Questionnaire for security vetting of II degree

Transcription

1 RESTRICTED AFTER COMPLETION Questionnaire for security vetting of II degree NOTICE: - Complete the Questionnaire in block letters, in pen only; - Round off the correct answer in case it is offered; - Complete all sections of the Questionnaire; - In sections where you do not have any information, put the following mark: / ; - In case there is not enough space for an answer, use an additional sheet of paper, sign it and enclose it to the Questionnaire; - Unauthorized copying of this Questionnaire after its completion is strictly forbidden.

2 IDENTIFICATION INFORMATION Name Last name Parent's name Personal register number Tax number Former names and last names (if YES, which ones and when have you changed them) Date of birth Place of birth Country of birth Citizenship Do you have dual citizenship? (if YES, which one) Did you have any former citizenship? (if YES, which ones, the reason and date of change or termination) PERMANENT RESIDENCE ADDRESS Current residence address (street, number, city) Permanent residence addresses in the last 10 years (street, number, city and period) TEMPORARY RESIDENCE ADDRESS Current residence address (street, number, city) Temporary residence addresses in the last 10 years (street, number, city and period) TELEPHONE NUMBERS Mobile phone numbers Numbers place of work Numbers place of residence PASSPORT AND PERSONAL ID CARD Passport number Date of issue/expiry Name of the issuing authority

3 Number of personal ID card Date of issue/expiry FOR ACTIVE MILITARY PERSONNEL Personal rank The year when awarded/ promoted EDUCATION INFORMATION Primary school (Name of school, place) Secondary school (Name of school, place, period) University or college (Name of school, place, period) Profession Number and date (degree or diploma) Have you published any expert or scientific work? (if YES, please write down the title, place and date of issue) Do you speak any foreign languages? (if YES, please write down which ones and is your knowledge active or passive) EMPLOYMENT INFORMATION Name of current position/workplace Name and address of current employer Former employments, name of employer Name of workplace/position Duration of employment Reason for employment termination Are you engaged in any part-time job? (if YES, write down which one and its duration) Have there been any disciplinary proceedings initiated against you during last 4 years?

4 (if YES, write down which one and since when) Were there any measures adopted after the completion of disciplinary proceedings? (if YES, which ones and their duration) INFORMATION ON PROPERTY Write down your immovable property (e.g. apartment, house, weekend house, etc.) In case you own any immovable property, write down the name and place where it is located, its worth and the way in which you have gained its ownership. Write down your movable property (e.g. vehicles, boats, art pieces etc.) Do you own a company in the Republic of Croatia or abroad or do you have more than 5% ownership share? (if YES, write down the name and address of the company) Do you own any shares, stocks, bonds etc.? DA NE (if YES, write down in which company and their value) Name the banks in the Republic of Croatia and abroad where you have personal bank accounts (current account, foreignexchange account, transfer account, etc.) Write down the amount of your monthly salary Write down your other income

5 INFORMATION ON PARENTS, BROTHERS, SISTERS AND COHABITANTS Name and last name Kinship Place and date of birth Registered permanent residence Temporary residence Current workplace, name and address of employer CLOSE FAMILY MEMBERS LIVING ABROAD Name and last name City and country Temporary/permanent Employment MARITAL STATUS Are you married; living in common-law marriage; divorced; widower/widow? Name and last name of husband/wife or common-law

6 husband/wife Former names and last names (which ones and when they were changed) Date of birth Place of birth Country of birth Citizenship Do they have dual citizenship? (if YES, which one) Have they had former citizenship? (if YES, which ones, the reason and date of change or termination) Current work place /position Name and address of current employer Immovable property (e.g. apartment, house, weekend house, etc.) Movable property (e.g. vehicles, boats, art pieces etc.) Annual income INFORMATION ON HEALTH Have you ever been or are you currently treated for any mental diseases? (if YES, write down which ones and treatment duration ) Are you addicted to drugs, alcohol, gambling or anything else?

7 (if YES, write down what) INFORMATION ON MINOR AND CRIMINAL OFFENCES Has any criminal proceedings been initiated against you? (if YES, for which criminal offence, at which court and since when) Has any minor offence proceedings been initiated against you? (if YES, for which criminal offence, at which court and since when) Have any court rulings or decisions (final and invalid) been made against you? (if YES, which ruling or decision, for which offence, at which court and when) Place and country of military service Military unit Duration PARTICIPATION IN THE WAR ON INDEPENDENCE Have you participated in the War on Independence? Military unit (if YES, continue completing the section) Duration Reserve rank, year when awarded FOREIGN MILITARY UNITS AND INTERNATIONAL MISSIONS Have you been a member of foreign military units? (if YES, continue completing the section)

8 Country Military unit Duration Have you participated in operations by international military units? (if YES, continue completing the section) NATO, Name and place of operation Superior command Duration EU or UN RESIDENCE ABROAD Have you stayed abroad for more than three (3) months in a row? (if YES, which country, place, time and reason of stay) SECURITY INFORMATION Have you completed security Questionnaire or given security statement in the Republic of Croatia or another country, not in relation with a visa, residence or citizenship? (if YES, which country, time and reason of completion) Have you contacted the members of police, military or security and intelligence services of other countries? Does not refer to official contacts. (if YES, describe the circumstances, nature of contacts, time and place) Have you contacted persons (organizations) threatening or having threatened the security of the Republic of Croatia, other countries or values protected by

9 international law? Does not refer to official contacts. (if YES, describe the circumstances, nature of contacts, time and place) Have you contacted persons (organizations) involved in criminal activities? Does not refer to official contacts. (if YES, describe the circumstances, nature of contacts, time and place) NOTICE (in the following section you may write down the information which you consider relevant for security vetting implementation, or which can confirm what is stated in the Questionnaire) Consent for security vetting of II degree By completing and signing this Questionnaire, I hereby give my consent to the competent security and intelligence agency for checking and processing information stated herein as well as for undertaking procedures stipulated by the law for the implementation of security vetting of II degree. Place and date: Signature:

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