Questionnaire for Public Trust Positions

Transcription

1 Stndrd Form 85P Revised September 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 Questionnire for Public Trust Positions Form pproved: OMB NSN Follow instructions fully or we cnnot process your form. Be sure to sign nd dte the certifiction sttement on Pge 7 nd the relese on Pge 8. If you hve ny questions, cll the office tht gve you the form. Purpose of this Form The U.S. Government conducts bckground investigtions nd reinvestigtions to estblish tht pplicnts or incumbents either employed by the Government or working for the Government under contrct, re suitble for the job nd/or eligible for public trust or sensitive position. Informtion from this form is used primrily s the bsis for this investigtion. Complete this form only fter conditionl offer of employment hs been mde. Giving us the informtion we sk for is voluntry. However, we my not be ble to complete your investigtion, or complete it in timely mnner, if you don t give us ech item of informtion we request. This my ffect your plcement or employment prospects. Authority to Request this Informtion The U.S. Government is uthorized to sk for this informtion under Executive Orders nd 10577, sections 3301 nd 3302 of title 5, U.S. ; nd prts 5, 731, 732, nd 736 of Title 5, of Federl Regultions. Your Socil Security number is needed to keep records ccurte, becuse other people my hve the sme nme nd birth dte. Executive Order 9397 lso sks Federl gencies to use this number to help identify individuls in gency records. The Investigtive Process Bckground investigtions re conducted using your responses on this form nd on your Declrtion for Federl Employment ( 306) to develop informtion to show whether you re relible, trustworthy, of good conduct nd chrcter, nd loyl to the United Sttes. The informtion tht you provide on this form is confirmed during the investigtion. Your current employer must be contcted s prt of the investigtion, even if you hve previously indicted on pplictions or other forms tht you do not wnt this. In ddition to the questions on this form, inquiry lso is mde bout person s dherence to security requirements, honesty nd integrity, vulnerbility to exploittion or coercion, flsifiction, misrepresenttion, nd ny other behvior, ctivities, or ssocitions tht tend to show the person is not relible, trustworthy, or loyl. Your Personl Interview Some investigtions will include n interview with you s norml prt of the investigtive process. This provides you the opportunity to updte, clrify, nd explin informtion on your form more completely, which often helps to complete your investigtion fster. It is importnt tht the interview be conducted s soon s possible fter you re contcted. Postponements will dely the processing of your investigtion, nd declining to be interviewed my result in your investigtion being delyed or cnceled. You will be sked to bring identifiction with your picture on it, such s vlid Stte driver s license, to the interview. There re other documents you my be sked to bring to verify your identity s well. These include documenttion of ny legl nme chnge, Socil Security crd, nd/or birth certificte. You my lso be sked to bring documents bout informtion you provided on the form or other mtters requiring specific ttention. These mtters include lien registrtion, delinquent lons or txes, bnkruptcy, judgments, liens, or other finncil obligtions, greements involving child custody or support, limony or property settlements, rrests, convictions, probtion, nd/or prole. Instructions for Completing this Form 1. Follow the instructions given to you by the person who gve you the form nd ny other clrifying instructions furnished by tht person to ssist you in completion of the form. Find out how mny copies of the form you re to turn in. You must sign nd dte, in blck ink, the originl nd ech copy you submit. 2. Type or legibly print your nswers in blck ink (if your form is not legible, it will not be ccepted). You my lso be sked to submit your form in n pproved electronic formt. 3. All questions on this form must be nswered. If no response is necessry or pplicble, indicte this on the form (for exmple, enter "ne" or "N/A"). If you find tht you cnnot report n exct dte, pproximte or estimte the dte to the best of your bility nd indicte this by mrking "APPROX." or "EST." 4. Any chnges tht you mke to this form fter you sign it must be initiled nd dted by you. Under certin limited circumstnces, gencies my modify the form consistent with your intent. 5. You must use the Stte codes (bbrevitions) listed on the bck of this pge when you fill out this form. Do not bbrevite the nmes of cities or foreign countries. 6. The 5-digit postl ZIP codes re needed to speed the processing of your investigtion. The office tht provided the form will ssist you in completing the ZIP codes. 7. All telephone numbers must include re codes. 8. All dtes provided on this form must be in Month/Dy/Yer or formt. Use numbers (1-12) to indicte months. For exmple, June 10, 1978, should be shown s 6/10/ Whenever "" is shown in n ddress block, lso provide in tht block the nme of the country when the ddress is outside the United Sttes. 10. If you need dditionl spce to list your residences or employments/self-employments/unemployments or eduction, you should use continution sheet, SF 86A. If dditionl spce is needed to nswer other items, use blnk piece of pper. Ech blnk piece of pper you use must contin your nme nd Socil Security Number t the top of the pge.

2 Finl Determintion on Your Eligibility Finl determintion on your eligibility for public trust or sensitive position nd your being grnted security clernce is the responsibility of the Office of Personnel Mngement or the Federl gency tht requested your investigtion. You my be provided the opportunity personlly to explin, refute, or clrify ny informtion before finl decision is mde. Penlties for Inccurte or Flse Sttements The U.S. Criminl (title 18, section 1001) provides tht knowingly flsifying or conceling mteril fct is felony which my result in fines of up to $10,000, nd/or 5 yers imprisonment, or both. In ddition, Federl gencies generlly fire, do not grnt security clernce, or disqulify individuls who hve mterilly nd delibertely flsified these forms, nd this remins prt of the permnent record for future plcements. Becuse the position for which you re being considered is one of public trust or is sensitive, your trustworthiness is very importnt considertion in deciding your suitbility for plcement or retention in the position. Your prospects of plcement re better if you nswer ll questions truthfully nd completely. You will hve dequte opportunity to explin ny informtion you give us on the form nd to mke your comments prt of the record. Disclosure of Informtion The informtion you give us is for the purpose of investigting you for position; we will protect it from unuthorized disclosure. The collection, mintennce, nd disclosure of bckground investigtive informtion is governed by the Privcy Act. The gency which requested the investigtion nd the gency which conducted the investigtion hve published notices in the Federl Register describing the system of records in which your records will be mintined. You my obtin copies of the relevnt notices from the person who gve you this form. The informtion on this form, nd informtion we collect during n investigtion my be disclosed without your consent s permitted by the Privcy Act (5 USC 552(b)) nd s follows: PRIVACY ACT ROUTINE USES 1. the Deprtment of Justice when: () the gency or ny component thereof; or (b) ny employee of the gency in his or her officil cpcity; or (c) ny employee of the gency in his or her individul cpcity where the Deprtment of Justice hs greed to represent the employee; or (d) the United Sttes Government, is prty to litigtion or hs interest in such litigtion, nd by creful review, the gency determines tht the records re both relevnt nd necessry to the litigtion nd the use of such records by the Deprtment of Justice is therefore deemed by the gency to be for purpose tht is comptible with the purpose for which the gency collected the records. 2. court or djudictive body in proceeding when: () the gency or ny component thereof; or (b) ny employee of the gency in his or her officil cpcity; or (c) ny employee of the gency in his or her individul cpcity where the Deprtment of Justice hs greed to represent the employee; or (d) the United Sttes Government is prty to litigtion or hs interest in such litigtion, nd by creful review, the gency determines tht the records re both relevnt nd necessry to the litigtion nd the use of such records is therefore deemed by the gency to be for purpose tht is comptible with the purpose for which the gency collected the records. 3. Except s noted in Question 21, when record on its fce, or in conjunction with other records, indictes violtion or potentil violtion of lw, whether civil, criminl, or regultory in nture, nd whether rising by generl sttute, prticulr progrm sttute, regultion, rule, or order issued pursunt thereto, the relevnt records my be disclosed to the pproprite Federl, foreign, Stte, locl, tribl, or other public uthority responsible for enforcing, investigting or prosecuting such violtion or chrged with enforcing or implementing the sttute, rule, regultion, or order. 4. ny source or potentil source from which informtion is requested in the course of n investigtion concerning the hiring or retention of n employee or other personnel ction, or the issuing or retention of security clernce, contrct, grnt, license, or other benefit, to the extent necessry to identify the individul, inform the source of the nture nd purpose of the investigtion, nd to identify the type of informtion requested. 5. Federl, Stte, locl, foreign, tribl, or other public uthority the fct tht this system of records contins informtion relevnt to the retention of n employee, or the retention of security clernce, contrct, license, grnt, or other benefit. The other gency or licensing orgniztion my then mke request supported by written consent of the individul for the entire record if it so chooses. disclosure will be mde unless the informtion hs been determined to be sufficiently relible to support referrl to nother office within the gency or to nother Federl gency for criminl, civil, dministrtive, personnel, or regultory ction. 6. contrctors, grntees, experts, consultnts, or volunteers when necessry to perform function or service relted to this record for which they hve been engged. Such recipients shll be required to comply with the Privcy Act of 1974, s mended. 7. the news medi or the generl public, fctul informtion the disclosure of which would be in the public interest nd which would not constitute n unwrrnted invsion of personl privcy. 8. Federl, Stte, or locl gency, or other pproprite entities or individuls, or through estblished liison chnnels to selected foreign governments, in order to enble n intelligence gency to crry out its responsibilities under the Ntionl Security Act of 1947 s mended, the CIA Act of 1949 s mended, Executive Order or ny successor order, pplicble ntionl security directives, or clssified implementing procedures pproved by the Attorney Generl nd promulgted pursunt to such sttutes, orders or directives. 9. Member of Congress or to Congressionl stff member in response to n inquiry of the Congressionl office mde t the written request of the constituent bout whom the record is mintined. 10. the Ntionl Archives nd Records Administrtion for records mngement inspections conducted under 44 USC 2904 nd the Office of Mngement nd Budget when necessry to the review of privte relief legisltion. STATE CODES (ABBREVIATIONS) Albm Alsk Arizon Arknss Cliforni Colordo Connecticut Delwre Florid Georgi AL AK AZ AR CA CO CT DE FL GA Hwii Idho Illinois Indin Iow Knss Kentucky Louisin Mine Mrylnd HI ID IL IN IA KS KY LA ME MD Msschusetts Michign Minnesot Mississippi Missouri Montn Nebrsk Nevd New Hmpshire New Jersey MA MI MN MS MO MT NE NV NH NJ New Mexico New York rth Crolin rth Dkot Ohio Oklhom Oregon Pennsylvni Rhode Islnd South Crolin NM NY NC ND OH OK OR PA RI SC South Dkot Tennessee Texs Uth Vermont Virgini Wshington West Virgini Wisconsin Wyoming SD TN TX UT VT VA WA WV WI WY Americn Smo Trust Territory AS TT District of Columbi Virgin Islnds DC VI Gum GU PUBLIC BURDEN INFORMATION rthern Mrins CM Puerto Rico PR Public burden reporting for this collection of informtion is estimted to verge 60 minutes per response, including time for reviewing instructions, serching existing dt sources, gthering nd mintining the dt needed, nd completing nd reviewing the collection of informtion. Send comments regrding the burden estimte or ny other spect of this collection of informtion, including suggestions for reducing this burden to Reports nd Forms Mngement Officer, U.S. Office of Personnel Mngement, 1900 E Street, N.W., Room CHP-500, Wshington, D.C Do not send your completed form to this ddress.

3 Stndrd Form 85P (EG) Revised September 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 OPM USE ONLY Type of Investigtion QUESTIONNAIRE FOR PUBLIC TRUST POSITIONS Agency Use Only (Complete items A through P using instructions provided by USOPM) A B D Compu/ E G Geogrphic Loction J SON L SOI NOPAC-ALC Number Extr Coverge H O Position ne Other Address NPRC At SON ne Other Address At SOI NPI Accounting Dt nd/or Agency Cse Number s Cse Number C Sensitivity/ Nture of Dte of Risk Level ADP Action Action Form pproved: OMB NSN F Month Dy Yer P Requesting Nme nd Title Signture Telephone Number Dte Officil 1 FULL NAME K M Loction of Officil Personnel Folder Loction of Security Folder Persons completing this form should begin with the questions below. If you hve only initils in your nme, use them nd stte (IO). If you hve no middle nme, enter "NMN". I Position Title - If you re "Jr.," "Sr.," "II," etc., enter this in the box fter your middle nme. Lst Nme First Nme Middle Nme Jr., II, etc. 2 ZIP ZIP DATE BIRTH Month Dy Yer 3 PLACE BIRTH - Use the two letter code for the Stte. City County Stte Country (if not in the United Sttes) 4 SOCIAL SECURITY NUMBER 5 OTHER NAMES USED 6 7 Nme Nme OTHER IDENTIFYING INFORMATION TELEPHONE NUMBERS CITIZENSHIP Nme Nme #4 Height (feet nd inches) Weight (pounds) Hir Color Eye Color Work (include Are nd extension) Dy Night Home (include Are ) Dy Night Sex (Mrk one box) Femle Mle Your Mother s Miden Nme 8 I m U.S. citizen or ntionl by birth in the U.S. or U.S. territory/possession. Answer b Mrk the box t the right tht reflects your current citizenship sttus, nd follow its instructions. items b nd d. I m U.S. citizen, but I ws NOT born in the U.S. Answer items b, c nd d. I m not U.S. citizen. Answer items b nd e. c UNITED STATES CITIZENSHIP If you re U.S. Citizen, but were not born in the U.S., provide informtion bout one or more of the following proofs of your citizenship. Nturliztion Certificte (Where were you nturlized?) Court City Stte Certificte Number Month/Dy/Yer Issued Citizenship Certificte (Where ws the certificte issued?) City Stte Certificte Number Month/Dy/Yer Issued Stte Deprtment Form Report of Birth Abrod of Citizen of the United Sttes Give the dte the form ws Month/Dy/Yer Explntion prepred nd give n explntion if needed. U.S. Pssport This my be either current or previous U.S. Pssport Pssport Number Month/Dy/Yer Issued d e DUAL CITIZENSHIP If you re (or were) dul citizen of the United Sttes nd nother country, provide the nme of tht country in the spce to the right. ALIEN If you re n lien, provide the following informtion: Plce You Entered the United Sttes: City Stte Dte You Entered U.S. Month Dy Yer Exception to SF85, SF85P, SF85P-S, SF86, nd SF86A pproved by GSA September, Designed using Perform Pro, WHS/DIOR, Sep 95 Country Alien Registrtion Number Country(ies) of Citizenship Pge 1

4 9 WHERE YOU HAVE LIVED List the plces where you hve lived, beginning with the most recent () nd working bck 7 yers. All periods must be ccounted for in your list. Be sure to indicte the ctul physicl loction of your residence: do not use post office box s n ddress, do not list permnent ddress when you were ctully living t school ddress, etc. Be sure to specify your loction s closely s possible: for exmple, do not list only your bse or ship, list your brrcks number or home port. You my omit temporry militry duty loctions under 90 dys (list your permnent ddress insted), nd you should use your APO/FPO ddress if you lived overses. For ny ddress in the lst 5 yers, list person who knew you t tht ddress, nd who preferbly still lives in tht re (do not list people for residences completely outside this 5-yer period, nd do not list your spouse, former spouses, or other reltives). Also for ddresses in the lst 5 yers, if the ddress is "Generl Delivery," Rurl or Str Route, or my be difficult to locte, provide directions for locting the residence on n ttched continution sheet. Present Nme of Person Who Knows You Nme of Person Who Knew You Nme of Person Who Knew You #4 Nme of Person Who Knew You #5 Nme of Person Who Knew You Street Address Apt. # Stte ZIP Street Address Apt. # Street Address Apt. # Stte ZIP Street Address Apt. # Street Address Apt. # Stte ZIP Street Address Apt. # Street Address Apt. # Stte ZIP Street Address Apt. # Street Address Apt. # Stte ZIP Street Address Apt. # 10 WHERE YOU WENT TO SCHOOL List the schools you hve ttended, beyond Junior High School, beginning with the most recent () nd working bck 7 yers. List ll College or University degrees nd the dtes they were received. If ll of your eduction occurred more thn 7 yers go, list your most recent eduction beyond high school, no mtter when tht eduction occurred. Use one of the following codes in the "" block: 1 - High School 2 - College/University/Militry College 3 - Voctionl/Technicl/Trde School For schools you ttended in the pst 3 yers, list person who knew you t school (n instructor, student, etc.). Do not list people for eduction completely outside this 3-yer period. For correspondence schools nd extension clsses, provide the ddress where the records re mintined. Nme of School Degree/Diplom/Other Awrded Street Address nd of School Stte ZIP Nme of Person Who Knew You Street Address Apt. # Nme of School Degree/Diplom/Other Awrded Street Address nd of School Stte ZIP Nme of Person Who Knew You Street Address Apt. # Nme of School Degree/Diplom/Other Awrded Street Address nd of School Stte ZIP Nme of Person Who Knew You Street Address Apt. # Stte ZIP Telephone Number Pge 2

5 11 YOUR EMPLOYMENT ACTIVITIES List your employment ctivities, beginning with the present () nd working bck 7 yers. You should list ll full-time work, prt-time work, militry service, temporry militry duty loctions over 90 dys, self-employment, other pid work, nd ll periods of unemployment. The entire 7-yer period must be ccounted for without breks, but you need not list employments before your 16th birthdy.. Use one of the codes listed below to identify the type of employment: 1 - Active militry duty sttions 2 - Ntionl Gurd/Reserve 3 - U.S.P.H.S. Commissioned Corps 4 - Other Federl employment 5 - Stte Government (n-federl employment) 6 - Self-employment (Include business nd/or nme of person who cn verify) 7 - Unemployment (Include nme of 9 - Other person who cn verify) 8 - Federl Contrctor (List Contrctor, not Federl gency) Employer/Verifier Nme. List the business nme of your employer or the nme of the person who cn verify your self-employment or unemployment in this block. If militry service is being listed, include your duty loction or home port here s well s your brnch of service. You should provide seprte listings to reflect chnges in your militry duty loctions or home ports. Previous Periods of Activity. Complete these lines if you worked for n employer on more thn one occsion t the sme loction. After entering the most recent period of employment in the initil numbered block, provide previous periods of employment t the sme loction on the dditionl lines provided. For exmple, if you worked t XY Plumbing in Denver, CO, during 3 seprte periods of time, you would enter dtes nd informtion concerning the most recent period of employment first, nd provide dtes, position titles, nd supervisors for the two previous periods of employment on the lines below tht informtion. Employer/Verifier Nme/Militry Duty Loction Present Street Address of Job Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Job Loction) Your /Militry Rnk (Block ) Employer/Verifier Nme/Militry Duty Loction Street Address of Job Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Job Loction) Your /Militry Rnk (Block ) Employer/Verifier Nme/Militry Duty Loction Street Address of Job Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Job Loction) Your /Militry Rnk (Block ) Pge 3

6 YOUR EMPLOYMENT ACTIVITIES (CONTINUED) Employer/Verifier Nme/Militry Duty Loction #4 Street Address of Job Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Job Loction) Your /Militry Rnk (Block #4) #5 Employer/Verifier Nme/Militry Duty Loction Street Address of Job Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Job Loction) Your /Militry Rnk (Block #5) #6 Employer/Verifier Nme/Militry Duty Loction Street Address of Job Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Job Loction) Your /Militry Rnk (Block #6) 12 YOUR EMPLOYMENT RECORD Hs ny of the following hppened to you in the lst 7 yers? If "," begin with the most recent occurrence nd go bckwrd, providing dte fired, quit, or left, nd other informtion requested. Use the following codes nd explin the reson your employment ws ended: 1 - Fired from job 2 - Quit job fter being told you d be fired 3 - Left job by mutul greement following llegtions of misconduct 4 - Left job by mutul greement following llegtions of unstisfctory performnce 5 - Left job for other resons under unfvorble circumstnces Specify Reson Employer s Nme nd Address (Include city/country if outside U.S.) Stte ZIP Pge 4

7 13 PEOPLE WHO KNOW YOU WELL List three people who know you well nd live in the United Sttes. They should be good friends, peers, collegues, college roommtes, etc., whose combined ssocition with you covers s well s possible the lst 7 yers. Do not list your spouse, former spouses, or other reltives, nd try not to list nyone who is listed elsewhere on this form. Nme Dtes Known Telephone Number Mo/Yr Mo/Yr Dy Night Home or Work Address Stte ZIP Nme Dtes Known Telephone Number Mo/Yr Mo/Yr Dy Night Home or Work Address Stte ZIP Nme Dtes Known Telephone Number Mo/Yr Mo/Yr Dy Night Home or Work Address Stte ZIP 14 YOUR MARITAL STATUS Mrk one of the following boxes to show your current mritl sttus: 1 - Never mrried (go to question 15) 2 - Mrried 3 - Seprted 4 - Leglly Seprted 5 - Divorced 6 - Widowed Current Spouse Complete the following bout your current spouse. Full Nme Dte of Birth (Mo./Dy/Yr.) Plce of Birth (Include country if outside the U.S.) Socil Security Number Other Nmes Used (Specify miden nme, nmes by other mrriges, etc., nd show dtes used for ech nme) Country of Citizenship Dte Mrried (Mo./Dy/Yr.) Plce Mrried (Include country if outside the U.S.) Stte If Seprted, Dte of Seprtion (Mo./Dy/Yr.) If Leglly Seprted, Where is the Record Locted? Stte Address of Current Spouse (Street, city, nd country if outside the U.S.) Stte ZIP 15 YOUR RELATIVES Give the full nme, correct code, nd other requested informtion for ech of your reltives, living or ded, specified below. 1 - Mother (first) 2 - Fther (second) 3 - Stepmother 4 - Stepfther 5 - Foster Prent 6 - Child (dopted lso) 7 - Stepchild Full Nme (If decesed, check box on the left before entering nme) Dte of Birth Month/Dy/Yer Country of Birth Country(ies) of Citizenship Current Street Address nd City (country) of Living Reltives Stte 1 2 Pge 5

8 16 YOUR MILITARY HISTORY b Hve you served in the United Sttes militry? Hve you served in the United Sttes Merchnt Mrine? List ll of your militry service below, including service in Reserve, Ntionl Gurd, nd U.S. Merchnt Mrine. Strt with the most recent period of service () nd work bckwrd. If you hd brek in service, ech seprte period should be listed.. Use one of the codes listed below to identify your brnch of service: 1 - Air Force 2 - Army 3 - Nvy 4 - Mrine Corps 5 - Cost Gurd 6 - Merchnt Mrine 7 - Ntionl Gurd O/E. Mrk "O" block for Officer or "E" block for Enlisted. Sttus. "X" the pproprite block for the sttus of your service during the time tht you served. If your service ws in the Ntionl Gurd, do not use n "X": use the two-letter code for the stte to mrk the block. Country. If your service ws with other thn the U.S. Armed Forces, identify the country for which you served. Service/Certificte. O E Sttus Active Active Inctive Reserve Reserve Ntionl Gurd (Stte) Country 17 YOUR SELECTIVE SERVICE RECORD b Are you mle born fter December 31, 1959? If "," go to 18. If "," go to b. Hve you registered with the Selective Service System? If "," provide your registrtion number. If "," show the reson for your legl exemption below. Registrtion Number Legl Exemption Explntion 18 YOUR INVESTIGATIONS RECORD Hs the United Sttes Government ever investigted your bckground nd/or grnted you security clernce? If "," use the codes tht follow to provide the requested informtion below. If "," but you cn t recll the investigting gency nd/or the security clernce received, enter "Other" gency code or clernce code, s pproprite, nd "Don t know" or "Don t recll" under the "Other Agency" heding, below. If your response is "," or you don t know or cn t recll if you were investigted nd clered, check the "" box. s for Investigting Agency 1 - Defense Deprtment 2 - Stte Deprtment 3 - Office of Personnel Mngement Agency 4 - FBI 5 - Tresury Deprtment 6 - Other (Specify) Other Agency Clernce s for Security Clernce Received 0 - t Required 1 - Confidentil 2 - Secret 3 - p Secret 4 - Sensitive Comprtmented Informtion 5 - Q Agency Other Agency 6 - L 7 - Other Clernce b your knowledge, hve you ever hd clernce or ccess uthoriztion denied, suspended, or revoked, or hve you ever been debrred from government employment? If "," give dte of ction nd gency. te: An dministrtive downgrde or termintion of security clernce is not revoction. Deprtment or Agency Tking Action Deprtment or Agency Tking Action 19 FOREIGN COUNTRIES YOU HAVE VISITED List foreign countries you hve visited, except on trvel under officil Government orders, beginning with the most current () nd working bck 7 yers. (Trvel s dependent or contrctor must be listed.) Use one of these codes to indicte the purpose of your visit: 1 - Business 2 - Plesure 3 - Eduction 4 - Other Include short trips to Cnd or Mexico. If you hve lived ner border nd hve mde short (one dy or less) trips to the neighboring country, you do not need to list ech trip. Insted, provide the time period, the code, the country, nd note ("Mny Short Trips"). Do not repet trvel covered in items 9, 10, or 11. Country Country #5 #6 #7 #4 #8 Pge 6

9 20 YOUR POLICE RECORD (Do not include nything tht hppened before your 16th birthdy.) In the lst 7 yers, hve you been rrested for, chrged with, or convicted of ny offense(s)? (Leve out trffic fines of less thn $150.) If you nswered "," explin your nswer(s) in the spce provided. Offense Action Tken Lw Enforcement Authority or Court (City nd county/country if outside the U.S.) Stte ZIP 21 ILLEGAL DRUGS The following questions pertin to the illegl use of drugs or drug ctivity. You re required to nswer the questions fully nd truthfully, nd your filure to do so could be grounds for n dverse employment decision or ction ginst you, but neither your truthful responses nor informtion derived from your responses will be used s evidence ginst you in ny subsequent criminl proceeding. In the lst yer, hve you illeglly used ny controlled substnce, for exmple, mrijun, cocine, crck cocine, hshish, nrcotics (opium, morphine, codeine, heroin, etc.), mphetmines, depressnts (brbiturtes, methqulone, trnquilizers, etc.), hllucinogenics (LSD, PCP, etc.), or prescription drugs? b In the lst 7 yers, hve you been involved in the illegl purchse, mnufcture, trfficking, production, trnsfer, shipping, receiving, or sle of ny nrcotic, depressnt, stimulnt, hllucinogen, or cnnbis, for your own intended profit or tht of nother? If you nswered "" to "" bove, provide informtion relting to the types of substnce(s), the nture of the ctivity, nd ny other detils relting to your involvement with illegl drugs. Include ny tretment or counseling received. 22 YOUR FINANCIAL RECORD Controlled Substnce/Prescription Drug Used Number of Times Used In the lst 7 yers, hve you, or compny over which you exercised some control, filed for bnkruptcy, been declred bnkrupt, been subject to tx lien, or hd legl judgment rendered ginst you for debt? If you nswered "," provide dte of initil ction nd other informtion requested below. Type of Action Nme Action Occurred Under Nme/Address of Court or Agency Hndling Cse Stte ZIP b Are you now over 180 dys delinquent on ny lon or finncil obligtion? Include lons or obligtions funded or gurnteed by the Federl Government. If you nswered "," provide the informtion requested below: Type of Lon or Obligtion nd Account # Nme/Address of Creditor or Obligee Stte ZIP After completing this form nd ny ttchments, you should review your nswers to ll questions to mke sure the form is complete nd ccurte, nd then sign nd dte the following certifiction nd sign nd dte the relese on Pge 8. Certifiction Tht My Answers Are True My sttements on this form, nd ny ttchments to it, re true, complete, nd correct to the best of my knowledge nd belief nd re mde in good fith. I understnd tht knowing nd willful flse sttement on this form cn be punished by fine or imprisonment or both. (See section 1001 of title 18, United Sttes ). Signture (Sign in ink) Dte Pge 7

10 Stndrd Form 85P Revised September 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 Form pproved: OMB NSN UNITED STATES AMERICA AUTHORIZATION FOR RELEASE INFORMATION Crefully red this uthoriztion to relese informtion bout you, then sign nd dte it in ink. I Authorize ny investigtor, specil gent, or other duly ccredited representtive of the uthorized Federl gency conducting my bckground investigtion, to obtin ny informtion relting to my ctivities from individuls, schools, residentil mngement gents, employers, criminl justice gencies, credit bureus, consumer reporting gencies, collection gencies, retil business estblishments, or other sources of informtion. This informtion my include, but is not limited to, my cdemic, residentil, chievement, performnce, ttendnce, disciplinry, employment history, criminl history record informtion, nd finncil nd credit informtion. I uthorize the Federl gency conducting my investigtion to disclose the record of my bckground investigtion to the requesting gency for the purpose of mking determintion of suitbility or eligibility for security clernce. I Understnd tht, for finncil or lending institutions, medicl institutions, hospitls, helth cre professionls, nd other sources of informtion, seprte specific relese will be needed, nd I my be contcted for such relese t lter dte. Where seprte relese is requested for informtion relting to mentl helth tretment or counseling, the relese will contin list of the specific questions, relevnt to the job description, which the doctor or therpist will be sked. I Further Authorize ny investigtor, specil gent, or other duly ccredited representtive of the U.S. Office of Personnel Mngement, the Federl Bureu of Investigtion, the Deprtment of Defense, the Defense Investigtive Service, nd ny other uthorized Federl gency, to request criminl record informtion bout me from criminl justice gencies for the purpose of determining my eligibility for ssignment to, or retention in sensitive Ntionl Security position, in ccordnce with 5 U.S.C I understnd tht I my request copy of such records s my be vilble to me under the lw. I Authorize custodins of records nd other sources of informtion pertining to me to relese such informtion upon request of the investigtor, specil gent, or other duly ccredited representtive of ny Federl gency uthorized bove regrdless of ny previous greement to the contrry. I Understnd tht the informtion relesed by records custodins nd sources of informtion is for officil use by the Federl Government only for the purposes provided in this Stndrd Form 85P, nd tht it my be redisclosed by the Government only s uthorized by lw. Copies of this uthoriztion tht show my signture re s vlid s the originl relese signed by me. This uthoriztion is vlid for five (5) yers from the dte signed or upon the termintion of my ffilition with the Federl Government, whichever is sooner. Signture (Sign in ink) Full Nme (Type or Print Legibly) Dte Signed Other Nmes Used Socil Security Number Current Address (Street, City) Stte ZIP Home Telephone Number (Include Are ) Pge 8

11 Stndrd Form 85P Revised September 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 Form pproved: OMB NSN UNITED STATES AMERICA AUTHORIZATION FOR RELEASE MEDICAL INFORMATION Crefully red this uthoriztion to relese informtion bout you, then sign nd dte it in blck ink. Instructions for Completing this Relese This is relese for the investigtor to sk your helth prctitioner(s) the three questions below concerning your mentl helth consulttions. Your signture will llow the prctitioner(s) to nswer only these questions. I m seeking ssignment to or retention in position of public trust with the Federl Government s (n) (Investigtor instructed to write in position title.) As prt of the investigtive process, I hereby uthorize the investigtor, specil gent, or duly ccredited representtive of the uthorized Federl gency conducting my bckground investigtion, to obtin the following informtion relting to my mentl helth consulttions: Does the person under investigtion hve condition or tretment tht could impir his/her judgment or relibility? If so, plese describe the nture of the condition nd the extent nd durtion of the impirment or tretment. Wht is the prognosis? I understnd tht the informtion relesed pursunt to this relese is for use by the Federl Government only for purposes provided in the Stndrd Form 85P nd tht it my be redisclosed by the Government only s uthorized by lw. Copies of this uthoriztion tht show my signture re s vlid s the originl relese signed by me. This uthoriztion is vlid for 1 yer from the dte signed or upon termintion of my ffilition with the Federl Government, whichever is sooner. Signture (Sign in ink) Full Nme (Type or Print Legibly) Dte Signed Other Nmes Used Socil Security Number Current Address (Street, City) Stte ZIP Home Telephone Number (Include Are )