systems. Your responses to this 

form may be compared with your responses to previous SF-86 

questionnaires.

Providing this information is voluntary. If you do not provide each item of 

requested information, however, we will not be able to complete your 

investigation, which will adversely affect your eligibility for a national security 

position, eligibility for access to classified information, or logical or physical 

access. It is imperative that the information provided be true and accurate, to 

the best of your knowledge. Any information that you provide is evaluated on 

the basis of its currency, seriousness, relevance to the position and duties, 

and consistency with all other information about you. Withholding, 

misrepresenting, or falsifying information may affect your eligibility for access 

to classified information, eligibility for a sensitive position, or your ability to 

obtain or retain Federal or contract employment. In addition, withholding, 

misrepresenting, or falsifying information may affect your eligibility for 

physical and logical access to federally controlled facilities or information 

systems. Withholding, misrepresenting, or falsifying information may also 

negatively affect your employment prospects and job status, and the potential 

consequences include, but are not limited to, removal, debarment from 

Federal service, loss of eligibility for access to classified information, or 

prosecution.

Purpose of this Form

Authority to Request this Information

Follow instructions completely or your form will be unable to be processed. If 

you have any questions, contact the office that provided you the form. 

All questions on this form must be answered completely and truthfully in 

order that the Government may make the determinations described below on 

a complete record. Penalties for inaccurate or false statements are discussed 

below. If you are a current civilian employee of the federal government:

failure to answer any questions completely and truthfully could result in an 

adverse personnel action against you, including loss of employment; with 

respect to Sections 23, 27, and 29, however, neither your truthful responses 

nor information derived from those responses will be used as evidence 

against you in a subsequent criminal proceeding.

The investigation conducted on the basis of information provided on this form 

may be selected for studies and analyses in support of evaluating and 

improving the effectiveness and efficiency of the investigative and 

adjudicative methodologies. All study results released to the general public 

will delete personal identifiers such as name, social security number, and 

date and place of birth.

Background investigations for national security positions are conducted to 

gather information to determine whether you are reliable, trustworthy, of good 

conduct and character, and loyal to the U.S. The information that you provide 

on this form may be confirmed during the investigation. The investigation may 

extend beyond the time covered by this form, when necessary to resolve 

issues. Your current employer may be contacted as part of the investigation, 

although you may have previously indicated on applications or other forms 

that you do not want your current employer to be contacted. If you have a 

security freeze on your consumer or credit report file, then we may not be 

able to complete your investigation, which can adversely affect your eligibility 

for a national security position. To avoid such delays, you should request that 

the consumer reporting agencies lift the freeze in these instances.

The Investigative Process

In addition to the questions on this form, inquiry also is made about your 

adherence to security requirements, honesty and integrity, vulnerability to 

exploitation or coercion, falsification, misrepresentation, and any other 

behavior, activities, or associations that tend to demonstrate a person is not 

reliable, trustworthy, or loyal. Federal agency records checks may be 

conducted on your spouse, cohabitant(s), and immediate family members. 

After an eligibility determination has been completed, you also may be 

subject to continuous evaluation, which may include periodic reinvestigations, 

to determine whether retention in your position is clearly consistent with the 

interests of national security.

For the interview, you will be required to provide photo identification, such as 

a valid state driver's license. You may be required to provide other documents 

to verify your identity, as instructed by your investigator. These documents 

may include certification of any legal name change, Social Security card, 

passport, and/or your birth certificate. You may also be asked to provide 

documents regarding information that you provide on this form, or about other 

matters requiring specific attention. These matters include (a) alien 

registration or naturalization documents; (b) delinquent loans or taxes, 

bankruptcies, judgments, liens, or other financial obligations; (c) agreements 

involving child custody or support, alimony, or property settlements; (d) 

arrests, convictions, probation, and/or parole; or (e) other matters described 

in court records. 

Some investigations will include an interview with you as a routine part of the 

investigative process. The investigator may ask you to explain your answers 

to any question on this form. This provides you the opportunity to update, 

clarify, and explain information on your form more completely, which often 

assists in completing your investigation. It is imperative that the interview be 

conducted immediately 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.

Your Personal Interview

Instructions for Completing this Form

2.

3.

1. Follow the instructions, provided to you by the office that gave you this 

form and any other clarifying instructions provided by that office to assist 

you with completion of this form. You must sign and date, in ink, the 

original and each copy you submit. You should retain a copy of the 

completed form for your records.

Type or legibly print your answers in ink. If the form is not legible, it will 

not be accepted. You may also be asked to submit your form using the 

approved electronic format.

All questions on this form must be answered. If no response is 

necessary or applicable, indicate this on the form with "N/A," unless 

otherwise noted.

Any changes that you make to this form, after you sign it, must be 

initialed and dated by you. Under extremely limited circumstances, 

agencies may modify your response(s) with your consent.

4.

5. You must use the Location codes (abbreviations), immediately following 

the Privacy Act Routine Uses, when you fill out this form. Do not 

abbreviate the names of cities or foreign countries. 

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Form approved: 

OMB No. 3206 0005 

6. Place of birth requires Country entry, even if in the U.S.
To the Office of Management and Budget when necessary to the review of 

private relief legislation.

7.

9.

10.

8.

The 5-digit postal Zip Codes are required to process your investigation 

more rapidly. Refer to an automated system approved by the U.S. Postal 

Service to assist you with Zip Codes.

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

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

format. Use numbers (01-12) to indicate months. For example, July 29, 

1968, should be written as 07/29/1968. If you are unable to report an 

exact date, approximate or estimate the date to the best of your ability, 

and indicate "APPROX." or "EST" in the field.

If additional space is required for an explanation or to list your residences, 

employment/self- employment/unemployment, or education, you should 

use a continuation sheet, SF 86A, located at http://www.opm.gov/forms, 

select standard forms. If additional space is required to answer other 

items, use the Continuation Space, on page 121, or a blank sheet(s) of 

paper. Include your name and SSN at the top of each blank sheet (s) 

used.

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Form approved: 

OMB No. 3206 0005 

The U.S. Criminal Code (title 18, section 1001) provides that knowingly 

falsifying or concealing a material fact is a felony which may result in fines 

and/or up to five (5) years imprisonment. In addition, Federal agencies 

generally fire, do not grant a security clearance, or disqualify individuals who 

have materially and deliberately falsified these forms, and this remains a part 

of the permanent record for future placements. Your prospects of placement 

or security clearance are better if you answer all questions truthfully and 

completely. You will have adequate opportunity to explain any information you 

provide on this form and to make your comments part of the record.

Penalties for Inaccurate or False Statements

The information you provide is for the purpose of investigating you for a 

national security position, and the information will be protected from 

unauthorized disclosure. The collection, maintenance, and disclosure of 

background investigative information are governed by the Privacy Act. The 

agency that requested the investigation and the agency that conducted the 

investigation have published notices in the Federal Register describing the 

systems of records in which your records will be maintained. The information 

you provide on this form, and information collected during an investigation, 

may be disclosed without your consent by an agency maintaining the 

information in a system of records as permitted by the Privacy Act [5 U.S.C. 

552a(b)], and by routine uses, a list of which are published by the agency in 

the Federal Register. The office that gave you this form will provide you a 

copy of its routine uses.

Disclosure Information

Privacy Act Routine Uses

2.

3.

4.

5.

6.

7.

9.

10.

8.

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

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.

Except as noted in Sections 23 and 27, 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.

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.

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.

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.

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.

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.

To the National Archives and Records Administration for records 

management inspections conducted under 44 U.S.C. 2904 and 2906.

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.

11.

Final determination on your eligibility for a national security position is the 

responsibility of the Federal agency that requested your investigation and the 

agency that conducted your investigation. You will be provided the opportunity 

to explain, refute, or clarify any information before a final decision is made, if 

an unfavorable decision is considered. The United States Government does 

not discriminate on the basis of race, color, religion, sex, national origin, 

disability, or sexual orientation when granting access to classified information.

Final Determination on Your Eligibility

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.
Public burden reporting for this collection of information is estimated to average 150 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 U.S. Office of Personnel Management, 

Federal Investigative Services, Attn: OMB Number 3206-0005, 1900 E. Street N.W., Washington, DC 20415. Do not send your completed form to this address; 

send it to the office that provided you the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect this information, and you are 

not required to respond, unless this number is displayed.

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Form approved: 

OMB No. 3206 0005 

LOCATION CODES 

PUBLIC BURDEN INFORMATION

South Dakota SD 

Tennessee TN 

Texas TX 

Utah UT 

Vermont VT 

Virginia VA 

Washington WA 

West Virginia WV 

Wisconsin WI 

Wyoming WY 

 

 

Wake Island WQ 

APO/FPO America AA 

APO/FPO Europe AE 

APO/FPO Pacific AP

New Mexico NM 

New York NY 

North Carolina NC 

North Dakota ND 

Ohio OH 

Oklahoma OK 

Oregon OR 

Pennsylvania PA 

Rhode Island RI 

South Carolina SC 

 

Palmyra Atoll LQ 

Puerto Rico PR 

Virgin Islands, United VI 

States 

Massachusetts MA 

Michigan MI 

Minnesota MN 

Mississippi MS 

Missouri MO 

Montana MT 

Nebraska NE 

Nevada NV 

New Hampshire NH 

New Jersey NJ 

 

Midway Islands MQ 

Navassa Island BQ 

Northern Mariana Islands MP 

Palau PW 

Hawaii HI 

Idaho ID 

Illinois IL 

Indiana IN 

Iowa IA 

Kansas KS

Kentucky KY 

Louisiana LA 

Maine ME 

Maryland MD 

Johnson Atoll JQ 

Kingman Reef KQ 

Marshall Islands MH 

Micronesia, Federated FM 

States

Alabama AL 

Alaska AK 

Arizona AZ 

Arkansas AR 

California CA 

Colorado CO 

Connecticut CT 

Delaware DE 

District of Columbia DC 

Florida FL 

Georgia GA 

American Samoa AS 

Baker Island FQ 

Guam GU 

Howland Island HQ 

Jarvis Island DQ

V Applicant affiliation

None

J SON (Submitting Office Number)

Initial 

Reinvestigation

S Investigative requirement

Investigating agency user only Codes: (FIPC CODES) Case Number:

P Obligating document number Q Business Event Type Code

R Accounting data and/or Agency case number

T Requesting official - Name Title Signature

Title

Telephone number (Include Ext.) FED CIV CON

Other

Other address/Web address of e-OPF Zip Code

A Type of investigation C Sensitivity level Compu/ADP D Access/Eligibility E Nature of action code 

G Geographic location H Position code I Position title

K Location of official personnel folder

U Secondary requesting official - Name

B Extra coverage/Advance results

NPRC

At SON

e-OPF

Other

L SOI (Security Office Identifier) M Location of security folder None

NPI

At SOI

Other

Other address

Email address

Email address Telephone number (Include Ext.) Date (Month/Day/Year)

FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION PROVIDED 

IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE, THOSE 

DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.

Zip Code

MIL

N IPAC O Treasury Account Symbol

AGENCY USE BLOCK "AUB"

W Deployment/PCS - (Do not provide deployment data if Classified or Sensitive information) 

Point of contact at location Address/Unit/Duty location (Include City or Post Name)

Commercial and Government Entity (CAGE) Code Contract Number

F Date of action (Month/Day/Year)

Agency Special Instructions for the Investigative Service Provider.

From (Month/Day/Year) Reason(s) for temporary duty assignment or PCS

Location (if imminent)

Telephone number (Include Ext.)

Est.

Permanent Relocation

Est. To (Month/Day/Year)
Page 1

Provide your other name(s) used and the period of time you used it/them [for example: your maiden name(s), name(s) by a former marriage, former name(s), 

alias(es), or nickname(es)]. If you have only initials in your name(s), provide them and indicate "Initial only." If you do not have a middle name (s), indicate "No 

Middle Name" (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Form approved: 

OMB No. 3206 0005 

Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle 

Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Enter your Social Security Number before going to the next page

Last name First name Middle name

Provide the reason(s) why the name changed

#1

From (Month/Year) To (Month/Year) Maiden name?

YES NO

Suffix

Est. Est.

Present

 Section 5 - Other Names Used 

 Section 3 - Place of Birth 

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

to the penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), denial or revocation of a 

security clearance, and/or removal and debarment from Federal Service.

PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW AFTER CAREFULLY READING 

THE PRECEDING INSTRUCTIONS. 

YES NO

Provide your place of birth.

Last name First name Middle name

City County State Country (Required)

Have you used any other names? YES NO (If NO, proceed to Section 6)

Not applicable

Provide your U.S. Social Security Number.

Section 4 - Social Security Number

Male

Sex Female

 Section 6 - Your Identifying Information 

Weight (in pounds) Hair color Eye color

Provide your identifying information.

Suffix

(feet) (inches)

Height

 Section 2 - Date of Birth

Section 1 - Full Name

Provide your date of birth. 

(Month/Day/Year)

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

Last name First name Middle name

Provide the reason(s) why the name changed

#2

From (Month/Year) To (Month/Year) Maiden name?

YES NO

Suffix

Est. Est.

Present

Last name First name Middle name

Provide the reason(s) why the name changed

#3

From (Month/Year) To (Month/Year) Maiden name?

YES NO

Suffix

Est. Est.

Present

Last name First name Middle name

Provide the reason(s) why the name changed

#4

From (Month/Year) To (Month/Year) Maiden name?

YES NO

Suffix

Est. Est.

Present
Page 2

 Section 8 - U.S. Passport Information

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

YES NO (If NO, proceed to Section 9)

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

Passport number The following link will provide U.S. State Department 

passport help. http://travel.state.gov/passport

Issue date Expiration date

Est.

Provide the name in which passport was first issued.

Last name First name Middle name Suffix

 Section 9 - Citizenship

Select the box that reflects your current citizenship status.

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

(Proceed to Section 10) 

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

(Complete 9.1) 

I am not a U.S. citizen. (Complete 9.3)

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

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

Provide the place of issuance. (Provide City and Country if outside the United States; otherwise, provide City and State.)

City State Country

Provide the name in which document was issued.

Last name First name Middle name Suffix

Provide the address of the court that issued the citizenship certificate.

Provide the name in which the certificate was issued.

Last name First name Middle name Suffix

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

YES NO (If NO, proceed to Section 10)

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Est.

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

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

Est.

Provide your citizenship certificate number.

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

Est.

Provide type of documentation of U.S. citizen born abroad.

FS240 or FS545 DS 1350 Other (Provide explanation)

(Month/Day/Year) (Month/Day/Year)

 Section 7 - Your Contact Information 

Provide your contact information.

Home e-mail address Work e-mail address

Home telephone number Extension

International or DSN phone number

Night

Day Work telephone number Extension

International or DSN phone number

Night

Day Mobile/Cell telephone number Extension

International or DSN phone number

Night

Day

Provide the name of the court that issued the citizenship certificate.

Street City State Zip Code

Provide the name of the base.
Page 3

Provide the address of the court that issued the naturalization certificate.

City State

Provide the name in which the naturalization certificate was issued.

Last name First name Middle name Suffix

Street Zip Code

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

Est.

Provide your naturalization certificate number.

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Form approved: 

OMB No. 3206 0005 

Enter your Social Security Number before going to the next page

(Provide explanation)

9.3 Complete the following if you answered that you are not a U.S. Citizen.

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

Est.

Provide your residence status.

Provide the date document was issued

Est.

Provide your alien registration number.

Provide the name in which the document was issued.

Last name First name Middle name Suffix

Provide document number. Provide the expiration date of visa.

Est.

Provide the basis of naturalization.

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

Based on my own individual naturalization application Other

Provide type of document issued. (I-94, etc.)

I-94 U.S. Visa Other (Provide explanation)

Provide the name of the court that issued the 

naturalization certificate.

 Section 9 - Citizenship - (Continued)

Provide the address of the court that issued the citizenship certificate.

City State

Provide the name in which the citizenship certificate was issued.

Last name First name Middle name Suffix

Street Zip Code

(Month/Day/Year) (Month/Day/Year)

(Month/Day/Year)

Est.

Provide the date of entry into the U.S.

City State

Provide country(ies) of prior citizenship. 

#1 Country

Provide the location of entry into the U.S.

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

Provide your U.S. alien registration number.

Est.

Provide your citizenship certificate 

number.

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

Provide the name of the court that issued the citizenship 

certificate.

Provide the date the citizenship certificate was 

issued. (Month/Day/Year)

YES

NO

 

#2 Country

Provide your place of entry in the U.S.

City State

Provide country(ies) of prior citizenship. 

#1 Country

 

#2 Country
Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Form approved: 

OMB No. 3206 0005 

Page 4

 Section 10 - Dual/Multiple Citizenship & Foreign Passport Information

10.1 Do you now or have you EVER held dual/multiple citizenships? YES NO (If NO, proceed to 10.2)

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

Entry #1

Provide country of citizenship.

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

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

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

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

From Date (Month/Year)

Est.

To Date (Month/Year) Present

Est.

Have you taken any action to renounce your foreign citizenship?

YES NO Provide explanation:

Do you currently hold citizenship with this country?

YES NO Provide explanation:

Entry #2

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

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

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

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

From Date (Month/Year)

Est.

To Date (Month/Year) Present

Est.

Have you taken any action to renounce your foreign citizenship?

YES NO Provide explanation:

YES NO Provide explanation:

Do you currently hold citizenship with this country?

Provide country of citizenship.

10.2 Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.? YES NO (If NO, proceed to Section 11)

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

Entry #1

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

Est.

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

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

City Country

Last name First name Middle name Suffix

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

Est.

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

YES NO

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

Country From date (Month/Year) To date (Month/Year)

#1 Est. Est. Present

#2 Est. Est. Present

#3 Est. Est. Present

#4 Est. Est. Present

#5 Est. Est. Present

#6 Est. Est. Present

Enter your Social Security Number before going to the next page
Page 5

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

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

Enter your Social Security Number before going to the next page

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

Entry #2

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

Est.

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

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

City Country

Last name First name Middle name Suffix

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

Est.

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

YES NO

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

Country From date (Month/Year) To date (Month/Year)

#1 Est. Est. Present

#2 Est. Est. Present

#3 Est. Est. Present

#4 Est. Est. Present

#5 Est. Est. Present

#6 Est. Est. Present
Page 6

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 11 - Where You Have Lived

List the places where you have lived beginning with your present residence and working back 10 years. Residences for the entire period must be accounted 

for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you were not physically 

located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list residence before your 18th 

birthday unless to provide a minimum of 2 years residence history. 

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

For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew 

you well for residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives.

Entry #1

Evening telephone number Extension

International or DSN phone number

I don't know

Daytime telephone number Extension Cell/mobile telephone number Extension

Provide the following contact information for this person.

International or DSN phone number

I don't know

International or DSN phone number

I don't know

Provide dates of residence.

From Date

Est.

To Date Present

Est.

Owned by you

Military housing

Rented or leased by you

Other 

Is/was this residence:

(Provide explanation)

Street City State Country

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

Zip Code

Provide the name of a neighbor or other person who knows you at this address.

Last name First name Middle name Suffix

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

Neighbor Friend Landlord Business associate Other (Provide explanation)

Street City State Country

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

Zip Code

Provide e-mail address for this person.

I don't know

 (Month/Year) (Month/Year)

Enter residence information.

Est.

Provide date of last contact. 

(Month/Year)

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

Street Address/Unit/Duty Location City or Post Name State Country

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

Zip Code

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

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

(a) 

YES 

NO

Address APO or FPO APO/FPO State Code Zip Code

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

YES 

NO
Page 7

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 11 - Where You Have Lived - (Continued)

Entry #2

Evening telephone number Extension

International or DSN phone number

I don't know

Daytime telephone number Extension Cell/mobile telephone number Extension

Provide the following contact information for this person.

International or DSN phone number

I don't know

International or DSN phone number

I don't know

Provide dates of residence.

From Date

Est.

To Date Present

Est.

Owned by you

Military housing

Rented or leased by you

Other 

Is/was this residence:

(Provide explanation)

Street City State Country

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

Zip Code

Provide the name of a neighbor or other person who knows you at this address.

Last name First name Middle name Suffix

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

Neighbor Friend Landlord Business associate Other (Provide explanation)

Street City State Country

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

Zip Code

Provide e-mail address for this person.

I don't know

 (Month/Year) (Month/Year)

Enter residence information.

Est.

Provide date of last contact. 

(Month/Year)

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

Street Address/Unit/Duty Location City or Post Name State Country

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

Zip Code

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

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

(a) 

YES 

NO

Address APO or FPO APO/FPO State Code Zip Code

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

YES 

NO
Page 8

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 11 - Where You Have Lived - (Continued)

Entry #3

Evening telephone number Extension

International or DSN phone number

I don't know

Daytime telephone number Extension Cell/mobile telephone number Extension

Provide the following contact information for this person.

International or DSN phone number

I don't know

International or DSN phone number

I don't know

Provide dates of residence.

From Date

Est.

To Date Present

Est.

Owned by you

Military housing

Rented or leased by you

Other 

Is/was this residence:

(Provide explanation)

Street City State Country

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

Zip Code

Provide the name of a neighbor or other person who knows you at this address.

Last name First name Middle name Suffix

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

Neighbor Friend Landlord Business associate Other (Provide explanation)

Street City State Country

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

Zip Code

Provide e-mail address for this person.

I don't know

 (Month/Year) (Month/Year)

Enter residence information.

Est.

Provide date of last contact. 

(Month/Year)

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

Street Address/Unit/Duty Location City or Post Name State Country

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

Zip Code

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

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

(a) 

YES 

NO

Address APO or FPO APO/FPO State Code Zip Code

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

YES 

NO
Page 9

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 11 - Where You Have Lived - (Continued)

Entry #4

Evening telephone number Extension

International or DSN phone number

I don't know

Daytime telephone number Extension Cell/mobile telephone number Extension

Provide the following contact information for this person.

International or DSN phone number

I don't know

International or DSN phone number

I don't know

Provide dates of residence.

From Date

Est.

To Date Present

Est.

Is/was this residence:

(Provide explanation)

Street City State Country

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

Zip Code

Provide the name of a neighbor or other person who knows you at this address.

Last name First name Middle name Suffix

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

Neighbor Friend Landlord Business associate Other (Provide explanation)

Street City State Country

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

Zip Code

Provide e-mail address for this person.

I don't know

 (Month/Year) (Month/Year)

Enter residence information.

Est.

Provide date of last contact. 

(Month/Year)

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

Street Address/Unit/Duty Location City or Post Name State Country

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

Zip Code

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

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

(a) 

YES 

NO

Address APO or FPO APO/FPO State Code Zip Code

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

YES 

NO

Owned by you

Military housing

Rented or leased by you

Other 
Page 10

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

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Entry #1

 Section 12 - Where You Went to School

(a) Have you attended any schools in the last 10 years?

YES NO

(b) Have you received a degree or diploma more than 10 years ago? 

YES NO (If NO to 12(a) and 12(b), proceed to Section 13A)

Provide the dates of attendance. 

From Date

Est.

Present

Est.

High School Vocational/Technical/Trade School

College/University/Military College Correspondence/Distance/Extension/Online School

Select the most appropriate code to describe your school.

YES NO

Street City State Country

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

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

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

Zip Code

Did you receive a degree/diploma?

Provide the name of the school.

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods 

completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Last name First name I don't know

Street City State Zip Code Country

Telephone number Extension International or DSN phone number

Provide telephone number for this person. I don't know I don't know

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

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

Doctorate, Professional Degree (e.g. MD, DVM, JD), Other) Other degree/diploma Date awarded

(Month/Year) Est.

Provide email address for this person.

(Month/Year) To Date (Month/Year)

Entry #2

Provide the dates of attendance. 

From Date

Est.

Present

Est.

High School Vocational/Technical/Trade School

College/University/Military College Correspondence/Distance/Extension/Online School

Select the most appropriate code to describe your school.

Street City State Country

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

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

Zip Code

Provide the name of the school.

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods 

completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Last name First name I don't know

(Month/Year) To Date (Month/Year)

Day Night
Page 11

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

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

YES NO

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

Did you receive a degree/diploma?

Street City State Zip Code Country

I don't know

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

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

Doctorate, Professional Degree (e.g. MD, DVM, JD), Other) Other degree/diploma Date awarded (Month/Year) Est.

Provide email address for this person.

Entry #2 (Continued)

Entry #3

Provide the dates of attendance. 

From Date

Est.

Present

Est.

High School Vocational/Technical/Trade School

College/University/Military College Correspondence/Distance/Extension/Online School

Select the most appropriate code to describe your school.

YES NO

Street City State Country

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

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

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

Zip Code

Did you receive a degree/diploma?

Provide the name of the school.

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods 

completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Last name First name I don't know

Street City State Zip Code Country

I don't know

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

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

Doctorate, Professional Degree (e.g. MD, DVM, JD), Other) Other degree/diploma Date awarded (Month/Year) Est.

Provide email address for this person.

(Month/Year) To Date (Month/Year)

I don't know

International or DSN phone number Telephone number Extension

Provide telephone number for this person.

Day Night

International or DSN phone number

I don't know

Telephone number Extension

Provide telephone number for this person.

Day Night
Page 12

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

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

Entry #4

Provide the dates of attendance. 

From Date

Est.

Present

Est.

High School Vocational/Technical/Trade School

College/University/Military College Correspondence/Distance/Extension/Online School

Select the most appropriate code to describe your school.

YES NO

Street City State Country

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

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

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

Zip Code

Did you receive a degree/diploma?

Provide the name of the school.

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods 

completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.

Last name First name I don't know

Street City State Zip Code Country

I don't know

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

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

Doctorate, Professional Degree (e.g. MD, DVM, JD), Other) Other degree/diploma Date awarded (Month/Year) Est.

Provide email address for this person.

(Month/Year) To Date (Month/Year)

International or DSN phone number

I don't know

Telephone number Extension

Provide telephone number for this person.

Day Night
Page 13

Provide the name of your supervisor. Provide the rank/position title of your supervisor.

Provide supervisor's telephone number. Extension

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

Street City State Zip Code Country

Street Address/Unit/Duty Location City or Post Name State Country

If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home 

port/fleet headquarter. (Provide physical location data) (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Zip Code

Day Night

International or DSN phone number

Street City State Country

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

Zip Code

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Form approved: 

OMB No. 3206 0005 

 Section 13A - Employment Activities

Enter your Social Security Number before going to the next page

Telephone number Extension International or DSN phone number

Day Night

Provide the email address of your supervisor. I don't know

Entry #1 

List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 10 years. The entire period 

must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military 

duty station. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

Entry #1 

Est.

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time

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

From Date 

(Month/Year)

Est.

Present

To Date 

(Month/Year) Provide your most recent rank/position title.

Provide your assigned duty station during this period.

Select your employment activity:

Active military duty station (Complete 13A.1, 

13A.5 and 13A.6)

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

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1, 

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2, 

13A.5 and 13A.6)

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

13A.6)

State Government (Non-Federal employment) 

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

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

Unemployment (Complete 13A.4)

Federal Contractor (Complete 13A.2, 

13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 

13A.5 and 13A.6)

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 14

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 13A - Employment Activities - (Continued)

Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the 

same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information 

concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment 

as entries below).

Provide the name of your supervisor. Provide the position title of your supervisor.

Street City State Country

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

Zip Code

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

Street City State Zip Code Country

Provide telephone number Extension International or DSN phone number

Day Night

Entry #1

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

(b)

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

Provide telephone number Extension International or DSN phone number

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

Street City State Zip Code Country

Day Night

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

(a)

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time Provide the name of your employer.

Provide most recent position title.

Est.

Present

To Date 

(Month/Year)

Est.

From Date 

(Month/Year)

Not 

Applicable

From date (Month/Year) To date (Month/Year) Position Title Supervisor

Est. Est.

Est. Est.

Est. Est.

Est. Est.

Provide supervisor's telephone number. Extension

Day Night

Provide the email address of your supervisor. I don't know International or DSN phone number

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(b.1) 

(b.2) 

YES 

NO

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 15

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 13A - Employment Activities - (Continued)

Last name First name

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

Street City State Zip Code Country

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

Is your physical work address different than your employment address?

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

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

Street City State Zip Code Country

Telephone number Extension International or DSN phone number

Provide the telephone number for this address.

Day Night

Street City State Country

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

Zip Code

Provide telephone number. Extension International or DSN phone number

Day Night

Telephone number Extension International or DSN phone number

Day Night

Provide the telephone number for this person.

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

Entry #1

(b)

(a)

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time Provide the name of your employer.

Provide most recent position title.

Est.

Present

To Date 

(Month/Year)

Est.

From Date 

(Month/Year)

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

Street Address/Unit/Duty Location City or Post Name State Country

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(b.1) 

(b.2) 

YES 

NO

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 16

Last name First name

Provide the name of someone that can verify your unemployment activities 

and means of support.

Est.

To Date Present (Month/Year)

Est.

From Date (Month/Year)

Provide dates of unemployment.

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

Street City State Zip Code Country

Verifier telephone number Extension International or DSN phone number

Day Night

Provide the telephone number for this person.

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 13A - Employment Activities - (Continued)

Provide the reason for leaving the employment activity.

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

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

Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following 

notice of unsatisfactory performance. 

Left by mutual agreement following 

notice of unsatisfactory performance 

 

Left by mutual agreement following 

charges or allegations of misconduct

Quit after being told you would be 

fired

Fired

Select your type of incident:

Provide the reason(s) for unsatisfactory performance.

Provide the charges or allegations of misconduct.

Provide the reason for quitting.

Provide the reason for being fired.

Reason:

Est.

Employment departure date

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

Est.

Est.

Est.

Provide the date you left following charges or allegations 

of misconduct. (Month/Year)

Provide the date you quit after being told you would be 

fired. (Month/Year)

Provide the date you left by mutual agreement following 

a notice of unsatisfactory performance. (Month/Year)

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

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

Est.

Date: (Month/Year)

Date: (Month/Year)

Est.

#1

#2

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

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

Est.

Date: (Month/Year)

Date: (Month/Year)

Est.

#3

#4

YES NO

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct 

in the workplace, such as a violation of security policy?

Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State 

Government, Federal Contractor, Non-government employment, Self-Employment, or Other. 

Entry #1 Entry #1 Entry #1

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

13A.6 

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

Does your unemployment verifier have an APO/FPO address?

(a) 

(b) 

YES 

NO

Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State 

Government, Federal Contractor, Non-government employment, Self-Employment, or Other. 

13A.5 
Page 17

Provide the name of your supervisor. Provide the rank/position title of your supervisor.

Provide supervisor's telephone number. Extension

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

Street City State Zip Code Country

Street Address/Unit/Duty Location City or Post Name State Country

If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home 

port/fleet headquarter. (Provide physical location data) (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Zip Code

Day Night

International or DSN phone number

Street City State Country

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

Zip Code

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Form approved: 

OMB No. 3206 0005 

 Section 13A - Employment Activities

Enter your Social Security Number before going to the next page

Telephone number Extension International or DSN phone number

Day Night

Provide the email address of your supervisor. I don't know

Entry #2 

Entry #2 

Est.

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time

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

From Date 

(Month/Year)

Est.

Present

To Date 

(Month/Year) Provide your most recent rank/position title.

Provide your assigned duty station during this period.

Select your employment activity:

Active military duty station (Complete 13A.1, 

13A.5 and 13A.6)

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

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1, 

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2, 

13A.5 and 13A.6)

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

13A.6)

State Government (Non-Federal employment) 

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

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

Unemployment (Complete 13A.4)

Federal Contractor (Complete 13A.2, 

13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 

13A.5 and 13A.6)

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 18

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 13A - Employment Activities - (Continued)

Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the 

same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information 

concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment 

as entries below).

Provide the name of your supervisor. Provide the position title of your supervisor.

Street City State Country

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

Zip Code

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

Street City State Zip Code Country

Provide telephone number Extension International or DSN phone number

Day Night

Entry #2

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

(b)

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

Provide telephone number Extension International or DSN phone number

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

Street City State Zip Code Country

Day Night

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

(a)

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time Provide the name of your employer.

Provide most recent position title.

Est.

Present

To Date 

(Month/Year)

Est.

From Date 

(Month/Year)

Not 

Applicable

From date (Month/Year) To date (Month/Year) Position Title Supervisor

Est. Est.

Est. Est.

Est. Est.

Est. Est.

Provide supervisor's telephone number. Extension

Day Night

Provide the email address of your supervisor. I don't know International or DSN phone number

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(b.1) 

(b.2) 

YES 

NO

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 19

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 13A - Employment Activities - (Continued)

Last name First name

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

Street City State Zip Code Country

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

Is your physical work address different than your employment address?

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

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

Street City State Zip Code Country

Telephone number Extension International or DSN phone number

Provide the telephone number for this address.

Day Night

Street City State Country

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

Zip Code

Provide telephone number. Extension International or DSN phone number

Day Night

Telephone number Extension International or DSN phone number

Day Night

Provide the telephone number for this person.

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

Entry #2

(b)

(a)

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time Provide the name of your employer.

Provide most recent position title.

Est.

Present

To Date 

(Month/Year)

Est.

From Date 

(Month/Year)

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

Street Address/Unit/Duty Location City or Post Name State Country

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(b.1) 

(b.2) 

YES 

NO

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 20

Last name First name

Provide the name of someone that can verify your unemployment activities 

and means of support.

Est.

To Date Present (Month/Year)

Est.

From Date (Month/Year)

Provide dates of unemployment.

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

Street City State Zip Code Country

Verifier telephone number Extension International or DSN phone number

Day Night

Provide the telephone number for this person.

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 13A - Employment Activities - (Continued)

Provide the reason for leaving the employment activity.

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

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

Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following 

notice of unsatisfactory performance. 

Left by mutual agreement following 

notice of unsatisfactory performance 

 

Left by mutual agreement following 

charges or allegations of misconduct

Quit after being told you would be 

fired

Fired

Select your type of incident:

Provide the reason(s) for unsatisfactory performance.

Provide the charges or allegations of misconduct.

Provide the reason for quitting.

Provide the reason for being fired.

Reason:

Est.

Employment departure date

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

Est.

Est.

Est.

Provide the date you left following charges or allegations 

of misconduct. (Month/Year)

Provide the date you quit after being told you would be 

fired. (Month/Year)

Provide the date you left by mutual agreement following 

a notice of unsatisfactory performance. (Month/Year)

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

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

Est.

Date: (Month/Year)

Date: (Month/Year)

Est.

#1

#2

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

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

Est.

Date: (Month/Year)

Date: (Month/Year)

Est.

#3

#4

YES NO

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct 

in the workplace, such as a violation of security policy?

Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State 

Government, Federal Contractor, Non-government employment, Self-Employment, or Other. 

Entry #2 Entry #2 Entry #2

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

13A.6 

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

Does your unemployment verifier have an APO/FPO address?

(a) 

(b) 

YES 

NO

Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State 

Government, Federal Contractor, Non-government employment, Self-Employment, or Other. 

13A.5 
Page 21

Provide the name of your supervisor. Provide the rank/position title of your supervisor.

Provide supervisor's telephone number. Extension

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

Street City State Zip Code Country

Street Address/Unit/Duty Location City or Post Name State Country

If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home 

port/fleet headquarter. (Provide physical location data) (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Zip Code

Day Night

International or DSN phone number

Street City State Country

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

Zip Code

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Form approved: 

OMB No. 3206 0005 

 Section 13A - Employment Activities

Enter your Social Security Number before going to the next page

Telephone number Extension International or DSN phone number

Day Night

Provide the email address of your supervisor. I don't know

Entry #3 

Entry #3

Est.

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time

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

From Date 

(Month/Year)

Est.

Present

To Date 

(Month/Year) Provide your most recent rank/position title.

Provide your assigned duty station during this period.

Select your employment activity:

Active military duty station (Complete 13A.1, 

13A.5 and 13A.6)

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

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1, 

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2, 

13A.5 and 13A.6)

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

13A.6)

State Government (Non-Federal employment) 

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

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

Unemployment (Complete 13A.4)

Federal Contractor (Complete 13A.2, 

13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 

13A.5 and 13A.6)

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 22

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 13A - Employment Activities - (Continued)

Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the 

same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information 

concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment 

as entries below).

Provide the name of your supervisor. Provide the position title of your supervisor.

Street City State Country

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

Zip Code

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

Street City State Zip Code Country

Provide telephone number Extension International or DSN phone number

Day Night

Entry #3

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

(b)

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

Provide telephone number Extension International or DSN phone number

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

Street City State Zip Code Country

Day Night

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

(a)

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time Provide the name of your employer.

Provide most recent position title.

Est.

Present

To Date 

(Month/Year)

Est.

From Date 

(Month/Year)

Not 

Applicable

From date (Month/Year) To date (Month/Year) Position Title Supervisor

Est. Est.

Est. Est.

Est. Est.

Est. Est.

Provide supervisor's telephone number. Extension

Day Night

Provide the email address of your supervisor. I don't know International or DSN phone number

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(b.1) 

(b.2) 

YES 

NO

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 23

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 13A - Employment Activities - (Continued)

Last name First name

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

Street City State Zip Code Country

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

Is your physical work address different than your employment address?

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

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

Street City State Zip Code Country

Telephone number Extension International or DSN phone number

Provide the telephone number for this address.

Day Night

Street City State Country

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

Zip Code

Provide telephone number. Extension International or DSN phone number

Day Night

Telephone number Extension International or DSN phone number

Day Night

Provide the telephone number for this person.

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

Entry #3

(b)

(a)

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time Provide the name of your employer.

Provide most recent position title.

Est.

Present

To Date 

(Month/Year)

Est.

From Date 

(Month/Year)

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

Street Address/Unit/Duty Location City or Post Name State Country

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(b.1) 

(b.2) 

YES 

NO

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Last name First name

Provide the name of someone that can verify your unemployment activities 

and means of support.

Est.

To Date Present (Month/Year)

Est.

From Date (Month/Year)

Provide dates of unemployment.

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

Street City State Zip Code Country

Verifier telephone number Extension International or DSN phone number

Day Night

Provide the telephone number for this person.

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 13A - Employment Activities - (Continued)

Provide the reason for leaving the employment activity.

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

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

Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following 

notice of unsatisfactory performance. 

Left by mutual agreement following 

notice of unsatisfactory performance 

 

Left by mutual agreement following 

charges or allegations of misconduct

Quit after being told you would be 

fired

Fired

Select your type of incident:

Provide the reason(s) for unsatisfactory performance.

Provide the charges or allegations of misconduct.

Provide the reason for quitting.

Provide the reason for being fired.

Reason:

Est.

Employment departure date

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

Est.

Est.

Est.

Provide the date you left following charges or allegations 

of misconduct. (Month/Year)

Provide the date you quit after being told you would be 

fired. (Month/Year)

Provide the date you left by mutual agreement following 

a notice of unsatisfactory performance. (Month/Year)

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

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

Est.

Date: (Month/Year)

Date: (Month/Year)

Est.

#1

#2

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

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

Est.

Date: (Month/Year)

Date: (Month/Year)

Est.

#3

#4

YES NO

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct 

in the workplace, such as a violation of security policy?

Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State 

Government, Federal Contractor, Non-government employment, Self-Employment, or Other. 

Entry #3 Entry #3 Entry #3

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

13A.6 

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

Does your unemployment verifier have an APO/FPO address?

(a) 

(b) 

YES 

NO

Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State 

Government, Federal Contractor, Non-government employment, Self-Employment, or Other. 

13A.5 

Page 24
Page 25

Provide the name of your supervisor. Provide the rank/position title of your supervisor.

Provide supervisor's telephone number. Extension

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

Street City State Zip Code Country

Street Address/Unit/Duty Location City or Post Name State Country

If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home 

port/fleet headquarter. (Provide physical location data) (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Zip Code

Day Night

International or DSN phone number

Street City State Country

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

Zip Code

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

QUESTIONNAIRE FOR 

NATIONAL SECURITY POSITIONS

Form approved: 

OMB No. 3206 0005 

 Section 13A - Employment Activities

Enter your Social Security Number before going to the next page

Telephone number Extension International or DSN phone number

Day Night

Provide the email address of your supervisor. I don't know

Entry #4 

Entry #4 

Est.

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time

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

From Date 

(Month/Year)

Est.

Present

To Date 

(Month/Year) Provide your most recent rank/position title.

Provide your assigned duty station during this period.

Select your employment activity:

Active military duty station (Complete 13A.1, 

13A.5 and 13A.6)

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

and 13A.6)

USPHS Commissioned Corps (Complete 13A.1, 

13A.5 and 13A.6)

Other Federal employment (Complete 13A.2, 

13A.5 and 13A.6)

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

13A.6)

State Government (Non-Federal employment) 

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

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

Unemployment (Complete 13A.4)

Federal Contractor (Complete 13A.2, 

13A.5 and 13A.6)

Other (Provide explanation and complete 13A.2, 

13A.5 and 13A.6)

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 26

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 13A - Employment Activities - (Continued)

Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the 

same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information 

concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment 

as entries below).

Provide the name of your supervisor. Provide the position title of your supervisor.

Street City State Country

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

Zip Code

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

Street City State Zip Code Country

Provide telephone number Extension International or DSN phone number

Day Night

Entry #4

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

(b)

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

Provide telephone number Extension International or DSN phone number

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

Street City State Zip Code Country

Day Night

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

(a)

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time Provide the name of your employer.

Provide most recent position title.

Est.

Present

To Date 

(Month/Year)

Est.

From Date 

(Month/Year)

Not 

Applicable

From date (Month/Year) To date (Month/Year) Position Title Supervisor

Est. Est.

Est. Est.

Est. Est.

Est. Est.

Provide supervisor's telephone number. Extension

Day Night

Provide the email address of your supervisor. I don't know International or DSN phone number

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(b.1) 

(b.2) 

YES 

NO

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 27

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 13A - Employment Activities - (Continued)

Last name First name

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

Street City State Zip Code Country

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

Is your physical work address different than your employment address?

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

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

Street City State Zip Code Country

Telephone number Extension International or DSN phone number

Provide the telephone number for this address.

Day Night

Street City State Country

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

Zip Code

Provide telephone number. Extension International or DSN phone number

Day Night

Telephone number Extension International or DSN phone number

Day Night

Provide the telephone number for this person.

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

Entry #4

(b)

(a)

Provide dates of employment. Select the employment status for 

this position: 

Part-time

Full-time Provide the name of your employer.

Provide most recent position title.

Est.

Present

To Date 

(Month/Year)

Est.

From Date 

(Month/Year)

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

Street Address/Unit/Duty Location City or Post Name State Country

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(b.1) 

(b.2) 

YES 

NO

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

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

(a) 

(b) 

YES 

NO
Page 28

Last name First name

Provide the name of someone that can verify your unemployment activities 

and means of support.

Est.

To Date Present (Month/Year)

Est.

From Date (Month/Year)

Provide dates of unemployment.

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

Street City State Zip Code Country

Verifier telephone number Extension International or DSN phone number

Day Night

Provide the telephone number for this person.

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 13A - Employment Activities - (Continued)

Provide the reason for leaving the employment activity.

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

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

Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following 

notice of unsatisfactory performance. 

Left by mutual agreement following 

notice of unsatisfactory performance 

 

Left by mutual agreement following 

charges or allegations of misconduct

Quit after being told you would be 

fired

Fired

Select your type of incident:

Provide the reason(s) for unsatisfactory performance.

Provide the charges or allegations of misconduct.

Provide the reason for quitting.

Provide the reason for being fired.

Reason:

Est.

Employment departure date

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

Est.

Est.

Est.

Provide the date you left following charges or allegations 

of misconduct. (Month/Year)

Provide the date you quit after being told you would be 

fired. (Month/Year)

Provide the date you left by mutual agreement following 

a notice of unsatisfactory performance. (Month/Year)

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

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

Est.

Date: (Month/Year)

Date: (Month/Year)

Est.

#1

#2

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

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

Est.

Date: (Month/Year)

Date: (Month/Year)

Est.

#3

#4

YES NO

For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct 

in the workplace, such as a violation of security policy?

Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State 

Government, Federal Contractor, Non-government employment, Self-Employment, or Other. 

Entry #4 Entry #4 Entry #4

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

13A.6 

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

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

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

Does your unemployment verifier have an APO/FPO address?

(a) 

(b) 

YES 

NO

Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State 

Government, Federal Contractor, Non-government employment, Self-Employment, or Other. 

13A.5 
Page 29

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 13B - Employment Activities - Former Federal Service

YES NO (If NO, proceed to Section 13C)

Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report?

Complete the following if you selected "Yes" to having former federal civilian employment, excluding military service, NOT indicated previously.

Provide your position title.

Provide the name of the federal agency for 

which you are/were employed.

Street City State Country

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

Zip Code

Provide dates of federal civilian employment.

From Date

Est.

To Date Present

Est.

Entry #2

 Section 13C - Employment Record

Have any of the following happened to you in the last seven (7) years at employment activities that you have not previously listed? 

- Fired from a job? 

- Quit a job after being told you would be fired? 

- Have you left a job by mutual agreement following charges or allegations of misconduct? 

- Left a job by mutual agreement following notice of unsatisfactory performance? 

- Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in 

 the workplace, such as violation of a security policy?

NO (If NO, proceed to Section 14)

YES (If YES, you will be required to add an additional employment in Section 13A)

Enter your Social Security Number before going to the next page

(Month/Year) (Month/Year)

Provide your position title.

Provide the name of the federal agency for 

which you are/were employed.

Street City State Country

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

Zip Code

Provide dates of federal civilian employment.

From Date

Est.

To Date Present

Est.

Entry #1

(Month/Year) (Month/Year)

Provide your position title.

Provide the name of the federal agency for 

which you are/were employed.

Street City State Country

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

Zip Code

Provide dates of federal civilian employment.

From Date

Est.

To Date Present

Est.

Entry #4

(Month/Year) (Month/Year)

Provide your position title.

Provide the name of the federal agency for 

which you are/were employed.

Street City State Country

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

Zip Code

Provide dates of federal civilian employment.

From Date

Est.

To Date Present

Est.

Entry #3

(Month/Year) (Month/Year)
Page 30

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

No 

Yes

I don't know

Were you born a male after December 31, 1959? 

 Section 14 - Selective Service Record

Provide registration number:

Provide explanation:

Provide explanation:

The Selective Service website, www.sss.gov, can help provide the 

registration number for persons who have registered. Note: Selective 

Service Number is not your Social Security Number.

 Section 15 - Military History

YES NO (If NO, proceed to Section 15.2) 

Have you EVER served in the U.S. Military?

Army

Army National 

Guard

Navy

Air Force

Air National 

Guard

Marine Corps

Coast Guard

Provide the branch of service you served in.

15.1 Complete the following if you responded 'Yes' to having served in the U.S. Military.

State of service, if 

National Guard

Enlisted

Not Applicable

Officer

Officer or enlisted

Provide your dates of service.

From Date 

(Month/Year)

Est.

To Date 

(Month/Year) Present

Est.

Provide your service number.

YES NO

Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?

Provide the type of discharge you received:

Honorable

Dishonorable

Bad Conduct

Other (provide type)

Under Other than 

Honorable Conditions

General

Provide the date of 

discharge listed 

(Month/Year) 

Est.

Provide the reason(s) for the discharge, if discharge is other than Honorable

Have you registered with the Selective Service System (SSS)?

YES NO (If NO, proceed to Section 15)

Inactive Reserve

Active Duty

Active Reserve

Provide your status

Entry #1

Army

Army National 

Guard

Navy

Air Force

Air National 

Guard

Marine Corps

Coast Guard

Provide the branch of service you served in. State of service, if 

National Guard

Enlisted

Not Applicable

Officer

Officer or enlisted

Provide your dates of service.

From Date 

(Month/Year)

Est.

To Date 

(Month/Year) Present

Est.

Provide your service number.

YES NO

Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?

Provide the type of discharge you received:

Honorable

Dishonorable

Bad Conduct

Other (provide type)

Under Other than 

Honorable Conditions

General

Provide the date of 

discharge listed 

(Month/Year) 

Est.

Provide the reason(s) for the discharge, if discharge is other than Honorable

Inactive Reserve

Active Duty

Active Reserve

Provide your status

Entry #2
Page 31

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 15 - Military History - (Continued)

YES NO (If NO, proceed to Section 15.3) In the last seven (7) years, have you been subject to court martial or other disciplinary procedure 

under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's Mast, Article 135 

Court of Inquiry, etc?

Est.

Provide the date of the court martial or other disciplinary procedure. (Month/Year)

Entry #1

Provide a description of the Uniform Code of Military Justice (UCMJ) 

offense(s) for which you were charged.

Provide the name of the disciplinary procedure, such as Court Martial, 

Article 15, Captain's mast, Article 135 Court of Inquiry, etc.

Provide the description of the military court or other authority in which you 

were charged (title of court or convening authority, address, to include city 

and state or country if overseas).

Provide the description of the final outcome of the disciplinary procedure, 

such as found guilty, found not guilty, fine, reduction in rank, 

imprisonment, etc.

Est.

Provide the date of the court martial or other disciplinary procedure. (Month/Year)

Entry #2

Provide a description of the Uniform Code of Military Justice (UCMJ) 

offense(s) for which you were charged.

Provide the name of the disciplinary procedure, such as Court Martial, 

Article 15, Captain's mast, Article 135 Court of Inquiry, etc.

Provide the description of the military court or other authority in which you 

were charged (title of court or convening authority, address, to include city 

and state or country if overseas).

Provide the description of the final outcome of the disciplinary procedure, 

such as found guilty, found not guilty, fine, reduction in rank, 

imprisonment, etc.

Complete the following if you responded 'Yes' to In the last seven (7) years, have you been subject to court martial or other disciplinary procedure under the 

Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's Mast, Article 135 Court of Inquiry, etc. 

15.2
Page 32

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 15 - Military History - (Continued)

Have you EVER YES NO (If NO, proceed to Section 16) served, as a civilian or military member in a foreign country's military, intelligence, 

diplomatic, security forces, militia, other defense force, or government agency?

Military (Specify Army, Navy, 

Air Force, Marines, etc.)

Intelligence Service

Diplomatic Service

Security Forces

Militia

Other Defense Forces

Other Government Agency

During your foreign service, which organization were you serving under?

Complete the following if you responded 'Yes' to having EVER served as a civilian or military member in a foreign country's military, intelligence, diplomatic, 

security forces, militia, other defense force, or government agency.

Provide your period of service.

From Date

Est.

To Date

Est.

Present (Month/Year) (Month/Year)

Provide the name of the foreign organization.

Provide the name of the country. Provide the highest position/rank held. Provide division/department/office in which you served.

Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service.

Do you maintain contact with current or former associates, colleagues, or acquaintances from your service in this organization?

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

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the contact's full name.

Provide the length of your association with the contact.

Contact #1

From Date

Est.

To Date

Est.

Present (Month/Year) (Month/Year)

YES NO (If NO, proceed to Section 16)

Provide the contact's official title. Provide the frequency of contact.

15.3

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

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the contact's full name.

Provide the length of your association with the contact.

From Date

Est.

To Date

Est.

Present

Provide the contact's official title. Provide the frequency of contact.

Contact #2

(Month/Year) (Month/Year)

Page 32

Entry #1
Page 33

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 15 - Military History - (Continued)

Military (Specify Army, Navy, 

Air Force, Marines, etc.)

Intelligence Service

Diplomatic Service

Security Forces

Militia

Other Defense Forces

Other Government Agency

During your foreign service, which organization were you serving under?

Complete the following if you responded 'Yes' to having EVER served as a civilian or military member in a foreign country's military, intelligence, diplomatic, 

security forces, militia, other defense force, or government agency.

Provide your period of service.

From Date

Est.

To Date

Est.

Present (Month/Year) (Month/Year)

Provide the name of the foreign organization.

Provide the name of the country. Provide the highest position/rank held. Provide division/department/office in which you served.

Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service.

Do you maintain contact with current or former associates, colleagues, or acquaintances from your service in this organization?

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

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the contact's full name.

Provide the length of your association with the contact.

Contact #1

From Date

Est.

To Date

Est.

Present (Month/Year) (Month/Year)

YES NO (If NO, Proceed to Section 16)

Provide the contact's official title. Provide the frequency of contact.

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

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the contact's full name.

Provide the length of your association with the contact.

From Date

Est.

To Date

Est.

Present

Provide the contact's official title. Provide the frequency of contact.

Contact #2

(Month/Year) (Month/Year)

Page 33

Entry #2
Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Night

Last name First name Middle name

Provide e-mail address for this person. 

Suffix

Provide telephone number for 

this person.

International or DSN 

phone number Extension

From Date

Est.

Provide dates known.

To Date Present

Est.

(Month/Year) (Month/Year)

Provide relationship to you. (Check all that apply)

City

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street State Zip Code Country

Provide mobile/cell telephone 

number for this person.

I don't know

Schoolmate

Other (Provide explanation)

Provide rank/title

Friend

Neighbor

Not applicable

Provide full name.

I don't know

Work associate

Day Day Night

International or DSN 

phone number Extension

I don't know

 Section 16 - People Who Know You Well

Provide three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college roommates, associates, etc., 

who are collectively aware of your activities outside of your workplace, school, or neighborhood, and whose combined association with you covers at least

the last seven (7) years. Do not list your spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form.

Entry #1

Night

Last name First name Middle name

Provide e-mail address for this person. 

Suffix

Provide telephone number for 

this person.

International or DSN 

phone number Extension

From Date

Est.

Provide dates known.

To Date Present

Est.

(Month/Year) (Month/Year)

Provide relationship to you. (Check all that apply)

City

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street State Zip Code

Provide mobile/cell telephone 

number for this person.

I don't know

Schoolmate

Provide rank/title

Friend

Neighbor

Not applicable

Provide full name.

I don't know

Work associate

Day Day Night

International or DSN 

phone number Extension

I don't know

Entry #2

Night

Last name First name Middle name

Provide e-mail address for this person. 

Suffix

Provide telephone number for 

this person.

International or DSN 

phone number Extension

From Date

Est.

Provide dates known.

To Date Present

Est.

(Month/Year) (Month/Year)

Provide relationship to you. (Check all that apply)

City

Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street State Zip Code Country

Provide mobile/cell telephone 

number for this person.

I don't know

Schoolmate

Provide rank/title

Friend

Neighbor

Not applicable

Provide full name.

I don't know

Work associate

Day Day Night

International or DSN 

phone number Extension

I don't know

Entry #3

Country

Other (Provide explanation)

Other (Provide explanation)

Page 34
Page 35

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Country #1

Provide date married. (Month/Day/Year)

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Country #2

Provide your spouse's country(ies) of citizenship.

 Section 17 - Marital Status

Separated (Complete 17.1 and 17.3) Divorced (Complete 17.2 and 17.3)

Married (including Common Law) (Complete 17.1 and 17.3) Annulled (Complete 17.2 and 17.3)

Never Married (Complete 17.3)

Provide your current marital status.

Widowed (Complete 17.2 and 17.3)

Middle name

Provide spouse's date of birth.

Last name First name Suffix

Est.

Complete the following about your current spouse only. 

Provide spouse's full name.

(Month/Day/Year) 

DS 1350 Alien registration

U.S. Naturalization certificate

U.S. Passport (current or most recent)

U.S. Citizenship certificate

FS 240 or 545

For your foreign born spouse, provide one type of documentation that he or she possesses and the document number.

None (Provide explanation)

Other (Provide explanation)

Provide your spouse's U.S. Social Security Number.

Provide document number.

Not applicable

Explanation

Provide spouse's place of birth.

City County State Country (required)

17.1 Complete the following if you selected 'Married' or 'Separated.'

Provide other names used by your spouse (such as maiden name, names by other marriages, nicknames, etc. and provide dates Not applicable

used for each name).

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO
Page 36

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

NO

YES 

Street Address/Unit/Duty Location City or Post Name State Country

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

Address APO or FPO APO/FPO State Code Zip Code

Zip Code

Provide your spouse's APO/FPO address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United 

States.) 

Does your spouse have an APO/FPO address?

(a) 

(b) 

YES 

NO

Provide date of separation. 

(Month/Day/Year)

Est.

Provide place married. (Provide City and Country if outside the United States; otherwise, provide City or County and State.)

City County State Country

Provide telephone number. Extension Use my current telephone number Provide email address.

International or DSN phone number

Provide your spouse's current address, if different than your current address. (Provide City and Country if outside the United States; otherwise, provide City, State and 

Zip Code)

Street City State Zip Code Country

Are you separated from your spouse?

City State Country

If legally separated, provide the location of the record. 

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

Zip Code

Not Applicable

Day

Night

17.1 Complete the following if you selected 'Married' or 'Separated.' (Continued)

 Section 17 - Marital Status - (Continued)
Page 37

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, complete (a)) I don't know

Est.

Provide the country(ies) of citizenship for your former spouse.

Country #1 Country #2

Provide the date you married your 

former spouse. (Month/Day/Year)

Est.

Middle name

Provide the date of birth of your 

Last name First name Suffix former spouse. (Month/Day/Year)

Est.

Provide the full name of your former spouse.

Entry #1

Provide the place of birth for your former spouse. 

City State Zip Code Country (Required)

17.2 Complete the following if you selected 'Divorced', 'Annulled', 'Widowed', or 'Other Former Spouses'.

Provide the place married. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.)

City State Country

 Section 17 - Marital Status - (Continued)

Divorced Widowed Annulled

Provide the status of this marriage.

For your divorced or annulled marriage, provide where the record is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip 

Code)

City State Zip Code Country

Is this former spouse deceased?

For divorced or annulled marriage provide last known address of the former spouse. (Provide City and Country if outside the United 

States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

(a) I don't know

Provide the date divorced, annulled or widowed. (Month/Day/Year)
Page 38

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Est.

Provide the country(ies) of citizenship for your former spouse.

Country #1 Country #2

Provide the date you married your 

former spouse. (Month/Day/Year)

Est.

YES NO (If NO, complete (a)) I don't know

Is this former spouse deceased?

For divorced or annulled marriage provide last known address of the former spouse. (Provide City and Country if outside the United 

States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

(a) I don't know

Middle name

Provide the date of birth of your 

Last name First name Suffix former spouse. (Month/Day/Year)

Est.

Provide the full name of your former spouse.

Entry #2

Provide the place of birth for your former spouse. 

City State Zip Code Country (Required)

17.2 Complete the following if you selected 'Divorced', 'Annulled', 'Widowed', or 'Other Former Spouses'.

Provide the place married. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.)

City State Country

 Section 17 - Marital Status - (Continued)

Divorced Widowed Annulled

Provide the status of this marriage.

For your divorced or annulled marriage, provide where the record is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip 

Code)

City State Zip Code Country

Provide the date divorced, annulled or widowed. (Month/Day/Year)
Page 39

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Do you presently reside with a cohabitant? YES NO (If NO, proceed to Section 18)

(Month/Day/Year)

17.3

A cohabitant is a person with whom you share bonds of affection, obligation, or other commitment, as opposed to a person with whom you live 

with for reasons of convenience (e.g. a roommate). If applicable, complete the following about your cohabitant. If your cohabitant was born 

outside the U.S., provide citizenship information.

Complete the following if you presently reside with a cohabitant.

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Country #1

Provide date cohabitation began. 

Country #2 (Month/Day/Year)

Provide your cohabitant's country(ies) of citizenship.

Entry #1

Middle name

Provide the cohabitant date of birth.

Last name First name Suffix

Est.

Provide the cohabitant full name.

Date

Provide the cohabitant place of birth.

City State Country (Required)

 Section 17 - Marital Status - (Continued)

DS 1350

U.S. Passport (current or most recent)

U.S. Naturalization certificate

Alien registration

U.S. Citizenship certificate

FS 240 or 545

For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.

None (Provide explanation)

Other (Provide explanation)

Provide your cohabitant's U.S. Social Security Number.

Not applicable

Explanation

Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each Not applicable

name was used).

Provide document number.

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO
Page 40

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

(Month/Day/Year)

Complete the following if you presently reside with a cohabitant.

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Entry #2

Middle name

Provide the cohabitant date of birth.

Last name First name Suffix

Est.

Provide the cohabitant full name.

Date

Provide the cohabitant place of birth.

City State Country (Required)

DS 1350

U.S. Passport (current or most recent)

U.S. Naturalization certificate

Alien registration

U.S. Citizenship certificate

FS 240 or 545

For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number.

None (Provide explanation)

Other (Provide explanation)

Provide your cohabitant's U.S. Social Security Number.

Not applicable

Explanation

Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each Not applicable

name was used).

Provide document number.

 Section 17 - Marital Status - (Continued)

Country #1

Provide date cohabitation began. 

Country #2 (Month/Day/Year)

Provide your cohabitant's country(ies) of citizenship.

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO
Page 41

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Has this relative used any other names?

YES NO

Not applicable Provide other names used and the period of time that your relative used them (such as maiden name by a former marriage, former 

name, alias, or nickname).

City State Country (Required)

Provide your relative's place of birth.

Last name Middle name

Provide your relative's full name.

First name Suffix

Last name First name Middle name Suffix

If mother, provide your mother's maiden name. Same as listed

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

 Sister, Stepbrother, Stepsister, Half-brother, Half-sister. 

I don't know

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide relative type.

Country #1 Country #2

Provide your relative's country(ies) of citizenship.

Provide your relative's date of birth.

Est.

Date (Month/Day/Year)

Father Child (including adopted/foster)

Stepchild

Foster parent

Stepmother

Mother

Select each type of relative applicable to you, regardless if they are living or deceased. (An opportunity will be provided to list multiple relatives for each type.) 

Check all that apply.

 Section 18 - Relatives

Stepfather Brother

Sister

Stepbrother

Stepsister

Half-brother

Father-in-law

Half-sister

Mother-in-law

Guardian

Entry #1

Entry #1 
Page 42

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

DS 1350 U.S. Passport

U.S. Naturalization certificate

U.S. Citizenship certificate

FS 240 or 545

Provide one type of documentation that he or she possesses and the document number.

None

Other

Provide document number.

 (Provide explanation)

Provide the name of the court that issued the U.S. Citizenship/Naturalization certificate.

Provide the address of the court that issued the U.S. Citizenship/Naturalization certificate.

Street City State Zip Code

 (Provide explanation)

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

YES Provide your relative's APO/FPO address. 

NO

I don't know

Is your relative deceased? YES (If YES, proceed to 18.3) NO

Zip Code

Does this relative have an APO/FPO address?

Address APO or FPO APO/FPO State Code

Street City State Zip Code Country

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased. 

 OR 

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, 

foreign born and has a U.S. or APO/FPO address.

18.3 

18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Entry #1 Entry #1 
Page 43

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

(Provide explanation)

Provide document number

Other 

U.S. Alien registration U.S. Visa

Provide type of documentation he or she possesses to support U.S. residence.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

has a U.S. address and is not deceased. 

18.4 

18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

 has a foreign address and is not deceased. 

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Entry #1 Entry #1 
Page 44

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Has this relative used any other names?

YES NO

Not applicable Provide other names used and the period of time that your relative used them (such as maiden name by a former marriage, former 

name, alias, or nickname).

City State Country (Required)

Provide your relative's place of birth.

Last name Middle name

Provide your relative's full name.

First name Suffix

Last name First name Middle name Suffix

If mother, provide your mother's maiden name. Same as listed

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

 Sister, Stepbrother, Stepsister, Half-brother, Half-sister. 

I don't know

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide relative type.

Country #1 Country #2

Provide your relative's country(ies) of citizenship.

Provide your relative's date of birth.

Est.

Date (Month/Day/Year)

 Section 18 - Relatives - (Continued)

Entry #2

Entry #2 
Page 45

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

DS 1350 U.S. Passport

U.S. Naturalization certificate

U.S. Citizenship certificate

FS 240 or 545

Provide one type of documentation that he or she possesses and the document number.

None

Other

Provide document number.

 (Provide explanation)

Provide the name of the court that issued the U.S. Citizenship/Naturalization certificate.

Provide the address of the court that issued the U.S. Citizenship/Naturalization certificate.

Street City State Zip Code

 (Provide explanation)

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

YES Provide your relative's APO/FPO address. 

NO

I don't know

Is your relative deceased? YES (If YES, proceed to 18.3) NO

Zip Code

Does this relative have an APO/FPO address?

Address APO or FPO APO/FPO State Code

Street City State Zip Code Country

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased. 

 OR 

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, 

foreign born and has a U.S. or APO/FPO address.

18.3 

18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Entry #2 Entry #2 
Page 46

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

(Provide explanation)

Provide document number

Other 

U.S. Alien registration U.S. Visa

Provide type of documentation he or she possesses to support U.S. residence.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

has a U.S. address and is not deceased. 

18.4 

18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

 has a foreign address and is not deceased. 

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Entry #2 Entry #2 
Page 47

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Has this relative used any other names?

YES NO

Not applicable Provide other names used and the period of time that your relative used them (such as maiden name by a former marriage, former 

name, alias, or nickname).

City State Country (Required)

Provide your relative's place of birth.

Last name Middle name

Provide your relative's full name.

First name Suffix

Last name First name Middle name Suffix

If mother, provide your mother's maiden name. Same as listed

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

 Sister, Stepbrother, Stepsister, Half-brother, Half-sister. 

I don't know

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide relative type.

Country #1 Country #2

Provide your relative's country(ies) of citizenship.

Provide your relative's date of birth.

Est.

Date (Month/Day/Year)

 Section 18 - Relatives - (Continued)

Entry #3

Entry #3 
Page 48

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

DS 1350 U.S. Passport

U.S. Naturalization certificate

U.S. Citizenship certificate

FS 240 or 545

Provide one type of documentation that he or she possesses and the document number.

None

Other

Provide document number.

 (Provide explanation)

Provide the name of the court that issued the U.S. Citizenship/Naturalization certificate.

Provide the address of the court that issued the U.S. Citizenship/Naturalization certificate.

Street City State Zip Code

 (Provide explanation)

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

YES Provide your relative's APO/FPO address. 

NO

I don't know

Is your relative deceased? YES (If YES, proceed to 18.3) NO

Zip Code

Does this relative have an APO/FPO address?

Address APO or FPO APO/FPO State Code

Street City State Zip Code Country

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased. 

 OR 

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, 

foreign born and has a U.S. or APO/FPO address.

18.3 

18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Entry #3 Entry #3 
Page 49

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

(Provide explanation)

Provide document number

Other 

U.S. Alien registration U.S. Visa

Provide type of documentation he or she possesses to support U.S. residence.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

has a U.S. address and is not deceased. 

18.4 

18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

 has a foreign address and is not deceased. 

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Entry #3 Entry #3 
Page 50

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Has this relative used any other names?

YES NO

Not applicable Provide other names used and the period of time that your relative used them (such as maiden name by a former marriage, former 

name, alias, or nickname).

City State Country (Required)

Provide your relative's place of birth.

Last name Middle name

Provide your relative's full name.

First name Suffix

Last name First name Middle name Suffix

If mother, provide your mother's maiden name. Same as listed

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

 Sister, Stepbrother, Stepsister, Half-brother, Half-sister. 

I don't know

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide relative type.

Country #1 Country #2

Provide your relative's country(ies) of citizenship.

Provide your relative's date of birth.

Est.

Date (Month/Day/Year)

 Section 18 - Relatives - (Continued)

Entry #4

Entry #4 
Page 51

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

DS 1350 U.S. Passport

U.S. Naturalization certificate

U.S. Citizenship certificate

FS 240 or 545

Provide one type of documentation that he or she possesses and the document number.

None

Other

Provide document number.

 (Provide explanation)

Provide the name of the court that issued the U.S. Citizenship/Naturalization certificate.

Provide the address of the court that issued the U.S. Citizenship/Naturalization certificate.

Street City State Zip Code

 (Provide explanation)

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

YES Provide your relative's APO/FPO address. 

NO

I don't know

Is your relative deceased? YES (If YES, proceed to 18.3) NO

Zip Code

Does this relative have an APO/FPO address?

Address APO or FPO APO/FPO State Code

Street City State Zip Code Country

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased. 

 OR 

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, 

foreign born and has a U.S. or APO/FPO address.

18.3 

18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Entry #4 Entry #4 
Page 52

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

(Provide explanation)

Provide document number

Other 

U.S. Alien registration U.S. Visa

Provide type of documentation he or she possesses to support U.S. residence.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

has a U.S. address and is not deceased. 

18.4 

18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

 has a foreign address and is not deceased. 

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Entry #4 Entry #4 
Page 53

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Has this relative used any other names?

YES NO

Not applicable Provide other names used and the period of time that your relative used them (such as maiden name by a former marriage, former 

name, alias, or nickname).

City State Country (Required)

Provide your relative's place of birth.

Last name Middle name

Provide your relative's full name.

First name Suffix

Last name First name Middle name Suffix

If mother, provide your mother's maiden name. Same as listed

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

 Sister, Stepbrother, Stepsister, Half-brother, Half-sister. 

I don't know

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide relative type.

Country #1 Country #2

Provide your relative's country(ies) of citizenship.

Provide your relative's date of birth.

Est.

Date (Month/Day/Year)

 Section 18 - Relatives - (Continued)

Entry #5

Entry #5 
Page 54

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

DS 1350 U.S. Passport

U.S. Naturalization certificate

U.S. Citizenship certificate

FS 240 or 545

Provide one type of documentation that he or she possesses and the document number.

None

Other

Provide document number.

 (Provide explanation)

Provide the name of the court that issued the U.S. Citizenship/Naturalization certificate.

Provide the address of the court that issued the U.S. Citizenship/Naturalization certificate.

Street City State Zip Code

 (Provide explanation)

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

YES Provide your relative's APO/FPO address. 

NO

I don't know

Is your relative deceased? YES (If YES, proceed to 18.3) NO

Zip Code

Does this relative have an APO/FPO address?

Address APO or FPO APO/FPO State Code

Street City State Zip Code Country

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased. 

 OR 

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, 

foreign born and has a U.S. or APO/FPO address.

18.3 

18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Entry #5 Entry #5 
Page 55

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

(Provide explanation)

Provide document number

Other 

U.S. Alien registration U.S. Visa

Provide type of documentation he or she possesses to support U.S. residence.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

has a U.S. address and is not deceased. 

18.4 

18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

 has a foreign address and is not deceased. 

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Entry #5 Entry #5 
Page 56

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Has this relative used any other names?

YES NO

Not applicable Provide other names used and the period of time that your relative used them (such as maiden name by a former marriage, former 

name, alias, or nickname).

City State Country (Required)

Provide your relative's place of birth.

Last name Middle name

Provide your relative's full name.

First name Suffix

Last name First name Middle name Suffix

If mother, provide your mother's maiden name. Same as listed

18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

 Sister, Stepbrother, Stepsister, Half-brother, Half-sister. 

I don't know

#1 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#2 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#3 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

#4 Last name First name Middle name

From (Month/Year) To (Month/Year)

Suffix

Est. Est.

Maiden name? Present

YES NO

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide the reason(s) why the name changed.

Provide relative type.

Country #1 Country #2

Provide your relative's country(ies) of citizenship.

Provide your relative's date of birth.

Est.

Date (Month/Day/Year)

 Section 18 - Relatives - (Continued)

Entry #6

Entry #6 
Page 57

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

DS 1350 U.S. Passport

U.S. Naturalization certificate

U.S. Citizenship certificate

FS 240 or 545

Provide one type of documentation that he or she possesses and the document number.

None

Other

Provide document number.

 (Provide explanation)

Provide the name of the court that issued the U.S. Citizenship/Naturalization certificate.

Provide the address of the court that issued the U.S. Citizenship/Naturalization certificate.

Street City State Zip Code

 (Provide explanation)

Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

YES Provide your relative's APO/FPO address. 

NO

I don't know

Is your relative deceased? YES (If YES, proceed to 18.3) NO

Zip Code

Does this relative have an APO/FPO address?

Address APO or FPO APO/FPO State Code

Street City State Zip Code Country

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, 

Sister, Stepbrother, Stepsister, Half-brother, Half-sister and is a U.S. Citizen, foreign born and is deceased. 

 OR 

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, 

foreign born and has a U.S. or APO/FPO address.

18.3 

18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased.

Entry #6 Entry #6 
Page 58

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

 Section 18 - Relatives - (Continued)

Enter your Social Security Number before going to the next page

(Provide explanation)

Provide document number

Other 

U.S. Alien registration U.S. Visa

Provide type of documentation he or she possesses to support U.S. residence.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

has a U.S. address and is not deceased. 

18.4 

18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), 

 Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, 

 has a foreign address and is not deceased. 

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other 

Provide approximate frequency of contact.

Daily Monthly Annually

Weekly Quarterly Other (Provide explanation)

Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known).

Employer name

I don't know

Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City 

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

Street City State Zip Code Country

I don't know

(Provide explanation)

Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service?

NO

YES

I don't know

Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence 

service.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year) Present

Est.

Entry #6 Entry #6 
Page 59

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, proceed to Section 20A)

Provide place of birth. I don't know

Provide country(ies) of citizenship.

Country #1 Country #2

Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national.

 Section 19 - Foreign Contacts

Do you have, or have you had, close and/or continuing contact with a foreign national within the last seven 

(7) years with whom you, or your spouse, or cohabitant are bound by affection, influence, common interests, 

and/or obligation? Include associates as well as relatives, not previously listed in Section 18.

A foreign national is defined as any person who is not a citizen or national of the U.S.

Entry #1

I don't know

Last name First name Middle name Suffix Explanation if name is unknown

Provide the full name of the foreign national, if known.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year)

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other (Provide explanation)

Daily

Weekly

Monthly

Quarterly

Annually

Other (Provide explanation)

Provide the nature of relationship (Check all that apply).

Other (Provide explanation)

Professional or Business Personal (Such as family ties, friendship, affection, common interests, etc)

Obligation (Provide explanation)

Last name First name Middle name Suffix

Provide other names and/or nicknames, as appropriate.

Est.

Provide date of birth. 

(Month/Day/Year)

I don't know

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

Street City State Zip Code Country

I don't know

Provide the name of the foreign national's current employer, or provide the name of their most recent employer if not currently employed.

Employer name

I don't know

Provide the address of the foreign national's current employer, or provide the address of their most recent employer if not currently 

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

Street City State Zip Code Country

I don't know

Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?

YES

NO I don't know

Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service.

Zip Code

NO

YES

I don't know

Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address.

Address APO or FPO APO/FPO State Code

City Country (If country unknown, requires explanation)

Provide approximate frequency of contact.
Page 60

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Provide place of birth. I don't know

Provide country(ies) of citizenship.

Country #1 Country #2

I don't know

Last name First name Middle name Suffix Explanation if name is unknown

Provide the full name of the foreign national, if known.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year)

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other (Provide explanation)

Daily

Weekly

Monthly

Quarterly

Annually

Other (Provide explanation)

Provide the nature of relationship (Check all that apply).

Other (Provide explanation)

Professional or Business Personal (Such as family ties, friendship, affection, common interests, etc)

Obligation (Provide explanation)

Last name First name Middle name Suffix

Provide other names and/or nicknames, as appropriate.

Est.

Provide date of birth. 

(Month/Day/Year)

I don't know

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

Street City State Zip Code Country

I don't know

Provide the name of the foreign national's current employer, or provide the name of their most recent employer if not currently employed.

Employer name

I don't know

Provide the address of the foreign national's current employer, or provide the address of their most recent employer if not currently 

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

Street City State Zip Code Country

I don't know

Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?

NO

YES

I don't know

Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service.

NO

YES

I don't know

Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address.

City Country (If country unknown, requires explanation)

Provide approximate frequency of contact.

Address APO or FPO APO/FPO State Code Zip Code

Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national.

 Section 19 - Foreign Contacts - (Continued)

Entry #2
Page 61

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Provide place of birth. I don't know

Provide country(ies) of citizenship.

Country #1 Country #2

I don't know

Last name First name Middle name Suffix Explanation if name is unknown

Provide the full name of the foreign national, if known.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year)

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other (Provide explanation)

Daily

Weekly

Monthly

Quarterly

Annually

Other (Provide explanation)

Provide the nature of relationship (Check all that apply).

Other (Provide explanation)

Professional or Business Personal (Such as family ties, friendship, affection, common interests, etc)

Obligation (Provide explanation)

Last name First name Middle name Suffix

Provide other names and/or nicknames, as appropriate.

Est.

Provide date of birth. 

(Month/Day/Year)

I don't know

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

Street City State Zip Code Country

I don't know

Provide the name of the foreign national's current employer, or provide the name of their most recent employer if not currently employed.

Employer name

I don't know

Provide the address of the foreign national's current employer, or provide the address of their most recent employer if not currently 

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

Street City State Zip Code Country

I don't know

Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?

NO

YES

I don't know

Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service.

NO

YES

I don't know

Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address.

City Country (If country unknown, requires explanation)

Provide approximate frequency of contact.

Address APO or FPO APO/FPO State Code Zip Code

Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national.

 Section 19 - Foreign Contacts - (Continued)

Entry #3
Page 62

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Provide place of birth. I don't know

Provide country(ies) of citizenship.

Country #1 Country #2

I don't know

Last name First name Middle name Suffix Explanation if name is unknown

Provide the full name of the foreign national, if known.

Provide approximate date of first contact. (Month/Year)

Est.

Provide approximate date of last contact. (Month/Year)

Est.

Provide methods of contact (Check all that apply).

In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc)

Written correspondence Other (Provide explanation)

Daily

Weekly

Monthly

Quarterly

Annually

Other (Provide explanation)

Provide the nature of relationship (Check all that apply).

Other (Provide explanation)

Professional or Business Personal (Such as family ties, friendship, affection, common interests, etc)

Obligation (Provide explanation)

Last name First name Middle name Suffix

Provide other names and/or nicknames, as appropriate.

Est.

Provide date of birth. 

(Month/Day/Year)

I don't know

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

Street City State Zip Code Country

I don't know

Provide the name of the foreign national's current employer, or provide the name of their most recent employer if not currently employed.

Employer name

I don't know

Provide the address of the foreign national's current employer, or provide the address of their most recent employer if not currently 

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

Street City State Zip Code Country

I don't know

Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service?

NO

YES

I don't know

Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service.

NO

YES

I don't know

Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address.

City Country (If country unknown, requires explanation)

Provide approximate frequency of contact.

Address APO or FPO APO/FPO State Code Zip Code

Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national.

 Section 19 - Foreign Contacts - (Continued)

Entry #4
Page 63

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

20A.1 YES NO (If NO, proceed to 20A.2) 

Entry #1

Provide how the financial interest was acquired (such as purchase, gift, etc.).

Country #1 Country #2

Provide your co-owner's country(ies) of citizenship.

Country #1 Country #2

Provide your co-owner's country(ies) of citizenship.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the nature of your relationship with the co-owner.

Provide the date acquired. (Month/Day/Year)

Complete the following if you responded 'YES' to having foreign financial interests (such as stocks, property, investments, bank accounts, ownership of 

corporate entities, corporate interests or businesses) in which you had or have direct control or direct ownership? (Exclude financial interests in companies or 

diversified mutual funds that are publicly traded on a U.S. exchange.) 

 Section 20A - Foreign Activities

Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests (such as 

stocks, property, investments, bank accounts, ownership of corporate entities, corporate interests or 

businesses) in which you or they have direct control or direct ownership? (Exclude financial interests in 

companies or diversified mutual funds that are publicly traded on a U.S. exchange.)

Specify (Check all that apply): Yourself Spouse Cohabitant Dependent children

Provide the type of financial interest.

Provide the cost (in U.S. dollars) at time of 

acquisition.

Est.

Provide the current value (in U.S. dollars) or the value at the time control or 

ownership was sold, lost or otherwise disposed of:

Est.

Date Est.

Not Applicable

Provide explanation of how interest control or ownership was sold, lost or 

otherwise disposed of.

Provide the date control or ownership was relinquished. (Month/Day/Year)

Are there any co-owners of this foreign financial interest?

YES NO

#1 Provide full name of co-owner.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Provide full name of co-owner.

Last name First name Middle name Suffix

Provide the nature of your relationship with the co-owner.

#2

Est.
Page 64

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Entry #2

Complete the following if you responded 'YES' to having foreign financial interests (such as stocks, property, investments, bank accounts, ownership of 

corporate entities, corporate interests or businesses) in which you had or have direct control or direct ownership? (Exclude financial interests in companies or 

diversified mutual funds that are publicly traded on a U.S. exchange.) 

Provide how the financial interest was acquired (such as purchase, gift, etc.).

Country #1 Country #2

Provide your co-owner's country(ies) of citizenship.

Country #1 Country #2

Provide your co-owner's country(ies) of citizenship.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the nature of your relationship with the co-owner.

Provide the date acquired. (Month/Day/Year)

Specify (Check all that apply): Yourself Spouse Cohabitant Dependent children

Provide the type of financial interest.

Provide the cost (in U.S. dollars) at time of 

acquisition.

Est.

Provide the current value (in U.S. dollars) or the value at the time control or 

ownership was sold, lost or otherwise disposed of:

Est.

Date Est.

Not Applicable

Provide explanation of how interest control or ownership was sold, lost or 

otherwise disposed of.

Provide the date control or ownership was relinquished. (Month/Day/Year)

Are there any co-owners of this foreign financial interest?

YES NO

#1 Provide full name of co-owner.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Provide full name of co-owner.

Last name First name Middle name Suffix

Provide the nature of your relationship with the co-owner.

#2

Est.

 Section 20A - Foreign Activities (Continued)
Page 65

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO

Est.

Provide details regarding how the financial interest was acquired (such as 

purchase, gift, etc.).

First name

Provide the name of the individual who controls this financial interest on your behalf.

Last name

Provide this individual's 

relationship to you. 

Provide the date this financial interest 

was acquired. (Month/Day/Year)

Provide your relationship with the co-owner. 

Last name First name Middle name Suffix

#2 Provide the full name of co-owner.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

20A.2 

Entry #1

YES NO (If NO, Proceed to 20A.3)

Country #1 Country #2

Provide the co-owner's country(ies) of citizenship.

Complete the following if you responded 'YES' to you, your spouse, cohabitant, or dependent children having EVER had any foreign financial 

interests that someone controlled on your behalf. 

 Section 20A - Foreign Activities - (Continued)

Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests that 

someone controlled on your behalf?

Specify: (Check all that apply): Yourself Spouse Cohabitant Dependent children

Provide the type of financial 

interest.

Est.

Are there any co-owners of this foreign financial interest controlled on your behalf?

Provide the full name of co-owner.

Provide your relationship with the co-owner. 

Last name First name Middle name Suffix

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Country #1 Country #2

Provide the co-owner's country(ies) of citizenship.

#1

Provide the current value (in U.S. dollars) or 

value at the time interest was sold, lost or 

otherwise disposed of.

Est.

Est.

Provide the date interest was 

sold, lost, or other wise disposed 

of. (Month/Day/Year)

Not Applicable

Provide explanation if interest was sold, lost 

or otherwise disposed of.

Provide the cost (in U.S. dollars) 

at time of acquisition.
Page 66

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Entry #2

YES NO

Est.

Provide details regarding how the financial interest was acquired (such as 

purchase, gift, etc.).

First name

Provide the name of the individual who controls this financial interest on your behalf.

Last name

Provide this individual's 

relationship to you. 

Provide the date this financial 

interest was acquired. (Month/Year)

Provide your relationship with the co-owner. 

Last name First name Middle name Suffix

#2 Provide the full name of co-owner.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Country #1 Country #2

Provide the co-owner's country(ies) of citizenship.

Specify: (Check all that apply): Yourself Spouse Cohabitant Dependent children

Provide the type of financial 

interest.

Est.

Are there any co-owners of this foreign financial interest controlled on your behalf?

Provide the full name of co-owner.

Provide your relationship with the co-owner. 

Last name First name Middle name Suffix

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Country #1 Country #2

Provide the co-owner's country(ies) of citizenship.

#1

Provide the current value (in U.S. dollars) or 

value at the time interest was sold, lost or 

otherwise disposed of.

Est.

Est.

Provide the date interest was 

sold, lost, or other wise disposed 

of. (Month/Day/Year)

Not Applicable

Provide explanation if interest was sold, lost 

or otherwise disposed of.

Provide the cost (in U.S. dollars) 

at time of acquisition.

Complete the following if you responded 'YES' to you, your spouse, cohabitant, or dependent children having EVER had any foreign financial 

interests that someone controlled on your behalf. 

 Section 20A - Foreign Activities - (Continued)
Page 67

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Last name First name Middle name Suffix

#1 Provide the full name of co-owner.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

YES NO 

YES NO (If NO, Proceed to 20A.4) Have you, your spouse, cohabitant, or dependent children EVER owned, or do you anticipate owning, or 

plan to purchase real estate in a foreign country?

Est.

Provide the date to be acquired. 

(Month/Day/Year)

Last name First name Middle name Suffix

#2 Provide the full name of co-owner.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Provide the nature of your relationship with the co-owner.

Entry #1

Country #1 Country #2

Provide the co-owner's country(ies) of citizenship.

Country #1 Country #2 Provide the nature of your relationship with the co-owner.

Provide the co-owner's country(ies) of citizenship.

Complete the following if you responded 'Yes' to you, your spouse, cohabitant, or dependent children having EVER owned, or anticipate owning, or planning 

to purchase real estate in a foreign country.

 Section 20A - Foreign Activities - (Continued)

20A.3 

Specify (Check all that apply): Yourself Spouse Cohabitant Dependent children

Provide the type of real estate property 

(such as home, business, etc.).

Provide how the foreign real estate is to be acquired 

(such as purchase, gift, etc.).

Provide the cost (in U.S. dollars) 

expected at time of acquisition.

Est.

Are there any co-owners of this foreign real estate?

Country

Provide the location/address of property.

Street City
Page 68

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Entry #2

Last name First name Middle name Suffix

#1 Provide the full name of co-owner.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

YES NO 

Est.

Provide the date to be acquired. 

(Month/Day/Year)

Last name First name Middle name Suffix

#2 Provide the full name of co-owner.

Provide the co-owner's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)

Street City State Zip Code Country

Country #1 Country #2 Provide the nature of your relationship with the co-owner.

Provide the co-owner's country(ies) of citizenship.

Country #1 Country #2 Provide the nature of your relationship with the co-owner.

Provide the co-owner's country(ies) of citizenship.

Specify (Check all that apply): Yourself Spouse Cohabitant Dependent children

Provide the type of real estate property 

(such as home, business, etc.).

Provide how the foreign real estate is to be acquired 

(such as purchase, gift, etc.).

Provide the cost (in U.S. dollars) 

expected at time of acquisition.

Est.

Are there any co-owners of this foreign real estate?

Provide the location/address of property.

Complete the following if you responded 'Yes' to you, your spouse, cohabitant, or dependent children having EVER owned, or anticipate owning, or planning 

to purchase real estate in a foreign country.

 Section 20A - Foreign Activities - (Continued)

Street City Country
Page 69

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

NO

YES

YES NO (If NO, Proceed to 20A.5) 20A.4

(a)

(b)

(c)

Entry #1

Complete the following if you responded 'YES' to as a U.S. citizen, you, your spouse, cohabitant, or dependent children received of the past seven (7) 

years, or are eligible to receive in the future, any educational, medical, retirement, social welfare, or other such benefit from a foreign country.

 Section 20A - Foreign Activities - (Continued)

As a U.S. citizen, have you, your spouse, cohabitant, or dependent children received in the past seven 

(7) years, or are eligible to receive in the future, any educational, medical, retirement, social welfare, or 

other such benefit from a foreign country?

Specify (Check all that apply) Yourself Spouse Cohabitant Dependent children

If you have indicated that you, your spouse, cohabitant, or dependent children received a onetime benefit from a foreign country:

If yes, provide explanation.

Provide the type of benefit.

(Provide explanation)

Onetime benefit (Complete (a)) Future benefit (Complete (b)) Continuing benefit (Complete (c))

Other (Complete (c))

Provide the frequency of the 

benefit.

(Provide explanation)

Est.

Provide the total value (in U.S. 

dollars) of the benefit received. 

Est.

Provide the reason this benefit 

was received.

Provide the name of the country 

providing the benefit.

As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country?

If you have indicated that you, your spouse, cohabitant, or dependent children expect to receive a benefit from a foreign country:

Provide the name of the country providing this benefit.

If yes, provide explanation.

NO

YES

As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country?

Provide the date the benefit will 

begin. (Month/Day/Year)

Est.

Provide the value (in U.S. dollars) of the 

benefit to be received. 

Est.

Provide the reason this benefit will be 

received.

Annually

Quarterly

Monthly Other 

Weekly

(Provide explanation)

Provide the frequency the benefit will be received.

If have indicated that you, your spouse, cohabitant, or dependent children receive a continuing or other benefit from a foreign country:

Provide the name of the country providing this 

benefit.

If yes, provide explanation.

NO

YES

As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country?

Provide the date the benefit began. (Month/Day/Year)

Est.

Provide the total value (in U.S. dollars) of 

benefit.

Est.

Provide the reason this benefit is being 

received.

Annually

Quarterly

Monthly

Weekly

Other (Provide explanation)

Provide the frequency that this benefit is received.

Provide the date the benefit is expected to end. (Month/Day/Year)

Est.

Provide the date the benefit 

was received. (Month/Day/Year)

Educational Medical Retirement Social Welfare

Other such benefit
Page 70

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 20A - Foreign Activities - (Continued)

Entry #2

Complete the following if you responded 'YES' to as a U.S. citizen, you, your spouse, cohabitant, or dependent children received in the past seven (7) 

years, or are eligible to receive in the future, any educational, medical, retirement, social welfare, or other such benefit from a foreign country.

NO

YES

(a)

(b)

(c)

Specify (Check all that apply) Yourself Spouse Cohabitant Dependent children

If you have indicated that you, your spouse, cohabitant, or dependent children received a onetime benefit from a foreign country:

If yes, provide explanation.

Provide the type of benefit.

(Provide explanation)

Onetime benefit (Complete (a)) Future benefit (Complete (b)) Continuing benefit (Complete (c))

Other (Complete (c))

Provide the frequency of the 

benefit.

(Provide explanation)

Est.

Provide the total value (in U.S. 

dollars) of the benefit received. 

Est.

Provide the reason this benefit 

was received.

Provide the name of the country 

providing the benefit.

As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country?

If you have indicated that you, your spouse, cohabitant, or dependent children expect to receive a benefit from a foreign country:

Provide the name of the country providing this benefit.

If yes, provide explanation.

NO

YES

As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country?

Provide the date the benefit will 

begin. (Month/Day/Year)

Est.

Provide the value (in U.S. dollars) of the 

benefit to be received. 

Est.

Provide the reason this benefit will be 

received.

Annually

Quarterly

Monthly Other 

Weekly

(Provide explanation)

Provide the frequency the benefit will be received.

If have indicated that you, your spouse, cohabitant, or dependent children receive a continuing or other benefit from a foreign country:

Provide the name of the country providing this 

benefit.

If yes, provide explanation.

NO

YES

As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country?

Provide the date the benefit began. (Month/Day/Year)

Est.

Provide the total value (in U.S. dollars) of 

benefit.

Est.

Provide the reason this benefit is being 

received.

Annually

Quarterly

Monthly

Weekly

Other (Provide explanation)

Provide the frequency that this benefit is received.

Provide the date the benefit is expected to end. (Month/Day/Year)

Est.

Provide the date the benefit 

was received. (Month/Day/Year)

Educational Medical Retirement Social Welfare

Other such benefit
Page 71

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Provide the name of the foreign national you support or have supported financially.

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

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the nature of your relationship with the foreign national listed above.

Est.

Provide the frequency of your support.

Provide the amount (in U.S. dollars) of all financial support provided.

20A.5 YES NO (If NO, proceed to 20B)

Country #1 Country #2

Provide this foreign national's country(ies) of citizenship.

Provide the name of the foreign national you support or have supported financially.

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

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the nature of your relationship with the foreign national listed above.

Est.

Provide the frequency of your support.

Provide the amount (in U.S. dollars) of all financial support provided.

Country #1 Country #2

Provide this foreign national's country(ies) of citizenship.

Complete the following if you responded 'Yes' to providing financial support for any foreign national.

 Section 20A - Foreign Activities - (Continued)

Have you EVER provided financial support for any foreign national?

Entry #1

Entry #2
Page 72

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Last name First name Middle name Suffix

Provide the name of the individual to whom advice or support was provided.

Provide the name of the foreign organization or foreign business with whom the individual is 

associated.

Provide the country of origin for the organization or business.

Provide a description of advice/support provided.

Provide the date(s) during which this advice or support was provided.

From Date (Month/Year)

Est.

To Date (Month/Year) Present

Est.

Describe what compensation, if any, was provided for your service.

YES NO (If NO, proceed to 20B.2) 20B.1

Last name First name Middle name Suffix

Provide the name of the individual to whom advice or support was provided.

Provide the name of the foreign organization or foreign business with whom the individual is 

associated.

Provide the country of origin for the organization or business.

Provide a description of advice/support provided.

Provide the date(s) during which this advice or support was provided.

From Date (Month/Year)

Est.

To Date (Month/Year) Present

Est.

Describe what compensation, if any, was provided for your service.

Entry #2

YES NO (If NO, proceed to 20B.3) 20B.2

(Month/Year)

Complete the following if you responded 'Yes' to you, your spouse, cohabitant, or any member of your immediate family having in the past seven (7) years

been asked to provide advice or serve as a consultant, even informally, by any foreign government official or agency.

Have you, your spouse, cohabitant, or any member of your immediate family in the past seven (7) years

been asked to provide advice or serve as a consultant, even informally, by any foreign government 

official or agency? (Answer 'No' if all the advice or support was authorized pursuant to official U.S. 

Government business.)

Entry #1

Provide the name of the government official.

Last name First name Middle name Suffix

Provide the name of the agency. Provide the country with which the government official or agency is affiliated.

Provide the date of the request. Provide the circumstances of request.

Est.

For this question, 'Immediate Family' means your spouse, parents, step-parents, siblings, half and step-siblings, children, step-children, and cohabitant.

Entry #2

Provide the name of the government official.

Last name First name Middle name Suffix

Provide the name of the agency. Provide the country with which the government official or agency is affiliated.

Provide the date of the request. Provide the circumstances of request.

Est.

(Month/Year)

Complete the following if you responded 'Yes' to having in the past seven (7) years provided advice or support to any individual associated with a foreign 

business or other foreign organization that you have not previously listed as a former employer.

 Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts

Have you in the past seven (7) years provided advice or support to any individual associated with a 

foreign business or other foreign organization that you have not previously listed as a former employer? 

(Answer "No" if all your advice or support was authorized pursuant to official U.S. Government business.)

Entry #1
Page 73

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, proceed to 20B.4) 20B.3

Entry #2

Provide the name of the foreign national who made the offer.

Last name First name Middle name Suffix

Provide a description of the position offered. Provide the date when this offer 

was extended. (Month/Year)

Est.

YES

NO

Did you accept the offer?

Explanation

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

City State Zip Code Country

Complete the following if you responded 'Yes' to any foreign national having in the past seven (7) years offered you a job, asked you to work as a 

consultant, or consider employment with them.

 Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)

Has any foreign national in the past seven (7) years offered you a job, asked you to work as a 

consultant, or consider employment with them?

Entry #1

Provide the name of the foreign national who made the offer.

Last name First name Middle name Suffix

Provide a description of the position offered. Provide the date when this offer 

was extended. (Month/Year)

Est.

YES

NO

Did you accept the offer?

Explanation

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

City State Zip Code Country

Explanation

Explanation
Page 74

Complete the following if you responded 'Yes' to having in the past seven (7) years been involved in any other type of business venture with a foreign 

national not described above.

 Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)

Have you in the past seven (7) years been involved in any other type of business venture with a foreign 

national not described above (own, co-own, serve as business consultant, provide financial support, etc.)?

Entry #1

Provide the full name of this foreign national.

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

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the nature of association with 

this business venture.

Provide a description of the business venture. Provide your relationship to this foreign national.

Provide the length of time you have been involved in the business venture.

From Date (Month/Year)

Est.

To Date (Month/Year) Present

Est.

Provide the service you provided. Provide a description of what compensation was provided for your service.

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Provide the position you held.

Provide the financial support involved.

Entry #2

Provide the full name of this foreign national.

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

Street City State Zip Code Country

Last name First name Middle name Suffix

Provide the nature of association with 

this business venture.

Provide the length of time you have been involved in the business venture.

From Date (Month/Year)

Est.

To Date (Month/Year) Present

Est.

Provide the service you provided. Provide a description of what compensation was provided for your service.

Provide the position you held.

Provide the financial support involved.

20B.4 YES NO (If NO, proceed to 20B.5)

Country #1 Country #2

Provide the citizenship(s) of this foreign national.

Provide a description of the business venture. Provide your relationship to this foreign national.

Country #1 Country #2

Provide the citizenship(s) of this foreign national.
Page 75

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, proceed to 20B.6) 20B.5

Entry #2

Provide the name and description of event.

Provide the country where the event was held.

Provide the purpose of the event.

Provide the name of sponsoring organization.

Provide the dates for the event.

From Date

Est.

To Date Present

Est.

(Month/Year) (Month/Year)

Provide the city where the event was held.

NO

YES

Was there any subsequent contact with any foreign nationals as a result of the event?

Contact #1

Contact #2

Contact #3

Contact #4

Provide explanation 

for each contact.

Complete the following if you responded 'Yes' to in the past seven (7) years having attended or participated in any conferences, trade shows, seminars, 

or meetings outside the U.S.

 Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)

Have you in the past seven (7) years attended or participated in any conferences, trade shows, 

seminars, or meetings outside the U.S.? (Do not include those you attended or participated in on official 

business for the U.S. government.)

Entry #1

Provide the name and description of event.

Provide the country where the event was held.

Provide the purpose of the event.

Provide the name of sponsoring organization.

Provide the dates for the event.

From Date

Est.

To Date Present

Est.

(Month/Year) (Month/Year)

Provide the city where the event was held.

NO

YES

Was there any subsequent contact with any foreign nationals as a result of the event?

Contact #1

Contact #2

Contact #3

Contact #4

Provide explanation 

for each contact.
Page 76

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, Proceed to 20B.7) 20B.6

Provide the type of establishment (such as 

embassy, consulate, agency, military service, 

intelligence or security service, etc.) involved.

Entry #2

Provide the type of establishment (such as Provide the purpose/circumstances of contact.

embassy, consulate, agency, military service, 

intelligence or security service, etc.) involved.

Provide the name of the individual involved in the contact.

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

City State Zip Code Country

Last name First name Middle name Suffix

NO

YES

Was there any subsequent contact initiated by you, your immediate family member, or a representative of the foreign organization?

Provide the purpose of the subsequent contact Provide date of most recent 

contact (Month/Day/Year) Provide plans for future contact

For this question, 'Immediate Family' means your spouse, parents, step-parents, siblings, half and step-siblings, children, step-children, and cohabitant.

Complete the following if you responded 'Yes' to you or any member of your immediate family having in the past seven (7) years had any contact with a 

foreign government, its establishment (such as embassy, consulate, agency, military service, intelligence or security service, etc.) or its representatives, 

whether inside or outside the U.S.

 Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)

Have you or any member of your immediate family in the past seven (7) years had any contact with a 

foreign government, its establishment (such as embassy, consulate, agency, military service, intelligence 

or security service, etc.) or its representatives, whether inside or outside the U.S.? (Answer 'No' if the 

contact was for routine visa applications and border crossings related to either official U.S. Government 

travel or foreign travel on a U.S. passport.)

Entry #1

Provide the name of the individual involved in the contact.

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

City State Zip Code Country

Last name First name Middle name Suffix

Provide the date of contact.

(Month/Year)

Est.

NO

YES

Was there any subsequent contact initiated by you, your immediate family member, or a representative of the foreign organization?

Provide the purpose of the subsequent contact Provide date of most recent 

contact (Month/Day/Year) Provide plans for future contact

Country #1 Country #2

Provide the foreign government(s) involved.

Provide the date of contact.

(Month/Year)

Est.

Country #1 Country #2

Provide the foreign government(s) involved.

Provide the names of the foreign 

representatives involved in contact.

Provide the names of the foreign 

representatives involved in contact.

Provide the purpose/circumstances of contact.
Page 77

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, proceed to 20B.8) 20B.7

Complete the following if you responded 'Yes' to in the past seven (7) years having sponsored any foreign national to come to the U.S. as a student, for 

work, or for permanent residence.

 Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)

Have you in the past seven (7) years sponsored any foreign national to come to the U.S. as a student, 

for work, or for permanent residence?

Entry #1

Provide the name of the sponsored foreign national.

Provide the date of birth for the sponsored foreign national.

City State Country (Required)

Provide the place of birth for the sponsored foreign national.

Zip Code

Date (Month/Year)

Est.

Last name First name Middle name Suffix

Provide the dates of stay in the U.S. for the sponsored foreign national.

From Date (Month/Year)

Est.

To Date (Month/Year) Present

Est.

Provide the purpose of stay in the U.S. for the sponsored foreign national. Provide the purpose of your sponsorship for the sponsored foreign national.

I don't know

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

Street City State Zip Code Country

Provide the address of the organization through which sponsorship was arranged, if applicable. (Provide City and Country if outside the 

United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Not Applicable

Provide the address of the sponsored foreign national while residing in the U.S.

Street City State Zip Code

Not Applicable

Country #1 Country #2

Provide the country(ies) of citizenship for the sponsored foreign national. Provide the name of the organization through 

which sponsorship was arranged, if applicable.
Page 78

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)

Complete the following if you responded 'Yes' to in the past seven (7) years having sponsored any foreign national to come to the U.S. as a student, for 

work, or for permanent residence.

Entry #2

Provide the name of the sponsored foreign national.

Provide the date of birth for the sponsored foreign national.

City State Country (Required)

Provide the place of birth for the sponsored foreign national.

Zip Code

Date (Month/Year)

Est.

Last name First name Middle name Suffix

Provide the dates of stay in the U.S. for the sponsored foreign national.

From Date (Month/Year)

Est.

To Date (Month/Year) Present

Est.

Provide the purpose of stay in the U.S. for the sponsored foreign national. Provide the purpose of your sponsorship for the sponsored foreign national.

I don't know

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

Street City State Zip Code Country

Provide the address of the organization through which sponsorship was arranged, if applicable. (Provide City and Country if outside the 

United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Not Applicable

Provide the address of the sponsored foreign national while residing in the U.S.

Street City State Zip Code

Not Applicable

Country #1 Country #2

Provide the country(ies) of citizenship for the sponsored foreign national. Provide the name of the organization through 

which sponsorship was arranged, if applicable.
Page 79

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Complete the following if you responded 'Yes' to having EVER voted in the election of a foreign country.

Have you EVER YES NO (If NO, Proceed to 20C) voted in the election of a foreign country?

Entry #1

Provide your current eligibility to vote in a foreign country.

Provide the date you voted in the foreign election. (Month/Year)

Est.

Provide the reason(s) for these activities.

Provide the name of the country involved.

20B.8 YES NO (If NO, proceed to 20B.9)

Entry #2

Entry #2

Provide your current eligibility to vote in a foreign country.

Provide the date you voted in the foreign election. (Month/Year)

Est.

Provide the reason(s) for these activities.

Provide the name of the country involved.

20B.9

Provide the position held.

Provide your current eligibility to hold political office in a foreign country.

Provide the name of the country involved.

Provide the reason(s) for these activities.

Provide the dates you held political office.

Est.

To Date (Month/Year) Present

Est.

From Date (Month/Year)

Complete the following if you responded 'Yes' to having EVER held political office in a foreign country.

 Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued)

Have you EVER held political office in a foreign country?

Entry #1

Provide the position held.

Provide your current eligibility to hold political office in a foreign country.

Provide the name of the country involved.

Provide the reason(s) for these activities.

Provide the dates you held political office.

Est.

To Date (Month/Year) Present

Est.

From Date (Month/Year)
Page 80

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, proceed to Section 21)

YES (If YES, proceed to Section 21) NO

Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government 

business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official 

U.S. Government business.

 Section 20C - Foreign Travel

Have you traveled outside the U.S. in the last seven (7) years?

Entry #1

Has your travel in the last seven (7) years been solely for U.S. Government business (i.e., no personal trips 

in conjunction with the official U.S. Government business)?

Provide the dates of your travel to this country. 

From Date

Est.

To Date Present

Est.

(Month/Year) (Month/Year)

If yes, provide explanation.

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local 

customs or security service officials when entering or leaving this country?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you involved in any encounter with the police?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign 

intelligence, terrorist, security, or military organizations?

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in you or your job?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive 

information?

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign 

intelligence or security service?

Provide the country visited. Provide the total number of days involved in the visit.

6-10

1-5 11-20

21-30

More than 30

Many short trips

Visit family or friends

Education Trade shows, conferences, and seminars

Volunteer activities Tourism

Business/Professional conference

Provide the purpose of the travel to this country (Check all that apply).

Other

NO

YES
Page 81

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government 

business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official 

U.S. Government business.

 Section 20C - Foreign Travel - (Continued)

Entry #2

Provide the dates of your travel to this country. 

From Date

Est.

To Date Present

Est.

(Month/Year) (Month/Year)

If yes, provide explanation.

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local 

customs or security service officials when entering or leaving this country?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you involved in any encounter with the police?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign 

intelligence, terrorist, security, or military organizations?

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in you or your job?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive 

information?

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign 

intelligence or security service?

Provide the country visited. Provide the total number of days involved in the visit.

6-10

1-5 11-20

21-30

More than 30

Many short trips

Visit family or friends

Education Trade shows, conferences, and seminars

Volunteer activities Tourism

Business/Professional conference

Provide the purpose of the travel to this country (Check all that apply).

Other

NO

YES
Page 82

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government 

business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official 

U.S. Government business.

 Section 20C - Foreign Travel - (Continued)

Entry #3

Provide the dates of your travel to this country. 

From Date

Est.

To Date Present

Est.

(Month/Year) (Month/Year)

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local 

customs or security service officials when entering or leaving this country?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you involved in any encounter with the police?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign 

intelligence, terrorist, security, or military organizations?

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in you or your job?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive 

information?

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign 

intelligence or security service?

Provide the country visited. Provide the total number of days involved in the visit.

6-10

1-5 11-20

21-30

More than 30

Many short trips

Visit family or friends

Education Trade shows, conferences, and seminars

Volunteer activities Tourism

Business/Professional conference

Provide the purpose of the travel to this country (Check all that apply).

Other
Page 83

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Complete the following if you responded 'Yes' to having traveled outside the U.S. in the last seven (7) years for other than solely U.S. Government 

business. Provide information about all such trips made outside the United States including personal trips made in conjunction with official 

U.S. Government business.

 Section 20C - Foreign Travel - (Continued)

Entry #4

Provide the dates of your travel to this country. 

From Date

Est.

To Date Present

Est.

(Month/Year) (Month/Year)

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for normal customs requirements) by the local 

customs or security service officials when entering or leaving this country?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you involved in any encounter with the police?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign 

intelligence, terrorist, security, or military organizations?

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in you or your job?

If yes, provide explanation.

NO

YES

While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive 

information?

If yes, provide explanation.

NO

YES

While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign 

intelligence or security service?

Provide the country visited. Provide the total number of days involved in the visit.

6-10

1-5 11-20

21-30

More than 30

Many short trips

Visit family or friends

Education Trade shows, conferences, and seminars

Volunteer activities Tourism

Business/Professional conference

Provide the purpose of the travel to this country (Check all that apply).

Other
Page 84

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, proceed to Section 22)

Complete the following if you responded 'Yes' to having consulted with a health care professional regarding a mental or emotional health condition or were 

hospitalized for such a condition.

 Section 21 - Psychological and Emotional Health

21.1

Entry #1

Provide the name of the health 

care professional.

Provide the dates of counseling or treatment.

Day Night

Mental health counseling in and of itself is not a reason to revoke or deny eligibility for access to classified information or for a sensitive position, suitability or 

fitness to obtain or retain Federal employment, fitness to obtain or retain contract employment, or eligibility for physical or logical access to federally controlled 

facilities or information systems.

Telephone number Extension

International or DSN phone number

Provide the telephone number of the health care professional.

Provide the name of agency/organization/facility where counseling/treatment was provided.

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

Street City State Zip Code Country

Same as above

Provide the address of agency/organization/facility provider. (Provide City and Country if outside the United States; otherwise, provide City, 

State and Zip Code)

Street City State Zip Code Country

Same as above

From Date 

(Month/Year)

Est.

To Date 

(Month/Year) Present

Est.

YES NO 

Were you EVER admitted as an inpatient to the agency/organization where counseling/treatment was provided?

Voluntary

You responded 'YES' to having been admitted as an inpatient to the agency/organization where counseling/treatment was provided, was the admission 

voluntary or involuntary?

Involuntary Explanation

Entry #2

Provide the name of the health 

care professional.

Provide the dates of counseling or treatment.

Day Night

Telephone number Extension

International or DSN phone number

Provide the telephone number of the health care professional.

Provide the name of agency/organization/facility where counseling/treatment was provided.

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

Street City State Zip Code Country

Same as above

Provide the address of agency/organization/facility provider. (Provide City and Country if outside the United States; otherwise, provide City, 

State and Zip Code)

Street City State Zip Code Country

Same as above

From Date 

(Month/Year)

Est.

To Date 

(Month/Year) Present

Est.

YES NO 

Were you EVER admitted as an inpatient to the agency/organization where counseling/treatment was provided?

Voluntary

You responded 'YES' to having been admitted as an inpatient to the agency/organization where counseling/treatment was provided, was the admission 

voluntary or involuntary?

Involuntary Explanation

In the last seven (7) years, have you consulted with a health care professional regarding an 

emotional or mental health condition or were you hospitalized for such a condition? Answer 'No' if 

the counseling was for any of the following reasons and was not court-ordered: 

- strictly marital, family, grief not related to violence by you; or 

- strictly related to adjustments from service in a military combat environment

Please respond to this question with the following additional instruction: Victims of sexual assault 

who have consulted with the health care professional regarding an emotional or mental health 

condition during this period strictly in relation to the sexual assault are instructed to answer No.
Page 85

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

(Month/Year)

YES NO (If NO, proceed to Section 22)

YES NO

Complete the following if you responded 'Yes' to having a court or administrative agency EVER declare you mentally incompetent. 

 Section 21 - Psychological and Emotional Health - (Continued)

Has a court or administrative agency EVER declared you mentally incompetent?

Provide the date this occurred.

Est.

Provide the name of the court or administrative agency that declared you mentally incompetent.

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

Street City State Zip Code Country

Was this matter appealed to a higher court?

Provide the name of the court.

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

Street City State Zip Code Country

Provide the final disposition.

21.2

Appeal #1

Appeal #2

Provide the name of the court.

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

Street City State Zip Code Country

Provide the final disposition.

Entry #1

(Month/Year)

YES NO (If NO, proceed to Section 22)

Provide the date this occurred.

Est.

Provide the name of the court or administrative agency that declared you mentally incompetent.

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

Street City State Zip Code Country

Was this matter appealed to a higher court?

Provide the name of the court.

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

Street City State Zip Code Country

Provide the final disposition.

Appeal #1

Appeal #2

Provide the name of the court.

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

Street City State Zip Code Country

Provide the final disposition.

Entry #2
Page 86

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

22.1 YES NO (If NO, proceed to 22.2)

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

(a)

(b)

(c)

- In the past seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding

 against you? (Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include 

 alcohol or drugs) 

- In the past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement 

 official? 

- In the past seven (7) years have you been charged, convicted, or sentenced of a crime in any court? (Include all qualifying 

 charges convictions or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form). 

- In the past seven (7) years have you been or are you currently on probation or parole?

- Are you currently on trial or awaiting a trial on criminal charges?

NO

Provide the name of the court. 

(If YES, complete (c.1))

Entry #1

(Check all that apply.)

 Section 22 - Police Record

Have any of the following happened? (If 'Yes' you will be asked to provide details for each offense that 

pertains to the actions that are identified below.) 

 

Entry #1

Provide the date of offense. (Month/Year)

Est.

Provide a description of the specific nature of the offense.

For this section report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or 

the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order 

under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.

Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City State Zip Code Country

Did this offense involve any of the following? 

 

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or 

someone with whom you share a child in common?

Involve firearms or explosives?

Involve alcohol or drugs?

YES NO

Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other 

type of law enforcement official?

Provide the name of the law enforcement agency that arrested/cited/summoned you.

Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City State Zip Code Country

As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?

YES

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

City State Zip Code Country

Provide explanation

Felony/misdemeanor Charge Outcome Date (Month/Year) 

Est.

Est.

Est.

Est.

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge 

dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser 

offense.

County

County

County

(c.1)
Page 87

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

(d)

YES (If YES, complete (d.1)) NO (If NO, complete (d.2))

(d.1)

(Month/Year) (Month/Year)

(Month/Year) (Month/Year)

(d.2)

Entry #1

Complete the following if you responded 'Yes' to one of the following: 

- In the past seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?

 (Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs) 

- In the past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?

- In the past seven (7) years have you been charged, convicted, or sentenced of a crime in any court? (Include all qualifying charges, convictions 

 or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form). 

- In the past seven (7) years have you been or are you currently on probation or parole?

- Are you currently on trial or awaiting a trial on criminal charges?

 Section 22 - Police Record - (Continued)

Were you sentenced as a result of this offense?

Provide a description of the sentence.

Were you sentenced to imprisonment for a term exceeding 1 year? YES NO

Were you incarcerated as a result of that sentence for not less than 1 year? YES NO

If the conviction resulted in imprisonment, provide the dates that you 

actually were incarcerated.

From Date

Est.

To Date Present

Est.

If conviction resulted in probation or parole, provide the dates of 

probation or parole.

From Date

Est.

To Date Present

Est.

Not Applicable

Not Applicable

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? YES NO

Provide explanation.
Page 88

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Complete the following if you responded 'Yes' to one of the following: 

- In the past seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?

 (Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs) 

- In the past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?

- In the past seven (7) years have you been charged, convicted, or sentenced of a crime in any court? (Include all qualifying charges, convictions 

 or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form). 

- In the past seven (7) years have you been or are you currently on probation or parole?

- Are you currently on trial or awaiting a trial on criminal charges?

Entry #2

Entry #2

(a)

(Check all that apply.)

Provide the date of offense. (Month/Year)

Est.

Provide a description of the specific nature of the offense.

Did this offense involve any of the following? 

 

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or 

someone with whom you share a child in common?

Involve firearms or explosives?

Involve alcohol or drugs?

YES NO

 Section 22 - Police Record - (Continued)

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

(b)

Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City State Zip Code Country

Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police officer, sheriff, marshal or any other 

type of law enforcement official?

Provide the name of the law enforcement agency that arrested/cited/summoned you.

Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code)

City State Zip Code Country

Felony/misdemeanor Charge Outcome Date (Month/Year) 

Est.

Est.

Est.

Est.

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, charge 

dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list separately both the original charge and the lesser 

offense.

County

County

(c)

NO

Provide the name of the court. 

(If YES, complete (c.1))

As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court in a criminal proceeding against you?

YES

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

City State Zip Code Country

Provide explanation

County

(c.1)
Page 89 Entry #2

Form approved: QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

(d)

YES (If YES, complete (d.1)) NO (If NO, complete (d.2))

(d.1)

(Month/Year) (Month/Year)

(Month/Year) (Month/Year)

(d.2)

Complete the following if you responded 'Yes' to one of the following: 

- In the past seven (7) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you?

 (Do not check if all the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs) 

- In the past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?

- In the past seven (7) years have you been charged, convicted, or sentenced of a crime in any court? (Include all qualifying charges, convictions 

 or sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form). 

- In the past seven (7) years have you been or are you currently on probation or parole?

- Are you currently on trial or awaiting a trial on criminal charges?

 Section 22 - Police Record - (Continued)

Were you sentenced as a result of this offense?

Provide a description of the sentence.

Were you sentenced to imprisonment for a term exceeding 1 year? YES NO

Were you incarcerated as a result of that sentence for not less than 1 year? YES NO

If the conviction resulted in imprisonment, provide the dates that you 

actually were incarcerated.

From Date

Est.

To Date Present

Est.

If conviction resulted in probation or parole, provide the dates of 

probation or parole.

From Date

Est.

To Date Present

Est.

Not Applicable

Not Applicable

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? YES NO

Provide explanation.
Page 90

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone 

with whom you share a child in common?

Involve firearms or explosives?

Involve alcohol or drugs?

YES NO (If NO, proceed to 22.3) 22.2

(a)

(b)

YES NO

(b.1)

- Have you EVER been convicted in any court of the United States of a crime, sentenced to imprisonment for a term exceeding 1 year for

 that crime, and incarcerated as a result of that sentence for not less than 1 year? (Include all qualifying convictions in Federal, state, 

 local, or military court, even if previously listed on this form) 

- Have you EVER been charged with any felony offense? (Include those under the Uniform Code of Military Justice and non-military/ 

 civilian felony offenses) 

- Have you EVER been convicted of an offense involving domestic violence or a crime of violence (such as battery or assault) against your 

 child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common? 

- Have you EVER been charged with an offense involving firearms or explosives? 

- Have you EVER been charged with an offense involving alcohol or drugs?

(Month/Year)

(Month/Year)

(Month/Year)

(Month/Year)

Felony/misdemeanor Charge Outcome Date (Month/Year) 

Est.

Est.

Est.

Est.

(Check all that apply).

 Section 22 - Police Record - (Continued)

Other than those offenses already listed, have you EVER had the following happen to you? 

Entry #1

Provide the date of offense. (Month/Year)

Est.

Provide a description of the specific nature of the offense.

Did this offense involve any of the following? 

Provide the name of the court.

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

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or 

charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser 

offense separately.

Were you sentenced as a result of these charges? 

YES (If YES, complete (b.1)) NO (If NO, complete (b.2))

Provide a description of the sentence.

Were you sentenced to imprisonment for a term exceeding 1 year? YES NO

Were you incarcerated as a result of that sentence for not less than 1 year? YES NO

If the conviction resulted in imprisonment, provide the dates that you 

actually were incarcerated.

From Date

Est.

To Date Present

Est.

If conviction resulted in probation or parole, provide the dates of 

probation or parole.

From Date

Est.

To Date Present

Est.

Not Applicable

Not Applicable

(b.2)

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? YES NO

Provide explanation.

City County State Zip Code Country
Page 91

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 

Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone 

with whom you share a child in common?

Involve firearms or explosives?

Involve alcohol or drugs?

(a)

(b)

YES NO

(b.1)

(Month/Year)

(Month/Year)

(Month/Year)

(Month/Year)

Felony/misdemeanor Charge Outcome Date (Month/Year) 

Est.

Est.

Est.

Est.

(Check all that apply).

 Section 22 - Police Record - (Continued)

Entry #2

Provide the date of offense. (Month/Year)

Est.

Provide a description of the specific nature of the offense.

Did this offense involve any of the following? 

Provide the name of the court.

Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or 

charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser 

offense separately.

Were you sentenced as a result of these charges? 

YES (If YES, complete (b.1)) NO (If NO, complete (b.2))

Provide a description of the sentence.

Were you sentenced to imprisonment for a term exceeding 1 year? YES NO

Were you incarcerated as a result of that sentence for not less than 1 year? YES NO

If the conviction resulted in imprisonment, provide the dates that you 

actually were incarcerated.

From Date

Est.

To Date Present

Est.

If conviction resulted in probation or parole, provide the dates of 

probation or parole.

From Date

Est.

To Date Present

Est.

Not Applicable

Not Applicable

(b.2)

Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? YES NO

Provide explanation.

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

City County State Zip Code Country
Page 92

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO (If NO, proceed to Section 23) 22.3

 Section 22 - Police Record - (Continued)

Is there currently a domestic violence protective order or restraining order issued against you?

Entry #1

Provide the date the order was issued. (Month/Year)

Est.

Provide explanation.

Provide the name of the court or agency that issued the order.

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City State Zip Code Country

Complete the following if you responded 'Yes' to currently having a domestic violence protective order or restraining order issued against you?

Entry #2

Provide the date the order was issued. (Month/Year)

Est.

Provide explanation.

Provide the name of the court or agency that issued the order.

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City State Zip Code Country

Entry #3

Provide the date the order was issued. (Month/Year)

Est.

Provide explanation.

Provide the name of the court or agency that issued the order.

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City State Zip Code Country

Entry #4

Provide the date the order was issued. (Month/Year)

Est.

Provide explanation.

Provide the name of the court or agency that issued the order.

Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

City State Zip Code Country
Page 93

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

YES NO

23.1

YES NO

Entry #2

Provide the type of drug or controlled substance.

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide an estimate of the month 

and year of first use. (Month/Year)

Est.

Provide an estimate of the month and 

year of most recent use. (Month/Year)

Est.

Provide nature of use, frequency, and number of times used.

Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in 

a position directly and immediately affecting the public safety?

Was your use while possessing a security clearance? YES NO

Do you intend to use this drug or controlled substance in the future? YES NO

Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.

 Section 23 - Illegal Use of Drugs and Drug Activity

We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as 

evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal 

government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity.

YES NO (If NO, proceed to 23.2) In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or 

controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise 

consuming any drug or controlled substance.

Complete the following if you answered 'Yes' to in the last seven (7) years having illegally used a drug or controlled substance.

Entry #1

Provide the type of drug or controlled substance.

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide an estimate of the month 

and year of first use. (Month/Year)

Est.

Provide an estimate of the month and 

year of most recent use. (Month/Year)

Est.

Provide nature of use, frequency, and number of times used.

Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in 

a position directly and immediately affecting the public safety?

Was your use while possessing a security clearance? YES NO

Do you intend to use this drug or controlled substance in the future? YES NO

Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future.
Page 94

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

23.2

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide an estimate of the month and Provide the nature and frequency of activity.

year of first involvement. (Month/Year)

Est.

Provide an estimate of the month and year 

of most recent involvement. (Month/Year)

Est.

Provide explanation.

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Provide explanation.

Entry #2

Provide the type of drug or controlled substance.

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a 

position directly and immediately affecting the public safety?

YES NO

Was your involvement while possessing a security clearance? YES NO

Do you intend to engage in this activity in the future?

NO

YES

Provide the reason(s) why you engaged in the activity

 Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)

In the last seven (7) years, have you been involved in the illegal purchase, manufacture, cultivation, YES NO (If NO, proceed to 23.3)

trafficking, production, transfer, shipping, receiving, handling or sale of any drug or controlled substance?

Complete the following if you answered 'Yes' to in the last seven (7) years having been involved in the illegal purchase, manufacture, cultivation, 

trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance.

Entry #1

Provide the type of drug or controlled substance.

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a 

position directly and immediately affecting the public safety?

YES NO

Was your involvement while possessing a security clearance? YES NO

Do you intend to engage in this activity in the future?

YES

NO

Provide the reason(s) why you engaged in the activity

Provide an estimate of the month and Provide the nature and frequency of activity.

year of first involvement. (Month/Year)

Est.

Provide an estimate of the month and year 

of most recent involvement. (Month/Year)

Est.
Page 95

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

23.3

Present (Month/Year) (Month/Year)

Present (Month/Year) (Month/Year)

Entry #2

From Date

Est.

To Date

Est.

Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this 

drug or controlled substance while possessing a security clearance.

Provide a description of your involvement.

Present From Date (Month/Year) (Month/Year)

Est.

To Date

Est.

Present From Date (Month/Year) (Month/Year)

Est.

To Date

Est.

Entry #2

Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this 

drug or controlled substance while employed in this capacity.

Provide a description of the drugs or controlled substances used and your involvement.

23.4 Have you EVER YES NO (If NO, proceed to 23.5) illegally used or otherwise been involved with a drug or controlled substance while 

employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and 

immediately affecting the public safety other than previously listed?

Complete the following if you responded 'Yes' to having EVER illegally used, or otherwise been involved with a drug or controlled substance while employed 

as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety other than previously 

listed.

Entry #1

Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this 

drug or controlled substance while employed in this capacity.

Provide a description of the drugs or controlled substances used and your involvement.

 Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)

Have you EVER YES NO (If NO, proceed to 23.4) illegally used or otherwise been involved with a drug or controlled substance while 

possessing a security clearance other than previously listed?

Complete the following if you responded 'Yes' to having EVER illegally used or otherwise been involved with a drug or controlled substance while 

possessing a security clearance, other than previously listed.

Entry #1

From Date

Est.

To Date

Est.

Provide the dates of involvement/use. Provide an estimate of the number of times you used and/or were involved with this 

drug or controlled substance while possessing a security clearance.

Provide a description of your involvement.
Page 96

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

23.5

Present From Date (Month/Year) (Month/Year)

Est.

To Date

Est.

Present From Date (Month/Year) (Month/Year)

Est.

To Date

Est.

 Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)

YES NO (If NO, proceed to 23.6) In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of

whether or not the drugs were prescribed for you or someone else?

Complete the following if you responded 'Yes' to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless 

of whether the drugs were prescribed for you or someone else.

Entry #1

Provide the dates of involvement/use Provide the reason(s) for and circumstances of the misuse of the prescription drug.

Provide the name of the prescription drug that you misused.

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a 

position directly and immediately affecting the public safety?

YES NO

Was your involvement while possessing a security clearance? YES NO

Entry #2

Provide the dates of involvement/use Provide the reason(s) for and circumstances of the misuse of the prescription drug.

Provide the name of the prescription drug that you misused.

Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a 

position directly and immediately affecting the public safety?

YES NO

Was your involvement while possessing a security clearance? YES NO
Page 97

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

23.6

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

From Date (Month/Year) (Month/Year) Present

Est.

To Date

Est.

Provide the dates of treatment.

 Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)

Have you EVER YES NO (If NO, proceed to 23.7) been ordered, advised, or asked to seek counseling or treatment as a result of your 

illegal use of drugs or controlled substances?

Complete the following if you responded 'Yes' to having EVER been ordered, advised, or asked to seek counseling or treatment as a result of your 

illegal use of drugs or controlled substances.

Entry #1

Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or controlled substances? 

(Check all that apply):

An employer, military commander, or employee assistance program

A medical professional

A mental health professional

A court official / judge

 

I have not been ordered, advised, or asked to seek 

counseling or treatment by any of the above

Provide the type of drug or controlled substance for which you were treated.

Provide explanation

Did you take action to receive counseling or treatment? YES (If YES, complete (b)) NO (If NO, complete (a))

Provide explanation.

(a) You have indicated that you did not receive treatment.

(b) You have indicated that you did receive treatment.

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

Street City State Zip Code Country

Last name First name

Provide a telephone number for the 

treatment provider.

Extension International or DSN 

phone number

Day Night

Provide the name of the treatment provider.

Did you successfully complete the treatment? YES NO (Provide explanation)
Page 98

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

From Date (Month/Year) (Month/Year) Present

Est.

To Date

Est.

Provide the dates of treatment.

 Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)

Complete the following if you responded 'Yes' to having EVER been ordered, advised, or asked to seek counseling or treatment as a result of your 

illegal use of drugs or controlled substances.

Entry #2

Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or controlled substances? 

(Check all that apply):

An employer, military commander, or employee assistance program

A medical professional

A mental health professional

A court official / judge

 

I have not been ordered, advised, or asked to seek 

counseling or treatment by any of the above

Provide the type of drug or controlled substance for which you were treated.

Provide explanation

Did you take action to receive counseling or treatment? YES (If YES, complete (b)) NO (If NO, complete (a))

Provide explanation.

(a) You have indicated that you did not receive treatment.

(b) You have indicated that you did receive treatment.

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

Street City State Zip Code Country

Last name First name

Provide a telephone number for the 

treatment provider.

Extension International or DSN 

phone number

Day Night

Provide the name of the treatment provider.

Did you successfully complete the treatment? YES NO (Provide explanation)
Page 99

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

23.7

Cocaine or crack cocaine (Such as rock, freebase, etc.)

THC (Such as marijuana, weed, pot, hashish, etc.)

Ketamine (Such as special K, jet, etc.)

Narcotics (Such as opium, morphine, codeine, heroin, etc.)

Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)

Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)

Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)

Steroids (Such as the clear, juice, etc.)

Inhalants (Such as toluene, amyl nitrate, etc.)

Other (Provide explanation)

Entry #2

Provide the type of drug or controlled substance for which you were treated.

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

Street City State Zip Code Country

From Date (Month/Year) (Month/Year) Present

Est.

To Date

Est.

Provide a telephone number for the Provide the dates of treatment.

treatment provider.

Extension International or DSN phone 

number

Day Night

Last name First name

Provide the name of the treatment provider.

Did you successfully complete the treatment? YES NO (Provide explanation)

 Section 23 - Illegal Use of Drugs and Drug Activity - (Continued)

Have you EVER YES NO (If NO, proceed to Section 24) voluntarily sought counseling or treatment as a result of your use of a drug or 

controlled substance?

Complete the following if you responded 'Yes' to having EVER voluntarily sought counseling or treatment as a result of your use of a drug or 

controlled substance?

Entry #1

Provide the type of drug or controlled substance for which you were treated.

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

Street City State Zip Code Country

From Date (Month/Year) (Month/Year) Present

Est.

To Date

Est.

Provide a telephone number for the Provide the dates of treatment.

treatment provider.

Extension International or DSN 

phone number

Day Night

Last name First name

Provide the name of the treatment provider.

Did you successfully complete the treatment? YES NO (Provide explanation)
Page 100

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

24.1

Entry #2

 Section 24 - Use of Alcohol

In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your YES NO (If NO, proceed to 24.2)

professional or personal relationships, your finances, or resulted in intervention by law enforcement/public 

safety personnel?

Complete the following if you responded 'Yes' to your alcohol use having had a negative impact on your work performance, your professional or personal 

relationships, your finances, or resulted in intervention by law enforcement/public safety personnel.

Entry #1

Provide the month/year when this 

negative impact occurred.

From Date (Month/Year)

Est.

Provide circumstances. Provide negative impact.

Provide the dates of involvement or use.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Provide the month/year when this 

negative impact occurred.

From Date (Month/Year)

Est.

Provide circumstances. Provide negative impact.

Provide the dates of involvement or use.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Entry #4

Entry #3

Provide the month/year when this 

negative impact occurred.

From Date (Month/Year)

Est.

Provide circumstances. Provide negative impact.

Provide the dates of involvement or use.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Provide the month/year when this 

negative impact occurred.

From Date (Month/Year)

Est.

Provide circumstances. Provide negative impact.

Provide the dates of involvement or use.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.
Page 101

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

An employer, military commander, or employee assistance program A court official / judge

A medical professional

 

I have not been ordered, advised, or asked to seek 

counseling or treatment by any of the above A mental health professional Other 

International or DSN phone number

Day Night

 Section 24 - Use of Alcohol - (Continued)

Have you EVER YES NO (If NO, proceed to 24.3) been ordered, advised, or asked to seek counseling or treatment as a result of your use of 

alcohol?

Complete the following if you responded 'Yes' to having been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol.

Entry #1

Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your use of alcohol? (Check all that apply)

Provide telephone number. Extension

(Provide explanation)

Did you take action to receive counseling or treatment? YES (If YES, complete (b)) NO (If NO, complete (a))

Provide explanation.

(a) You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.

(b) You responded 'Yes' to having taken action to seek counseling or treatment.

Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide the name of the individual counselor or treatment provider.

Did you successfully complete the treatment? YES NO (Provide explanation)

24.2

Provide the dates of counseling or treatment.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

An employer, military commander, or employee assistance program A court official / judge

A medical professional

 

I have not been ordered, advised, or asked to seek 

counseling or treatment by any of the above A mental health professional Other 

Entry #2

Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your use of alcohol? (Check all that apply):

(Provide explanation)

Enter your Social Security Number before going to the next page

International or DSN phone number

Day Night

Provide telephone number. Extension

Did you take action to receive counseling or treatment? YES (If YES, complete (b)) NO (If NO, complete (a))

Provide explanation.

(a) You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment.

(b) You responded 'Yes' to having taken action to seek counseling or treatment.

Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide the name of the individual counselor or treatment provider.

Did you successfully complete the treatment? YES NO (Provide explanation)

Provide the dates of counseling or treatment.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.
Page 102

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

24.3

Entry #2

Provide the full address of the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide telephone number. Extension International or DSN phone number

Day Night

Provide the dates of counseling or treatment. Provide the name of the individual counselor or treatment provider.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Did you successfully complete the treatment? YES NO (Provide explanation)

 Section 24 - Use of Alcohol - (Continued)

Have you EVER YES NO (If NO, proceed to 24.4) voluntarily sought counseling or treatment as a result of your use of alcohol?

Complete the following if you responded 'Yes' to voluntarily seeking counseling or treatment.

Entry #1

Provide the full address of the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide telephone number. Extension International or DSN phone number

Day Night

Provide the dates of counseling or treatment. Provide the name of the individual counselor or treatment provider.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Did you successfully complete the treatment? YES NO (Provide explanation)
Page 103

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

24.4

Did you successfully complete your counseling or treatment? YES (Provide explanation) NO (Provide explanation)

Explanation

Did you successfully complete your counseling or treatment? YES (Provide explanation) NO (Provide explanation)

Explanation

Entry #2

Provide the full address of the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Name

Provide the name of the individual counselor or treatment provider.

Provide the address of agency/organization where counseling/treatment was provided. (Provide City and Country if outside the United States; 

otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Same as above

Provide the dates of counseling or treatment.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Name

Provide the name of agency/organization where counseling/treatment was provided.

 Section 24 - Use of Alcohol - (Continued)

Have you EVER YES NO (If NO, proceed to Section 25) received counseling or treatment as a result of your use of alcohol in addition to what 

you have already listed on this form?

Complete the following if you responded 'Yes' to having EVER received counseling or treatment as a result of your use of alcohol.

Entry #1

Provide the full address of the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Name

Provide the name of the individual counselor or treatment provider.

Provide the address of agency/organization where counseling/treatment was provided. (Provide City and Country if outside the United States; 

otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Same as above

Provide the dates of counseling or treatment.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Name

Provide the name of agency/organization where counseling/treatment was provided.
Page 104

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

(Provide name of government)

25.1

Date the investigation was completed (Month/Year)

Est.

I don't know Provide the date clearance eligibility/access was granted. (Month/Year)

Est.

I don't know

(Provide name of government)

Date the investigation was completed (Month/Year)

Est.

I don't know Provide the date clearance eligibility/access was granted. (Month/Year)

Est.

I don't know

Entry #2

Provide the investigating agency:

U.S. Department of Defense

U.S. Department of State

U.S. Office of Personnel Management

Federal Bureau of Investigation

U.S. Department of Treasury

U.S. Department of Homeland Security

Foreign government 

I don't know

Other (Provide explanation)

Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.

Provide the level of clearance eligibility/access granted:

None

Confidential

Secret

Top Secret

Sensitive Compartmented Information (SCI)

Q

L

I don't know

Other (Provide explanation)

Issued by foreign country

 Section 25 - Investigations and Clearance Record

YES NO (If NO, proceed to 25.2) Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you 

a security clearance eligibility/access?

Complete the following if you responded 'Yes' to the U.S. Government (or a foreign government) having investigated your background and/or having

granted you a security clearance eligibility/access.

Entry #1

Provide the investigating agency:

U.S. Department of Defense

U.S. Department of State

U.S. Office of Personnel Management

Federal Bureau of Investigation

U.S. Department of Treasury

U.S. Department of Homeland Security

Foreign government 

I don't know

Other (Provide explanation)

Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency.

Provide the level of clearance eligibility/access granted:

None

Confidential

Secret

Top Secret

Sensitive Compartmented Information (SCI)

Q

L

I don't know

Other (Provide explanation)

Issued by foreign country
Page 105

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

25.2

Entry #2

Provide the date security clearance 

eligibility/access authorization was denied, 

suspended or revoked. (Month/Year)

Est.

Provide the name of the agency that took 

the action.

Provide an explanation of the circumstances of the denial,

suspension or revocation action.

25.3

Provide the name of the government 

agency taking debarment action.

Est.

Provide the date the debarment occurred. 

(Month/Year)

Provide the name of the government 

agency taking debarment action.

Est.

Provide the date the debarment occurred. 

(Month/Year)

Entry #2

Provide an explanation of the circumstances of the 

debarment.

 Section 25 - Investigations and Clearance Record - (Continued)

YES NO (If NO, proceed to 25.3) Have you EVER had a security clearance eligibility/access authorization denied, suspended, or 

revoked? (Note: An administrative downgrade or administrative termination of a security clearance is 

not a revocation.)

Complete the following if you responded 'Yes' to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked.

Entry #1

Provide the date security clearance 

eligibility/access authorization was denied, 

suspended or revoked. (Month/Year)

Est.

Provide the name of the agency that took 

the action.

Provide an explanation of the circumstances of the denial,

suspension or revocation action.

Have you EVER YES NO (If NO, proceed to Section 26) been debarred from government employment?

Complete the following if you responded 'Yes' to having EVER been debarred from government employment.

Entry #1

Provide an explanation of the circumstances of the 

debarment.
Page 106

 Section 26 - Financial Record

In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?

Provide the bankruptcy court docket/account number.

Provide the date bankruptcy was 

filed. (Month/Year)

Est.

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

YES NO (If NO, proceed to 26.2) 

Complete the following if you responded 'Yes' to in the last seven (7) years having filed a petition under any chapter of the bankruptcy code.

Chapter 7 Chapter 11 Chapter 13

Select the applicable bankruptcy petition type.

Est.

Provide the date of bankruptcy 

discharge. (Month/Year) Not Applicable

Entry #1

Provide the total amount (in U.S. 

dollars) involved in the bankruptcy.

Est.

Provide the name debt is recorded under.

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

Street City State Zip Code Country

Last name First name Middle name Suffix

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

Street City State Zip Code Country

Provide the name of the trustee for this bankruptcy.

Were you discharged of all debts claimed in the bankruptcy?

Provide Explanation.

(a) If Chapter 13 previously selected:

Provide the name of the court involved.

26.1

YES (Provide explanation) NO (Provide explanation)

Provide the bankruptcy court docket/account number.

Provide the date bankruptcy was 

filed. (Month/Year)

Est.

Chapter 7 Chapter 11 Chapter 13

Select the applicable bankruptcy petition type.

Est.

Provide the date of bankruptcy 

discharge. (Month/Year) Not Applicable

Entry #2

Provide the total amount (in U.S. 

dollars) involved in the bankruptcy.

Est.

Provide the name debt is recorded under.

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

Street City State Zip Code Country

Last name First name Middle name Suffix

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

Street City State Zip Code Country

Provide the name of the trustee for this bankruptcy.

Were you discharged of all debts claimed in the bankruptcy?

Provide Explanation.

(a) If Chapter 13 previously selected:

Provide the name of the court involved.

YES (Provide explanation) NO (Provide explanation)
Page 107

 Section 26 - Financial Record - (Continued)

Have you EVER experienced financial problems due to gambling?

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

YES NO (If NO, proceed to 26.3)

Complete the following if you responded 'Yes' to having EVER experienced financial problems due to gambling.

26.2

Entry #1

Provide a description of your financial problems due to gambling.

Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

If you have taken any action(s) to rectify your financial problems due to gambling,provide 

a description of your actions. If you have not taken any action(s), provide explanation.

Entry #2

Provide a description of your financial problems due to gambling.

Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

If you have taken any action(s) to rectify your financial problems due to gambling,provide 

a description of your actions. If you have not taken any action(s), provide explanation.

In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when required by 

law or ordinance?

Provide the year you failed to file or pay your Federal, state, or other taxes.

YES NO (If NO, proceed to 26.4)

Complete the following if you responded 'Yes' to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.

File Pay Both

Did you fail to file, pay as required, or both?

Est.

Provide date satisfied. (Month/Year) Not Applicable

Entry #1

Provide the Federal, state, or other agency 

to which you failed to file or pay taxes.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not 

taken any action(s) provide explanation.

Provide the reason(s) for your failure to file or pay required taxes. Provide the type of taxes you failed to file or 

pay (such as property, income, sales, etc.).

Provide the amount (in U.S. dollars) of the taxes.

Est.

26.3

Provide the year you failed to file or pay your Federal, state, or other taxes.

File Pay Both

Did you fail to file, pay as required, or both?

Est.

Provide date satisfied. (Month/Year) Not Applicable

Entry #2

Provide the Federal, state, or other agency 

to which you failed to file or pay taxes.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not 

taken any action(s) provide explanation.

Provide the reason(s) for your failure to file or pay required taxes. Provide the type of taxes you failed to file or 

pay (such as property, income, sales, etc.).

Provide the amount (in U.S. dollars) of the taxes.

Est.

Est.

Est.
Page 108

 Section 26 - Financial Record - (Continued)

In the past seven (7) years have you been counseled, warned, or disciplined for violating the terms of 

agreement for a travel or credit card provided by your employer?

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

YES NO (If NO, proceed to 26.5)

Complete the following if you responded 'Yes' to having been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card 

provided by your employer.

Entry #1

Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any 

action(s) provide explanation.

Provide the date of your counseling, warning, or disciplinary action.

Est.

Provide the name of the agency or company.

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

Street City State Zip Code Country

Provide the reason(s) for the counseling, warning, or disciplinary action

26.4

(Month/Year)

Est.

Provide the amount (in U.S. dollars) 

of violation.

Entry #2

Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any 

action(s) provide explanation.

Provide the date of your counseling, warning, or disciplinary action.

Est.

Provide the name of the agency or company.

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

Street City State Zip Code Country

(Month/Year) Provide the reason(s) for the counseling, warning, or disciplinary action

Est.

Provide the amount (in U.S. dollars) 

of violation.

Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to 

resolve your financial difficulties?

YES NO (If NO, proceed to 26.6)

Complete the following if you responded 'Yes' to being currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to 

resolve your financial difficulties.

Entry #1

As a result of this counseling, provide a description of any action(s) you have taken to resolve your financial difficulties. If you have not taken any action(s), 

provide explanation.

Provide explanation.

Provide the location of the credit counseling organization.

Telephone number Extension City State

Provide the telephone number of the credit counseling organization.

International or DSN phone number

Day Night

Provide the name of the credit counseling organization or resource.

Entry #2

As a result of this counseling, provide a description of any action(s) you have taken to resolve your financial difficulties. If you have not taken any action(s), 

provide explanation.

Provide explanation.

Provide the location of the credit counseling organization.

Telephone number Extension City State

Provide the telephone number of the credit counseling organization.

International or DSN phone number

Day Night

Provide the name of the credit counseling organization or resource.

26.5
Page 109

 Section 26 - Financial Record - (Continued)

Other than previously listed, have any of the following happened to you? (You will be asked to provide 

details about each financial obligation that pertains to the items identified below) 

- In the past seven (7) years, you have been delinquent on alimony or child support payments. 

- In the past seven (7) years, you had a judgment entered against you. (Include financial 

 obligations for which you were the sole debtor, as well as those for which you were a cosigner 

 or guarantor). 

- In the past seven (7) years, you had a lien placed against your property for failing to pay taxes 

 or other debts. (Include financial obligations for which you were the sole debtor, as well as 

 those for which you were a cosigner or guarantor). 

- You are currently delinquent on any Federal debt. (Include financial obligations for which you 

 are the sole debtor, as well as those for which you are a cosigner or guarantor).

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

YES NO (If NO, Proceed to 26.7)

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not 

taken any action(s), provide explanation.

Provide the associated loan/account number(s) involved.

Est.

Did/does this financial issue include any of the following? (Check all that apply)

Entry #1

Identify/describe the type of property involved (if any).

Provide the reason(s) for the financial issue. Provide the current status of the financial issue.

Provide the date the financial 

issue began. (Month/Year)

Est.

Provide date the financial issue 

was resolved. (Month/Year)

Est.

Provide the name of the court involved.

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

Street City State Zip Code Country

Provide the amount (in U.S. dollars) of the financial issue.

Provide the name of agency/organization/individual to which debt is/was owed.

Not Resolved

In the past seven (7) years, you have been delinquent on alimony or child support payments.

In the past seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those 

for which you were a cosigner or guarantor).

In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which 

you were the sole debtor, as well as those for which you were a cosigner or guarantor).

You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a 

cosigner or guarantor).

26.6

YES NO (If NO, Proceed to 26.7)
Page 110

 Section 26 - Financial Record - (Continued)

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not 

taken any action(s), provide explanation.

Provide the associated loan/account number(s) involved.

Est.

Did/does this financial issue include any of the following? (Check all that apply)

Entry #2

Identify/describe the type of property involved (if any).

Provide the reason(s) for the financial issue. Provide the current status of the financial issue.

Provide the date the financial 

issue began. (Month/Year)

Est.

Provide date the financial issue 

was resolved. (Month/Year)

Est.

Provide the name of the court involved.

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

Street City State Zip Code Country

Provide the amount (in U.S. dollars) of the financial issue.

Provide the name of agency/organization/individual to which debt is/was owed.

Not Resolved

In the past seven (7) years, you have been delinquent on alimony or child support payments.

In the past seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those 

for which you were a cosigner or guarantor).

In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which 

you were the sole debtor, as well as those for which you were a cosigner or guarantor).

You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a 

cosigner or guarantor).

YES NO (If NO, Proceed to 26.7)
Page 111

 Section 26 - Financial Record - (Continued)

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

YES NO (If NO, proceed to Section 27)

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not 

taken any action(s), provide explanation.

Provide the associated loan/account number(s) involved.

Est.

Did/does this financial issue include any of the following? (Check all that apply) YES NO (If NO, proceed to Section 27)

In the past seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations 

for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for 

which you were a cosigner or guarantor)

Entry #1

Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue. Provide the current status of the financial issue.

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason?

In the past seven (7) years, you have been over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you 

were the sole debtor, as well as those for which you were a cosigner or guarantor)

You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you 

are a cosigner or guarantor)

Provide the name of agency/organization/individual to which debt is/was owed.

Provide the date the financial issue began. (Month/Year)

Est.

Provide date the financial issue was resolved. (Month/Year)

Est.

Not Resolved

Other than previously listed, have any of the following happened? 

- In the past seven (7) years, you had any possessions or property voluntarily or involuntarily 

 repossessed or foreclosed? (Include financial obligations for which you were the sole debtor, 

 as well as those for which you were a cosigner or guarantor) 

- In the past seven (7) years, you defaulted on any type of loan? (Include financial 

 obligations for which you were the sole debtor, as well as those for which you were a 

 cosigner or guarantor) 

- In the past seven (7) years, you had bills or debts turned over to a collection agency? 

 (Include financial obligations for which you were the sole debtor, as well as those for which 

 you were a cosigner or guarantor) 

- In the past seven (7) years, you had any account or credit card suspended, charged off, or 

 cancelled for failing to pay as agreed? (Include financial obligations for which you were the 

 sole debtor, as well as those for which you were a cosigner or guarantor) 

- In the past seven (7) years, you were evicted for non-payment? 

- In the past seven (7) years, you had your wages, benefits, or assets garnished or attached 

 for any reason? 

- In the past seven (7) years, you have been over 120 days delinquent on any debt not 

 previously entered? (Include financial obligations for which you were the sole debtor, as well 

 as those for which you were a cosigner or guarantor) 

- You are currently over 120 days delinquent on any debt? (Include financial obligations for 

 which you are the sole debtor, as well as those for which you are a cosigner or guarantor)

26.7

In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, 

as well as those for which you were a cosigner or guarantor)

In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial 

obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) 

In the past seven (7) years, you were evicted for non-payment?
Page 112

 Section 26 - Financial Record - (Continued)

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.). If you have not 

taken any action(s), provide explanation.

Provide the associated loan/account number(s) involved.

Est.

Did/does this financial issue include any of the following? (Check all that apply) YES NO (If NO, proceed to Section 27)

In the past seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations 

for which you were the sole debtor, as well as those for which you were a cosigner or guarantor)

In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for 

which you were a cosigner or guarantor)

Entry #2

Identify/describe the type of property involved (if any).

Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue. Provide the current status of the financial issue.

Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues.

In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason?

In the past seven (7) years, you have been over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you 

were the sole debtor, as well as those for which you were a cosigner or guarantor)

You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you 

are a cosigner or guarantor)

Provide the name of agency/organization/individual to which debt is/was owed.

Provide the date the financial issue began. (Month/Year)

Est.

Provide date the financial issue was resolved. (Month/Year)

Est.

Not Resolved

In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, 

as well as those for which you were a cosigner or guarantor)

In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial 

obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) 

In the past seven (7) years, you were evicted for non-payment?
Page 113

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

27.1

 (Month/Year)

 (Month/Year)

Entry #2

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide the date of the incident. Provide a description of the nature of the incident or offense.

 (Month/Year)

Entry #1

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide the date of the incident. Provide a description of the nature of the incident or offense.

 (Month/Year)

Entry #2

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide the date of the incident. Provide a description of the nature of the incident or offense.

27.2

Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or 

denied others access to information residing on an information technology system or attempted any of the above.

YES NO (If NO, proceed to 27.3) In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or 

denied others access to information residing on an information technology system or attempted any of the 

above?

Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter into 

any information technology system.

 Section 27 - Use of Information Technology Systems

YES NO (If NO, proceed to 27.2) In the last seven (7) years have you illegally or without proper authorization accessed or attempted to 

access any information technology system?

Entry #1

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as 

evidence against you in a subsequent criminal proceeding. As to this particular section, this applies whether or not you are currently employed by the Federal 

government. The following questions ask about your use of information technology systems. Information technology systems include all related computer 

hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage or protection of information.

Est.

Provide the date of the incident. Provide a description of the nature of the incident or offense.
Page 114

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Enter your Social Security Number before going to the next page

 (Month/Year)

Entry #1

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide the date of the incident. Provide a description of the nature of the incident or offense.

 (Month/Year)

Entry #2

Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)

Street City State Zip Code Country

Provide a description of the action (administrative, criminal or other) taken as a result of this incident.

Est.

Provide the date of the incident. Provide a description of the nature of the incident or offense.

27.3

Complete the following if you responded 'Yes' to having in the last seven (7) years introduced, removed, or used hardware, software, or media in 

connection with any information technology system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations or 

attempted any of the above.

 Section 27 - Use of Information Technology Systems - (Continued)

YES NO (If NO, proceed to Section 28) In the last seven (7) years have you introduced, removed, or used hardware, software, or media in 

connection with any information technology system without authorization, when specifically prohibited 

by rules, procedures, guidelines, or regulations or attempted any of the above?
Page 115

 Section 28 - Involvement in Non-Criminal Court Actions

In the last ten (10) years, have you been a party to any public record civil court action not listed elsewhere on 

this form?

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

YES NO (If NO, proceed to Section 29)

Complete the following if you responded 'Yes' to having been a party to any public record civil court action(s) not listed elsewhere on this form in the last

ten (10) years.

Entry #1

Provide details of the nature of the action.

Provide the date of the civil action. Provide the court name.

Provide a description of the results of the action. Provide the name(s) of the principal parties 

involved in the court action.

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

Street City State Zip Code Country

Est.

 (Month/Year)

Entry #2

Provide details of the nature of the action.

Provide the date of the civil action. Provide the court name.

Provide a description of the results of the action. Provide the name(s) of the principal parties 

involved in the court action.

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

Street City State Zip Code Country

Est.

 (Month/Year)

Enter your Social Security Number before going to the next page
Page 116

The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an 

adverse employment, security, or credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are 

dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or 

coercion, or to affect the conduct of a government by mass destruction, assassination or kidnapping.

 Section 29 - Association Record

Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an 

awareness of the organization's dedication to that end, or with the specific intent to further such activities?

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

YES NO (If NO, proceed to 29.2)

Complete the following if you responded 'YES' to being or ever having been a member of an organization dedicated to terrorism, either with an awareness of 

the organization's dedication to that end, or with the specific intent to further such activities.

Entry #1

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the 

organization.

Provide the dates of your involvement with the organization. No positions held

Provide all contributions made to the No contributions made

organization, if any.

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

Street City State Zip Code Country

29.1

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Entry #2

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the 

organization.

Provide the dates of your involvement with the organization. No positions held

Provide all contributions made to the No contributions made

organization, if any.

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

Street City State Zip Code Country

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.
Page 117

 Section 29 - Association Record - (Continued)

Have you EVER knowingly engaged in any acts of terrorism?

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Complete the following if you responded 'Yes' to EVER having knowingly engaged in any acts of terrorism.

Entry #1

Describe the nature and reasons for the activity. Provide the dates for any such activities.

Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by 

force?

Complete the following if you responded 'Yes' to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by 

force.

Entry #1

Provide the reason(s) for advocating acts of terrorism. Provide the dates of advocating acts of terrorism.

YES NO (If NO, proceed to 29.3) 29.2

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

YES NO (Proceed to 29.4)

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Entry #2

Provide the reason(s) for advocating acts of terrorism. Provide the dates of advocating acts of terrorism.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

29.3

Entry #2

Describe the nature and reasons for the activity. Provide the dates for any such activities.

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.
Page 118

 Section 29 - Association Record - (Continued)

Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow 

the United States Government, and which engaged in activities to that end with an awareness of the 

organization's dedication to that end or with the specific intent to further such activities?

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

YES NO (If NO, proceed to 29.5)

Complete the following if you responded 'Yes' to having EVER been a member of an organization dedicated to the use of violence or force to overthrow the 

United States Government, and which engaged in activities to that end with an awareness of the organization's dedication to that end or with the specific 

intent to further such activities.

Entry #1

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the 

organization.

Provide the dates of your involvement with the organization. No positions held

Provide all contributions made to the No contributions made

organization, if any.

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

Street City State Zip Code Country

29.4

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.

Entry #2

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the 

organization.

Provide the dates of your involvement with the organization. No positions held

Provide all contributions made to the No contributions made

organization, if any.

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

Street City State Zip Code Country

From Date Present (Month/Year)

Est.

To Date (Month/Year)

Est.
Page 119

 Section 29 - Association Record - (Continued)

Have you EVER been a member of an organization that advocates or practices commission of acts of force 

or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the 

United States with the specific intent to further such action?

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Complete the following if you responded 'Yes' to being or EVER having been a member of an organization that advocates or practices commission of acts of 

force or violence to discourage others from exercising their rights under the U.S. Constitution or that of any state of the U.S. with the specific intent to further 

such action.

Entry #1

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the 

organization.

Provide the dates of your involvement with the organization. No positions held

Provide all contributions (in U.S. dollars) No contributions made

made to the organization, if any.

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

Street City State Zip Code Country

29.5 YES NO (If NO, proceed to 29.6)

Present From Date (Month/Year)

Est.

To Date (Month/Year)

Est.

Entry #2

Provide all positions held in the organization, if any.

Provide the full name of the organization.

Provide a description of the nature of and reasons for your involvement with the 

organization.

Provide the dates of your involvement with the organization. No positions held

Provide all contributions (in U.S. dollars) No contributions made

made to the organization, if any.

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

Street City State Zip Code Country

Present From Date (Month/Year)

Est.

To Date (Month/Year)

Est.
Page 120

 Section 29 - Association Record - (Continued)

Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Complete the following if you responded 'Yes' to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.

Entry #1

Describe the nature and reasons for the activity. Provide the dates of such activities.

Have you EVER associated with anyone involved in activities to further terrorism?

Complete the following if you responded 'Yes' to having EVER associated with anyone involved in activities to further terrorism.

Entry #1

Provide explanation.

Entry #2

Provide explanation.

29.6 YES NO (If NO, proceed to 29.7)

Present From Date (Month/Year)

Est.

To Date (Month/Year)

Est.

Entry #2

Describe the nature and reasons for the activity. Provide the dates of such activities.

Present From Date (Month/Year)

Est.

To Date (Month/Year)

Est.

29.7 YES NO 
Continuation Space

Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

Use the Standard Form 86A (SF 86A) for additional answers for Sections 11, 12 and 13. Use the space below to continue answers, to all other 

items. If additional space is required, use a blank sheet (s) of paper. Include your name and SSN at the top of each blank sheet (s). Before each 

answer, identify the number of the item and attempt to maintain sequential order and question format. 

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 following certification and the attached release(s).

Certification

My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I 

have carefully read the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this form can be punished by 

fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information may have a negative 

effect on my security clearance, employment prospects, or job status, up to and including denial or revocation of my security clearance, or my removal and 

debarment from Federal service.

Signature (Sign in ink) Date signed (mm/dd/yyyy)

Page 121
Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

AUTHORIZATION FOR RELEASE OF INFORMATION

UNITED STATES OF AMERICA

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, reinvestigation or continuous evaluation (as defined in Executive Order 12968 as 

amended by Executive Order 13467) 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 national security position.

 

I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security 

Number, and date of birth with information in SSA records and provide the results of the match) to the United States Office of 

Personnel Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined 

above. I authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting 

my investigation, in the event of a discrepancy. 

 

I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other 

sources of information, separate specific releases may be needed, and I may be contacted for such releases at a later date. 

 

I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of 

Investigation, the Department of Defense, the Department of State, 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 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 disclosed by the Government only as 

authorized by law. 

 

I Authorize the information to be used to conduct officially sanctioned and approved personnel security-related studies and 

analyses, which will be maintained in accordance with the Privacy Act. 

 

Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I remain 

employed in a sensitive position requiring eligibility for access to classified information.

Signature (Sign in ink) Full name (Type or print legibly) Date signed (mm/dd/yyyy)

Other names used Social Security Number

Current street address Apt. # City (Country) State Zip Code Home telephone number

Date of birth
Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT 

TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

If you answered "Yes" to Question 21, 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 questions below concerning your mental health 

consultations. Your signature will allow the practitioner(s) to answer only these questions. 

Authorization

I am seeking assignment to or retention in a national security position. As part of the clearance 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. 

In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to the U.S. Office 

of Personnel Management. I understand that I may revoke this authorization except to the extent that action has already been 

taken based on this authorization. Further, I understand that this authorization is voluntary. My treatment, payment, enrollment 

in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 

I understand the information disclosed pursuant to this release is for use by the Federal Government only for purposes provided 

in the Standard Form 86 and that it may be disclosed by the Government only as authorized by law, but will no longer be subject 

to the HIPAA privacy rule. 

Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed or 

upon termination of my affiliation with the Federal Government, whichever is sooner.

For Use By Practitioner(s) Only

Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to properly 

safeguard classified national security information?

YES NO

Signature (Sign in ink) Practitioner name Date signed (mm/dd/yyyy)

What is the prognosis?

Signature (Sign in ink) Full name (Type or print legibly) Date signed (mm/dd/yyyy)

Other names used Social Security Number

Current street address Apt. # City (Country) State Zip Code Home telephone number

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

Dates of treatment?
Enter your Social Security Number before going to the next page

Form approved: 

QUESTIONNAIRE FOR OMB No. 3206 0005 

NATIONAL SECURITY POSITIONS

Standard Form 86 

Revised December 2010 

U.S. Office of Personnel Management 

5 CFR Parts 731, 732, and 736

UNITED STATES OF AMERICA

FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION

Disclosure

One or more reports from consumer reporting agencies may be obtained for employment purposes pursuant to the Fair Credit 

Reporting Act, codified at 15 U.S.C. § 1681 et seq. 

Purpose

Information provided by you on this form will be furnished to the consumer reporting agency in order to obtain information in 

connection with a background investigation to determine your (1) fitness for Federal employment, (2) clearance to perform 

contractual service for the Federal government, and/or (3) eligibility for a sensitive position or access to classified information. 

The information obtained may be disclosed to other Federal agencies for the above purposes in fulfillment of official 

responsibilities to the extent that such disclosure is permitted by law. Information from the consumer report will not be used in 

violation of any applicable Federal or state equal employment opportunity law or regulation. 

Authorization

I hereby authorize the investigative agency conducting my background to obtain such reports from any consumer reporting 

agency for employment purposes described above. 

Note: If you have a security freeze on your consumer or credit report file, then we may not be able to complete your 

investigation, which can adversely affect your eligibility for a national security position. To avoid such delays, you should request 

that the consumer reporting agencies lift the freeze in these instances. 

Your Social Security Number (SSN) is needed to identify your unique records. Although disclosure of your SSN is not 

mandatory, failure to disclose your SSN may prevent or delay the processing of your background investigation. The authority for 

soliciting and verifying your SSN is Executive Order 9397.

Signature (Sign in ink)

Print Name

Date signed (mm/dd/yyyy)

Social Security Number