Stndrd Form 86 Revised Septemer 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 Questionnire for Ntionl Security Positions Form pproved: OMB. 3206-0007 NSN 7540-00-634-4036 86-111 Follow instructions fully or we cnnot process your form. Be sure to sign nd dte the certifiction sttement on Pge 9 nd the relese on Pge 10. If you hve ny questions, cll the office tht gve you the form. Purpose of this Form The U.S. Government conducts ckground investigtions nd reinvestigtions to estlish tht militry personnel, pplicnts for or incuments in ntionl security positions, either employed y the Government or working for Government contrctors, licensees, certificte holders, nd grntees, re eligile for required security clernce. Informtion from this form is used primrily s the sis for investigtion for ccess to clssified informtion or specil nucler informtion or mteril. Complete this form only fter conditionl offer of employment hs een mde for position requiring security clernce. Giving us the informtion we sk for is voluntry. However, we my not e le 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 security clernce prospects. Authority to Request this Informtion Depending upon the purpose of your investigtion, the U.S. Government is uthorized to sk for this informtion under Executive Orders 10450, 10865, 12333, nd 12356; sections 3301 nd 9101 of title 5, U.S. ; sections 2165 nd 2201 of title 42, U.S. ; sections 781 to 887 of title 50, U.S. ; nd prts 5, 732, nd 736 of Title 5, of Federl Regultions. Your Socil Security numer is needed to keep records ccurte, ecuse other people my hve the sme nme nd irth dte. Executive Order 9397 lso sks Federl gencies to use this numer to help identify individuls in gency records. The Investigtive Process Bckground investigtions for ntionl security positions re conducted to develop informtion to show whether you re relile, trustworthy, of good conduct nd chrcter, nd loyl to the United s. The informtion tht you provide on this form is confirmed during the investigtion. Investigtion my extend eyond the time covered y this form when necessry to resolve issues. Your current employer must e 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 out person s dherence to security requirements, honesty nd integrity, vulnerility to exploittion or coercion, flsifiction, misrepresenttion, nd ny other ehvior, ctivities, or ssocitions tht tend to show the person is not relile, 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 e conducted s soon s possile fter you re contcted. Postponements will dely the processing of your investigtion, nd declining to e interviewed my result in your investigtion eing delyed or cnceled. You will e sked to ring identifiction with your picture on it, such s vlid driver s license, to the interview. There re other documents you my e sked to ring to verify your identity s well. These include documenttion of ny legl nme chnge, Socil Security crd, nd/or irth certificte. You my lso e sked to ring documents out informtion you provided on the form or other mtters requiring specific ttention. These mtters include lien registrtion, delinquent lons or txes, nkruptcy, judgments, liens, or other finncil oligtions, greements involving child custody or support, limony or property settlements, rrests, convictions, protion, nd/or prole. Orgniztion of this Form This form hs two prts. Prt 1 sks for ckground informtion, including where you hve lived, gone to school, nd worked. Prt 2 sks out your ctivities nd such mtters s firings from jo, criminl history record, use of illegl drugs, nd use of lcohol. In nswering ll questions on this form, keep in mind tht your nswers re considered together with the informtion otined in the investigtion to rech n pproprite djudiction. Instructions for Completing this Form 1. Follow the instructions given to you y the person who gve you the form nd ny other clrifying instructions furnished y 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 lck ink, the originl nd ech copy you sumit. You should retin copy of the completed form for your records. 2. Type or legily print your nswers in lck ink (if your form is not legile, it will not e ccepted). You my lso e sked to sumit your form in n pproved electronic formt. 3. All questions on this form must e nswered. If no response is necessry or pplicle, 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 est of your ility nd indicte this y mrking "APPROX." or "EST." 4. Any chnges tht you mke to this form fter you sign it must e initiled nd dted y you. Under certin limited circumstnces, gencies my modify the form consistent with your intent. 5. You must use the codes (revitions) listed on the ck of this pge when you fill out this form. Do not revite 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 numers must include re codes. 8. All dtes provided on this form must e in Month/Dy/Yer or formt. Use numers (1-12) to indicte months. For exmple, June 8, 1978, should e shown s 6/8/78. 9. Whenever "" is shown in n ddress lock, lso provide in tht lock the nme of the country when the ddress is outside the United s. 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 lnk piece of pper. Ech lnk piece of pper you use must contin your nme nd Socil Security Numer t the top of the pge.
Finl Determintion on Your Eligiility Finl determintion on your eligiility for ccess to clssified informtion is the responsiility of the Federl gency tht requested your investigtion. You my e provided the opportunity personlly to explin, refute, or clrify ny informtion efore finl decision is mde. Penlties for Inccurte or Flse ments 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 oth. In ddition, Federl gencies generlly fire, do not grnt security clernce, or disqulify individuls who hve mterilly nd deliertely flsified these forms, nd this remins prt of the permnent record for future plcements. Becuse the position for which you re eing considered is sensitive one, your trustworthiness is very importnt considertion in deciding your eligiility for security clernce. Your prospects of plcement or security clernce re etter 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 ntionl security position; we will protect it from unuthorized disclosure. The collection, mintennce, nd disclosure of ckground investigtive informtion is governed y the Privcy Act. The gency which requested the investigtion nd the gency which conducted the investigtion hve pulished notices in the Federl Register descriing the systems of records in which your records will e mintined. You my otin 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 e disclosed without your consent s permitted y the Privcy Act (5 USC 552()) nd s follows: PRIVACY ACT ROUTINE USES 1. the Deprtment of Justice when: () the gency or ny component thereof; or () 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 s Government, is prty to litigtion or hs interest in such litigtion, nd y creful review, the gency determines tht the records re oth relevnt nd necessry to the litigtion nd the use of such records y the Deprtment of Justice is therefore deemed y the gency to e for purpose tht is comptile with the purpose for which the gency collected the records. 2. court or djudictive ody in proceeding when: () the gency or ny component thereof; or () 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 s Government, is prty to litigtion or hs interest in such litigtion, nd y creful review, the gency determines tht the records re oth relevnt nd necessry to the litigtion nd the use of such records is therefore deemed y the gency to e for purpose tht is comptile with the purpose for which the gency collected the records. 3. Except s noted in Question 24, 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 y generl sttute, prticulr progrm sttute, regultion, rule, or order issued pursunt thereto, the relevnt records my e disclosed to the pproprite Federl, foreign,, locl, tril, or other pulic uthority responsile 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 enefit, 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,, locl, foreign, tril, or other pulic 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 enefit. The other gency or licensing orgniztion my then mke request supported y written consent of the individul for the entire record if it so chooses. disclosure will e mde unless the informtion hs een determined to e sufficiently relile 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 een engged. Such recipients shll e required to comply with the Privcy Act of 1974, s mended. 7. the news medi or the generl pulic, fctul informtion the disclosure of which would e in the pulic interest nd which would not constitute n unwrrnted invsion of personl privcy. 8. Federl,, or locl gency, or other pproprite entities or individuls, or through estlished liison chnnels to selected foreign governments, in order to enle n intelligence gency to crry out its responsiilities under the Ntionl Security Act of 1947 s mended, the CIA Act of 1949 s mended, Executive Order 12333 or ny successor order, pplicle ntionl security directives, or clssified implementing procedures pproved y the Attorney Generl nd promulgted pursunt to such sttutes, orders or directives. 9. Memer of Congress or to Congressionl stff memer in response to n inquiry of the Congressionl office mde t the written request of the constituent out whom the record is mintined. 10. the Ntionl Archives nd Records Administrtion for records mngement inspections conducted under 44 USC 2904 nd 2906. 11. the Office of Mngement nd Budget when necessry to the review of privte relief legisltion. STATE CODES (ABBREVIATIONS) Alm 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 Nersk 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 Dist. of Columi Virgin Islnds DC VI Gum GU PUBLIC BURDEN INFORMATION rthern Mrins CM Puerto Rico PR Pulic urden reporting for this collection of informtion is estimted to verge 90 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 urden estimte or ny other spect of this collection of informtion, including suggestions for reducing this urden to Reports nd Forms Mngement Officer, U.S. Office of Personnel Mngement, 1900 E Street, N.W., Room CHP-500, Wshington, D.C. 20415. Do not send your completed form to this ddress.
Stndrd Form 86 (EG) Revised Septemer 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 Prt 1 A G Type of Investigtion Geogrphic Loction J SON L SOI N OPAC-ALC Numer Extr Coverge QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Investigting Agency Use Only s Cse Numer Agency Use Only (Complete items A through P using instructions provided y the Investigting gency). B C D Access E Nture of Dte of H Position O Sensitivity Level ne Other Address NPRC At SON ne Other Address At SOI NPI Accounting Dt nd/or Agency Cse Numer Form pproved: OMB. 3206-0007 NSN 7540-00-634-4036 86-111 F Month Dy Yer Action P Requesting Nme nd Title Signture Dte Officil 1 FULL NAME K M Loction of Officil Personnel Folder Loction of Security Folder I Position Title Persons completing this form should egin with the questions elow. If you hve only initils in your nme, use them nd stte (IO). If you hve no middle nme, enter "NMN". If you re "Jr.," "Sr.," "II," etc., enter this in the ox fter your middle nme. Lst Nme First Nme Middle Nme Jr., II, etc. Action 2 DATE OF BIRTH Month Dy Yer 3 PLACE OF BIRTH - Use the two letter code for the. City County Country (if not in the United s) 4 SOCIAL SECURITY 5 OTHER NAMES USED Give other nmes you used nd the period of time you used them (for exmple: your miden nme, nme(s) y former mrrige, former nme(s), lis(es), or nicknme(s)). If the other nme is your miden nme, put "nee" in front of it. Nme Nme #3 Nme Nme #4 6 OTHER IDENTIFYING Height (feet nd inches) Weight (pounds) Hir Color Eye Color Sex (Mrk one ox) INFORMATION Femle Mle 7 TELEPHONE NUMBERS Work (Include Are nd extension) Dy Night Home (Include Are ) Dy Night Your Mother s Miden Nme 8 CITIZENSHIP Mrk the ox t the right tht reflects your current citizenship sttus, nd follow its instructions. I m U.S. citizen or ntionl y irth in the U.S. or U.S. territory/possession. (Answer items nd d) I m U.S. citizen, ut I ws NOT orn in the U.S. (Answer items, c nd d) I m not U.S. citizen. (Answer items nd e) c UNITED STATES CITIZENSHIP If you re U.S. citizen, ut were not orn in the U.S., provide informtion out one or more of the following proofs of your citizenship. Nturliztion Certificte (Where were you nturlized?) Court City Certificte Numer Month/Dy/Yer Issued Citizenship Certificte (Where ws the certificte issued?) City Certificte Numer Month/Dy/Yer Issued Deprtment Form 240 - Report of Birth Arod of Citizen of the United s Give the dte the form ws Month/Dy/Yer Explntion prepred nd give n explntion if needed. U.S. Pssport This my e either current or previous U.S. Pssport. Pssport Numer Month/Dy/Yer Issued d e DUAL CITIZENSHIP If you re (or were) dul citizen of the United s 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 s: City Dte You Entered U.S. Month Dy Yer Exception to SF85, SF85P, SF85P-S, SF86, nd SF86A pproved y GSA Septemer, 1995. Designed using Perform Pro, WHS/DIOR, Sep 95 Country Alien Registrtion Numer Country(ies) of Citizenship Pge 1
9 WHERE YOU HAVE LIVED List the plces where you hve lived, eginning with the most recent () nd working ck 7 yers. All periods must e ccounted for in your list. Be sure to indicte the ctul physicl loction of your residence: do not use post office ox 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 possile: for exmple, do not list only your se or ship, list your rrcks numer 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 preferly 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 five yers, if the ddress is "Generl Delivery," Rurl or Str Route, or my e 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 #3 Nme of Person Who Knew You #4 Nme of Person Who Knew You #5 Nme of Person Who Knew You Street Address Apt. # Street Address Apt. # Street Address Apt. # Street Address Apt. # Street Address Apt. # Street Address Apt. # Street Address Apt. # Street Address Apt. # Street Address Apt. # Street Address Apt. # 10 WHERE YOU WENT TO SCHOOL List the schools you hve ttended, eyond Junior High School, eginning with the most recent () nd working ck 7 yers. List 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 eyond high school, no mtter when tht eduction occurred. Use one of the following codes in the "" lock: 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 Nme of Person Who Knew You Street Address Apt. # Nme of School Degree/Diplom/Other Awrded Street Address nd of School Nme of Person Who Knew You Street Address Apt. # Nme of School Degree/Diplom/Other Awrded #3 Street Address nd of School Nme of Person Who Knew You Street Address Apt. # Enter your Socil Security Numer efore going to the next pge Pge 2
11 YOUR EMPLOYMENT ACTIVITIES List your employment ctivities, eginning with the present () nd working ck 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 e ccounted for without reks, ut you need not list employments efore your 16th irthdy. EXCEPTION: Show ll Federl civilin service, whether it occurred within the lst 7 yers or not.. Use one of the codes listed elow 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 - Government (n-federl employment) 6 - Self-employment (Include usiness nme 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 usiness nme of your employer or the nme of the person who cn verify your self-employment or unemployment in this lock. If militry service is eing listed, include your duty loction or home port here s well s your rnch 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 numered lock, provide previous periods of employment t the sme loction on the dditionl lines provided. For exmple, if you worked t XY Pluming 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 elow tht informtion. Employer/Verifier Nme/Militry Duty Loction Present Employer s/verifier s Street Address Street Address of Jo Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Jo Loction) Your /Militry Rnk PREVIOUS PERIODS OF ACTIVITY (Block ) Employer/Verifier Nme/Militry Duty Loction Employer s/verifier s Street Address Street Address of Jo Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Jo Loction) Your /Militry Rnk PREVIOUS PERIODS OF ACTIVITY (Block ) #3 Employer/Verifier Nme/Militry Duty Loction Employer s/verifier s Street Address Street Address of Jo Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Jo Loction) Your /Militry Rnk PREVIOUS PERIODS OF ACTIVITY (Block #3) Enter your Socil Security Numer efore going to the next pge Pge 3
YOUR EMPLOYMENT ACTIVITIES (CONTINUED) Employer/Verifier Nme/Militry Duty Loction #4 Employer s/verifier s Street Address Street Address of Jo Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Jo Loction) PREVIOUS PERIODS OF ACTIVITY (Block #4) #5 PREVIOUS PERIODS OF ACTIVITY (Block #5) #6 PREVIOUS PERIODS OF ACTIVITY (Block #6) Employer s/verifier s Street Address Street Address of Jo Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Jo Loction) Employer s/verifier s Street Address Employer/Verifier Nme/Militry Duty Loction Street Address of Jo Loction (if different thn Employer s Address) s Nme & Street Address (if different thn Jo Loction) Employer/Verifier Nme/Militry Duty Loction Your /Militry Rnk Your /Militry Rnk Your /Militry Rnk ( ) ( ) ( 12 PEOPLE WHO KNOW YOU WELL List three people who know you well nd live in the United s. They should e good friends, peers, collegues, college roommtes, etc., whose comined ssocition with you covers s well s possile 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 Dy Night Home or Work Address ) Nme Dtes Known Dy Night Home or Work Address Nme Dtes Known Dy #3 Night Home or Work Address Enter your Socil Security Numer efore going to the next pge Pge 4
13 YOUR SPOUSE Mrk one ox to show your current mritl sttus nd provide informtion out your spouse(s) in items. nd/or. 1 - Never mrried 2 - Mrried 3 - Seprted 4 - Leglly Seprted 5 - Divorced 6 - Widowed Current Spouse Complete the following out your current spouse only. Full Nme Dte of Birth Plce of Birth (Include country if outside the U.S.) Socil Security Numer Other Nmes Used (Specify miden nme, nmes y other mrriges, etc., nd show dtes used for ech nme) Country(ies) of Citizenship Dte Mrried Plce Mrried (Include country if outside the U.S.) If Seprted, Dte of Seprtion If Leglly Seprted, Where is the Record Locted? Address of Current Spouse, if different thn your current ddress (Street, city, nd country if outside the U.S.) Former Spouse(s). Complete the following out your former spouse(s), use lnk sheets if needed. Full Nme Dte of Birth Plce of Birth (Include country if outside the U.S.) Country(ies) of Citizenship Dte Mrried Plce Mrried (Include country if outside the U.S.) Check one, Then Give Dte Month/Dy/Yer If Divorced, Where is the Record Locted? Divorced Widowed Address of Former Spouse (Street, city, nd country if outside the U.S.) 14 YOUR RELATIVES AND ASSOCIATES Give the full nme, correct code, nd other requested informtion for ech of your reltives nd ssocites, living or ded, specified elow. 1 - Mother (first) 2 - Fther (second) 3 - Stepmother 4 - Stepfther 5 - Foster prent 6 - Child (dopted lso) 7 - Stepchild 8 - Brother 9 - Sister 10 - Steprother 11 - Stepsister 12 - Hlf-rother 13 - Hlf-sister 14 - Fther-in-lw 15 - Mother-in-lw 16 - Gurdin 17 - Other Reltive* 18 - Associte* 19 - Adult Currently Living With You * 17 (Other Reltive) - include only foreign ntionl reltives not listed in 1-16 with whom you or your spouse re ound y ffection, oligtion, or close nd continuing contct. 18 (Assocites) - include only foreign ntionl ssocites with whom you or your spouse re ound y ffection, oligtion, or close nd continuing contct. Full Nme (If decesed, check ox on the left efore entering nme) Dte of Birth Month/Dy/Yer Country of Birth Country(ies) of Citizenship Current Street Address nd City (country) of Living Reltives 1 2 Enter your Socil Security Numer efore going to the next pge Pge 5
15 CITIZENSHIP OF YOUR RELATIVES AND ASSOCIATES If your mother, fther, sister, rother, child, or current spouse or person with whom you hve spouse-like reltionship is U.S. citizen y other thn irth, or n lien residing in the U.S., provide the nture of the individul s reltionship to you (Spouse, Spouse-like, Mother, etc.), nd the individul s nme nd dte of irth on the first line (this informtion is needed to pir it ccurtely with informtion in items 13 nd 14). On the second line, provide the individul s nturliztion certificte or lien registrtion numer nd use one of the document codes elow to identify proof of citizenship sttus. Provide dditionl informtion on tht line s requested. 1 - Nturliztion Certificte: Provide the dte issued nd the loction where the person ws nturlized (Court, City nd ). 2 - Citizenship Certificte: Provide the dte nd loction issued (City nd ). 3 - Alien Registrtion: Provide the dte nd plce where the person entered the U.S. (City nd ). 4 - Other: Provide n explntion in the "Additionl Informtion" lock. Assocition Nme Dte of Birth (Month/Dy/Yer) Certificte/Registrtion # Document Additionl Informtion Assocition Nme Dte of Birth (Month/Dy/Yer) Certificte/Registrtion # Document Additionl Informtion 16 YOUR MILITARY HISTORY Hve you served in the United s militry? Hve you served in the United s Merchnt Mrine? List ll of your militry service elow, including service in Reserve, Ntionl Gurd, nd U.S. Merchnt Mrine. Strt with the most recent period of service () nd work ckwrd. If you hd rek in service, ech seprte period should e listed.. Use one of the codes listed elow to identify your rnch 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" lock for Officer or "E" lock for Enlisted. Sttus. "X" the pproprite lock 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 lock. 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 () Country 17 YOUR FOREIGN ACTIVITIES c d Do you hve ny foreign property, usiness connections, or finncil interests? Are you now or hve you ever een employed y or cted s consultnt for foreign government, firm, or gency? Hve you ever hd ny contct with foreign government, its estlishments (emssies or consultes), or its representtives, whether inside or outside the U.S., other thn on officil U.S. Government usiness? (Does not include routine vis pplictions nd order crossing contcts.) In the lst 7 yers, hve you hd n ctive pssport tht ws issued y foreign government? If you nswered "" to,, c, or d ove, explin in the spce elow: provide inclusive dtes, nmes of firms nd/or governments involved, nd n explntion of your involvement. Firm nd/or Government Explntion 18 FOREIGN COUNTRIES YOU HAVE VISITED List foreign countries you hve visited, except on trvel under officil Government orders, eginning with the most current () nd working ck 7 yers. (Trvel s dependent or contrctor must e 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 order nd hve mde short (one dy or less) trips to the neighoring 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 #3 #4 This concludes Prt 1 of this form. If you hve used Pge 9, continution sheets, or lnk sheets to complete ny of the questions in Prt 1, give the numer for those questions in the spce to the right: Enter your Socil Security Numer efore going to the next pge Pge 6
Stndrd Form 86 Revised Septemer 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 OFFICIAL Prt 2 USE ONLY 19 YOUR MILITARY RECORD QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Form pproved: OMB. 3206-0007 NSN 7540-00-634-4036 86-111 Hve you ever received other thn n honorle dischrge from the militry? If "," provide the dte of dischrge nd type of dischrge elow. Type of Dischrge 20 YOUR SELECTIVE SERVICE RECORD Are you mle orn fter Decemer 31, 1959? If "," go to 21. If "," go to. Hve you registered with the Selective Service System? If "," provide your registrtion numer. If "," show the reson for your legl exemption elow. Registrtion Numer Legl Exemption Explntion 21 YOUR MEDICAL RECORD In the lst 7 yers, hve you consulted with mentl helth professionl (psychitrist, psychologist, counselor, etc.) or hve you consulted with nother helth cre provider out mentl helth relted condition? If you nswered "," provide the dtes of tretment nd the nme nd ddress of the therpist or doctor elow, unless the consulttion(s) involved only mritl, fmily, or grief counseling, not relted to violence y you. Nme/Address of Therpist or Doctor 22 YOUR EMPLOYMENT RECORD Hs ny of the following hppened to you in the lst 7 yers? If "," egin with the most recent occurrence nd go ckwrd, 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 jo 2 - Quit jo fter eing told you d e fired 3 - Left jo y mutul greement following llegtions of misconduct 4 - Left jo y mutul greement following llegtions of unstisfctory performnce 5 - Left jo for other resons under unfvorle circumstnces Specify Reson Employer s Nme nd Address (Include city/country if outside U.S.) 23 YOUR POLICE RECORD For this item, report informtion regrdless of whether the record in your cse hs een "seled" or otherwise stricken from the court record. The single exception to this requirement is for certin convictions under the Federl Controlled Sustnces Act for which the court issued n expungement order under the uthority of 21 U.S.C. 844 or 18 U.S.C. 3607. c d e f Hve you ever een chrged with or convicted of ny felony offense? (Include those under Uniform of Militry Justice) Hve you ever een chrged with or convicted of firerms or explosives offense? Are there currently ny chrges pending ginst you for ny criminl offense? Hve you ever een chrged with or convicted of ny offense(s) relted to lcohol or drugs? In the lst 7 yers, hve you een suject to court mrtil or other disciplinry proceedings under the Uniform of Militry Justice? (Include non-judicil, Cptin s mst, etc.) In the lst 7 yers, hve you een rrested for, chrged with, or convicted of ny offense(s) not listed in response to,, c, d, or e ove? (Leve out trffic fines of less thn $150 unless the violtion ws lcohol or drug relted.) If you nswered "" to,, c, d, e, or f ove, explin elow. Under "Offense," do not list specific penlty codes, list the ctul offense or violtion (for exmple, rson, theft, etc.). Offense Action Tken Lw Enforcement Authority/Court (Include City nd county/country if outside U.S.) Enter your Socil Security Numer efore going to the next pge Pge 7
24 YOUR USE OF ILLEGAL DRUGS AND DRUG ACTIVITY 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 e grounds for n dverse employment decision or ction ginst you, ut neither your truthful responses nor informtion derived from your responses will e used s evidence ginst you in ny susequent criminl proceeding. Since the ge of 16 or in the lst 7 yers, whichever is shorter, hve you illeglly used ny controlled sustnce, for exmple, mrijun, cocine, crck cocine, hshish, nrcotics (opium, morphine, codeine, heroin, etc.), mphetmines, depressnts (riturtes, methqulone, trnquilizers, etc.), hllucinogenics (LSD, PCP, etc.), or prescription drugs? Hve you ever illeglly used controlled sustnce while employed s lw enforcement officer, prosecutor, or courtroom officil; while possessing security clernce; or while in position directly nd immeditely ffecting the pulic sfety? c In the lst 7 yers, hve you een involved in the illegl purchse, mnufcture, trfficking, production, trnsfer, shipping, receiving, or sle of ny nrcotic, depressnt, stimulnt, hllucinogen, or cnnis for your own intended profit or tht of nother? If you nswered "" to or ove, provide the dte(s), identify the controlled sustnce(s) nd/or prescription drugs used, nd the numer of times ech ws used. Controlled Sustnce/Prescription Drug Used Numer of Times Used 25 YOUR USE OF ALCOHOL In the lst 7 yers, hs your use of lcoholic everges (such s liquor, eer, wine) resulted in ny lcohol-relted tretment or counseling (such s for lcohol use or lcoholism)? If you nswered "," provide the dtes of tretment nd the nme nd ddress of the counselor or doctor elow. Do not repet informtion reported in response to item 21 ove. Nme/Address of Counselor or Doctor 26 YOUR INVESTIGATIONS RECORD Hs the United s Government ever investigted your ckground nd/or grnted you security clernce? If "," use the codes tht follow to provide the requested informtion elow. If "," ut 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, elow. If your response is "," or you don t know or cn t recll if you were investigted nd clered, check the "" ox. s for Investigting Agency 1 - Defense Deprtment 2 - 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 your knowledge, hve you ever hd clernce or ccess uthoriztion denied, suspended, or revoked, or hve you ever een derred 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 27 YOUR FINANCIAL RECORD In the lst 7 yers, hve you filed petition under ny chpter of the nkruptcy code (to include Chpter 13)? In the lst 7 yers, hve you hd your wges grnished or hd ny property repossessed for ny reson? c In the lst 7 yers, hve you hd lien plced ginst your property for filing to py txes or other dets? d In the lst 7 yers, hve you hd ny judgments ginst you tht hve not een pid? If you nswered "" to,, c, or d, provide the informtion requested elow: Type of Action Amount Nme Action Occurred Under Nme/Address of Court or Agency Hndling Cse Enter your Socil Security Numer efore going to the next pge Pge 8
YOUR FINANCIAL DELINQUENCIES 28 In the lst 7 yers, hve you een over 180 dys delinquent on ny det(s)? Are you currently over 90 dys delinquent on ny det(s)? If you nswered "" to or, provide the informtion requested elow: Incurred Stisfied Amount Type of Lon or Oligtion nd Account Numer Nme/Address of Creditor or Oligee 29 PUBLIC RECORD CIVIL COURT ACTIONS In the lst 7 yers, hve you een prty to ny pulic record civil court ctions not listed elsewhere on this form? If you nswered "," provide the informtion out the pulic record civil court ction requested elow. Nture of Action Result of Action Nme of Prties Involved Court (Include City nd county/country if outside U.S.) 30 YOUR ASSOCIATION RECORD Hve you ever een n officer or memer or mde contriution to n orgniztion dedicted to the violent overthrow of the United s Government nd which engges in illegl ctivities to tht end, knowing tht the orgniztion engges in such ctivities with the specific intent to further such ctivities? Hve you ever knowingly engged in ny cts or ctivities designed to overthrow the United s Government y force? If you nswered "" to or, explin in the spce elow. Continution Spce Use the continution sheet(s) (SF86A) for dditionl nswers to items 9, 10, nd 11. Use the spce elow to continue nswers to ll other items nd ny informtion you would like to dd. If more spce is needed thn is provided elow, use lnk sheet(s) of pper. Strt ech sheet with your nme nd Socil Security Numer. Before ech nswer, identify the numer of the item. After completing Prts 1 nd 2 of 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 10. Certifiction Tht My Answers Are True My sttements on this form, nd ny ttchments to it, re true, complete, nd correct to the est of my knowledge nd elief nd re mde in good fith. I understnd tht knowing nd willful flse sttement on this form cn e punished y fine or imprisonment or oth. (See section 1001 of title 18, United s ). Signture (Sign in ink) Dte Enter your Socil Security Numer efore going to the next pge Pge 9
Stndrd Form 86 Revised Septemer 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 Form pproved: OMB. 3206-0007 NSN 7540-00-634-4036 86-111 UNITED STATES OF AMERICA AUTHORIZATION FOR RELEASE OF INFORMATION Crefully red this uthoriztion to relese informtion out 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 ckground investigtion, to otin ny informtion relting to my ctivities from individuls, schools, residentil mngement gents, employers, criminl justice gencies, credit ureus, consumer reporting gencies, collection gencies, retil usiness estlishments, or other sources of informtion. This informtion my include, ut 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 ckground investigtion to the requesting gency for the purpose of mking determintion of suitility or eligiility 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 e needed, nd I my e 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 jo description, which the doctor or therpist will e 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 out me from criminl justice gencies for the purpose of determining my eligiility for ccess to clssified informtion nd/or for ssignment to, or retention in sensitive Ntionl Security position, in ccordnce with 5 U.S.C. 9101. I understnd tht I my request copy of such records s my e ville to me under the lw. I Authorize custodins of records nd 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 ove regrdless of ny previous greement to the contrry. I Understnd tht the informtion relesed y records custodins nd sources of informtion is for officil use y the Federl Government only for the purposes provided in this Stndrd Form 86, nd tht it my e redisclosed y the Government only s uthorized y lw. Copies of this uthoriztion tht show my signture re s vlid s the originl relese signed y 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. Red, sign nd dte the relese on the next pge if you nswered "" to question 21. Signture (Sign in ink) Full Nme (Type or Print Legily) Dte Signed Other Nmes Used Socil Security Numer Current Address (Street, City) Home (Include Are ) Pge 10
Stndrd Form 86 Revised Septemer 1995 U.S. Office of Personnel Mngement 5 CFR Prts 731, 732, nd 736 Form pproved: OMB. 3206-0007 NSN 7540-00-634-4036 86-111 UNITED STATES OF AMERICA AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Crefully red this uthoriztion to relese informtion out you, then sign nd dte it in ink. Instructions for Completing this Relese This is relese for the investigtor to sk your helth prctitioner(s) the three questions elow 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 with the Federl government which requires ccess to clssified ntionl security informtion or specil nucler informtion or mteril. As prt of the clernce process, I herey uthorize the investigtor, specil gent, or duly ccredited representtive of the uthorized Federl gency conducting my ckground investigtion, to otin 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 reliility, prticulrly in the context of sfegurding clssified ntionl security informtion or specil nucler informtion or mteril? If so, plese descrie the nture of the condition nd the extent nd durtion of the impirment or tretment. Wht is the prognosis? I understnd the informtion relesed pursunt to this relese is for use y the Federl Government only for purposes provided in the Stndrd Form 86 nd tht it my e redisclosed y the Government only s uthorized y lw. Copies of this uthoriztion tht show my signture re s vlid s the originl relese signed y 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 Legily) Dte Signed Other Nmes Used Socil Security Numer Current Address (Street, City) Home (Include Are )