The document is a security release from Mission Essential Personnel, LLC regarding the protection of classified information. It states that employees must complete security form SF-86 jointly with a designated security employee to ensure all necessary information is provided and omitted information. It also notes that Mission Essential Personnel will maintain the confidentiality of the documents and destroy them once an applicant's eligibility is granted or denied. The employee must sign acknowledging they understand the security measures and allowing Mission Essential Personnel to review, store, and destroy their personal security information.
The document is a security release from Mission Essential Personnel, LLC regarding the protection of classified information. It states that employees must complete security form SF-86 jointly with a designated security employee to ensure all necessary information is provided and omitted information. It also notes that Mission Essential Personnel will maintain the confidentiality of the documents and destroy them once an applicant's eligibility is granted or denied. The employee must sign acknowledging they understand the security measures and allowing Mission Essential Personnel to review, store, and destroy their personal security information.
The document is a security release from Mission Essential Personnel, LLC regarding the protection of classified information. It states that employees must complete security form SF-86 jointly with a designated security employee to ensure all necessary information is provided and omitted information. It also notes that Mission Essential Personnel will maintain the confidentiality of the documents and destroy them once an applicant's eligibility is granted or denied. The employee must sign acknowledging they understand the security measures and allowing Mission Essential Personnel to review, store, and destroy their personal security information.
The document is a security release from Mission Essential Personnel, LLC regarding the protection of classified information. It states that employees must complete security form SF-86 jointly with a designated security employee to ensure all necessary information is provided and omitted information. It also notes that Mission Essential Personnel will maintain the confidentiality of the documents and destroy them once an applicant's eligibility is granted or denied. The employee must sign acknowledging they understand the security measures and allowing Mission Essential Personnel to review, store, and destroy their personal security information.
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The document discusses security procedures for reviewing and storing an employee's personal information as part of a security clearance process.
An employee's SF-86 form will be jointly completed and reviewed by the employee and a designated security employee from the company. The company will store then destroy the retained documentation.
When eligibility is granted or denied, the retained documentation shall be destroyed.
SECURITY RELEASE
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er Lhe naLlonal lndusLrlal SecurlLy rogram CperaLlng Manuel (nlSCM) ulrecLlve 2-202 (rocedures for CompleLlng Lhe Sl 86), Lhe Sl 86 shall be compleLed [olnLly by Lhe employee and Lhe lSC or an equlvalenL Mlsslon LssenLlal ersonnel, LLC securlLy employee(s) who has been speclflcally deslgnaLed by Mlsslon LssenLlal ersonnel, LLC Lo revlew an employee's Sl 86. 1he Sl 86 ls sub[ecL Lo revlew and a Mlsslon LssenLlal ersonnel, LLC securlLy employee shall revlew Lhe appllcaLlon solely Lo deLermlne lLs adequacy and Lo ensure LhaL necessary lnformaLlon has noL been omlLLed.
Mlsslon LssenLlal ersonnel, LLC shall malnLaln Lhe reLalned documenLaLlon ln such a manner LhaL Lhe confldenLlallLy of Lhe documenLs ls preserved and proLecLed agalnsL access by anyone wlLhln Lhe company oLher Lhan Lhe lSC or securlLy deslgnees'. When Lhe appllcanL's ellglblllLy for access Lo classlfled lnformaLlon has been granLed or denled, Lhe reLalned documenLaLlon shall be desLroyed.
8y slgnlng below, l acknowledge Lhe securlLy lnformaLlon proLecLlon measures ouLllned ln Lhls memorandum and glve Mlsslon LssenLlal ersonnel, LLC permlsslon Lo revlew, sLore and desLroy my personal securlLy lnformaLlon ouLllned above.
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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)]. f you have only initials in your name(s), provide them and indicate "nitial only." f you do not have a middle name (s), indicate "No Middle Name" (NMN). f 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. f you have only initials in your name, provide them and indicate "nitial only". f you do not have a middle name, indicate "No Middle Name". f you are a "Jr.," "Sr.," etc. enter this under Suffix. Enter your SociaI Security Number before going to the next page Middle name First name Last name Provide the reason(s) why the name changed #1 From (Month/Year) To (Month/Year) Maiden name? NO YES Suffix Est. Est. Present Section 5 - Other Names Used Section 3 - PIace of Birth I have read the instructions and I understand that if I withhoId, misrepresent, or faIsify information on this form, I am subject to the penaIties for inaccurate or faIse statement (per U. S. CriminaI Code, TitIe 18, section 1001), deniaI or revocation of a security cIearance, and/or removaI and debarment from FederaI 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 Country (Required) State YES NO (If NO, proceed to Section 6) Have you used any other names? Not applicable Provide your U.S. Social Security Number. Section 4 - SociaI Security Number Male Female Sex 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 - FuII Name Provide your date of birth. (Month/Day/Year) Complete the following if you have responded 'Yes' to having used other names. Middle name First name Last name Provide the reason(s) why the name changed #2 From (Month/Year) To (Month/Year) Maiden name? NO YES Suffix Est. Est. Present Middle name First name Last name Provide the reason(s) why the name changed #3 From (Month/Year) To (Month/Year) Maiden name? NO YES Suffix Est. Est. Present Middle name First name Last name Provide the reason(s) why the name changed #4 From (Month/Year) To (Month/Year) Maiden name? NO YES Suffix Est. Est. Present 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. Middle name Last name First 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.) Country State City Provide the name in which document was issued. Middle name Last name First name Suffix Provide the address of the court that issued the citizenship certificate. Provide the name in which the certificate was issued. Middle name Last name First 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: OMB No. 3206 0005
QUESTIONNAIRE FOR 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. State City Street Zip Code Provide the name of the base. Provide the address of the court that issued the naturalization certificate. State City Provide the name in which the naturalization certificate was issued. Middle name Last name First 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. Middle name Last name First name Suffix Provide the expiration date of visa. Provide document number. Est. Provide the basis of naturalization. By operation of law through my U.S. citizen parent Other Based on my own individual naturalization application 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. State City Provide the name in which the citizenship certificate was issued. Middle name Last name First name Suffix Street Zip Code (Month/Day/Year) (Month/Day/Year) (Month/Day/Year) Est. Provide the date of entry into the U.S. State City 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. State City 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
Section 10 - Dual/Multiple Citizenship & Foreign Passport Information 10.1 Do you now or have you EVER held dual/multiple citizenships? NO (If NO, proceed to 10.2) YES 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? NO YES Provide explanation: Do you currently hold citizenship with this country? NO YES 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: Provide explanation: YES NO 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.? NO (If NO, proceed to Section 11) YES 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? NO YES 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 Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Daytime telephone number Extension Cell/mobile telephone number Extension Provide the following contact information for this person. International or DSN phone number International or DSN phone number 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. Middle name Last name First 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 Does the person who knew you have an APO/FPO address? (b) YES NO Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Daytime telephone number Extension Cell/mobile telephone number Extension Provide the following contact information for this person. International or DSN phone number International or DSN phone number 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. Middle name Last name First 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 Does the person who knew you have an APO/FPO address? (b) YES NO Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Daytime telephone number Extension Cell/mobile telephone number Extension Provide the following contact information for this person. International or DSN phone number International or DSN phone number 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. Middle name Last name First 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 Does the person who knew you have an APO/FPO address? (b) YES NO Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Daytime telephone number Extension Cell/mobile telephone number Extension Provide the following contact information for this person. International or DSN phone number International or DSN phone number 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. Middle name Last name First 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 Does the person who knew you have an APO/FPO address? (b) YES NO Owned by you Military housing Rented or leased by you Other Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Section 11 - Where You Have Lived - (Continued) Entry #5 Evening telephone number Extension nternational or DSN phone number Daytime telephone number Extension Cell/mobile telephone number Extension Provide the following contact information for this person. nternational or DSN phone number nternational or DSN phone number Provide dates of residence. From Date Est. To Date Present Est. s/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. Middle name Last name First 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. 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 f you have indicated an APO/FPO address, complete (a). f 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 f you have indicated an APO/FPO address, complete (a). f 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 Does the person who knew you have an APO/FPO address? (b) YES NO Owned by you Military housing Rented or leased by you Other Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Section 11 - Where You Have Lived - (Continued) Entry #6 Evening telephone number Extension nternational or DSN phone number Daytime telephone number Extension Cell/mobile telephone number Extension Provide the following contact information for this person. nternational or DSN phone number nternational or DSN phone number Provide dates of residence. From Date Est. To Date Present Est. s/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. Middle name Last name First 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. 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 f you have indicated an APO/FPO address, complete (a). f 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 f you have indicated an APO/FPO address, complete (a). f 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 Does the person who knew you have an APO/FPO address? (b) YES NO Owned by you Military housing Rented or leased by you Other Do not list education before your 18th birthday, unless to provide a minimum of two years of education history. Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Country Zip Code 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) (Month/Year) To Date 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) (Month/Year) To Date Day Night Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Country Zip Code 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 Country Zip Code 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) (Month/Year) To Date 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 Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Country Zip Code 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) (Month/Year) To Date International or DSN phone number I don't know Telephone number Extension Provide telephone number for this person. Day Night Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page 13A EMPLOYMENT/UNEMPLOYMENT INFORMATION #1 Dates of EmpIoyment Month/Year To Month/Year Type of EmpIoyment Employment code EmpIoyer/Verifier Name of employer/verifier Telephone number Part-time Address of employer/verifier City (Country) PhysicaI Location Your actual work address (if different from employer address) Telephone number AdditionaI Periods of Activity with this EmpIoyer Position title Supervisor Position title Month/Year To Month/Year Position title Explanation/Reason for leaving Month/Year To Month/Year Supervisor (if different from employer) Name and title Telephone number Work address of supervisor State ZP Code State ZP Code State ZP Code Present City (Country) City (Country) Month/Year To Month/Year Supervisor Supervisor Position title/Military rank Work hours Full-time List all your employment activities, beginning with the present (#1) and working back 10 years. You should list all full-time and part-time work, paid or unpaid, consulting/contracting work, all military service duty locations, temporary military duty locations (TDY) over 90 days, self- employment, other paid work, and all periods of unemployment. The entire period must be accounted for without breaks. EXCEPTON: Do not list employments that occurred before your 18th birthday unless it is necessary for providing a minimum of 2 years of employment history. f you require additional space, use a continuation sheet (SF 86A). 7 - Unemployment (include name of verifier) 8 - Federal Contractor 9 - Other (explain) EmpIoyer/Verifier Information. List the business name of your employer or the name of a person who can verify your self-employment or unemployment in this block. f military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to reflect changes in your military duty locations or home ports. f you are a Federal Contractor, list company name, not Federal agency. AdditionaI Periods of Activity. Complete this block if you worked for an employer on more than one occasion at the same physical location. After entering the most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information. 13 EMPLOYMENT ACTIVITIES Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers. EmpIoyment Code: Use one of the codes listed below to identify the type of employment. 1 - Active military duty stations 2 - National Guard/Reserve 3 - U.S.P.H.S. Commissioned Corps 4 - Other Federal employment 5 - State Government (Non-Federal employment) 6 - Self-employment (include business name and/or name of person who can verify) PhysicaI Location EmpIoyer/Verifier Name of employer/verifier Telephone number Address of employer/verifier City (Country) Your actual work address (if different from employer address) Telephone number AdditionaI Periods of Activity with this EmpIoyer Month/Year To Month/Year Position title Supervisor Position title Month/Year To Month/Year Supervisor Position title Month/Year To Month/Year Supervisor City (Country) Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page 13A EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued) EmpIoyer/Verifier Name of employer/verifier Telephone number Address of employer/verifier City (Country) #3 Dates of EmpIoyment Month/Year To Month/Year Type of EmpIoyment PhysicaI Location Your actual work address (if different from employer address) Telephone number City (Country) Explanation/Reason for leaving #2 Dates of EmpIoyment Month/Year To Month/Year Type of EmpIoyment Full-time Work hours Position title/Military rank Employment code Part-time Employment code Full-time Work hours Position title/Military rank Part-time Supervisor (if different from employer) Name and title Telephone number Work address of supervisor City (Country) State ZP Code State ZP Code State ZP Code State ZP Code State ZP Code Supervisor (if different from employer) Work address of supervisor City (Country) Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page #4 Dates of EmpIoyment Type of EmpIoyment Month/Year To Month/Year EmpIoyer/Verifier Name of employer/verifier Telephone number Address of employer/verifier City (Country) PhysicaI Location Your actual work address (if different from employer address) Telephone number City (Country) Supervisor (if different from employer) Name and title Telephone number Work address of supervisor City (Country) 13A EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued) Employment code Work hours Full-time Part-time Position title/Military rank Telephone number Name and title Position title Month/Year To Month/Year Supervisor Position title Month/Year To Month/Year Supervisor Explanation/Reason for leaving AdditionaI Periods of Activity with this EmpIoyer Month/Year To Month/Year Position title Supervisor AdditionaI Periods of Activity with this EmpIoyer Month/Year To Month/Year Position title Supervisor Position title Month/Year To Month/Year Supervisor Position title Month/Year To Month/Year Supervisor Explanation/Reason for leaving State ZP Code State ZP Code State ZP Code State ZP Code PhysicaI Location EmpIoyer/Verifier Name of employer/verifier Telephone number Address of employer/verifier City (Country) Your actual work address (if different from employer address) Telephone number AdditionaI Periods of Activity with this EmpIoyer Month/Year To Month/Year Position title Supervisor Position title Month/Year To Month/Year Supervisor Position title Month/Year To Month/Year Supervisor City (Country) Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page 13A EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued) EmpIoyer/Verifier Name of employer/verifier Telephone number Address of employer/verifier City (Country) #6 Dates of EmpIoyment Month/Year To Month/Year Type of EmpIoyment PhysicaI Location Your actual work address (if different from employer address) Telephone number City (Country) Explanation/Reason for leaving #5 Dates of EmpIoyment Month/Year To Month/Year Type of EmpIoyment Full-time Work hours Position title/Military rank Employment code Part-time Employment code Full-time Work hours Position title/Military rank Part-time Supervisor (if different from employer) Name and title Telephone number Work address of supervisor City (Country) State ZP Code State ZP Code State ZP Code State ZP Code State ZP Code Supervisor (if different from employer) Work address of supervisor City (Country) Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page #7 Dates of EmpIoyment Type of EmpIoyment Month/Year To Month/Year EmpIoyer/Verifier Name of employer/verifier Telephone number Address of employer/verifier City (Country) PhysicaI Location Your actual work address (if different from employer address) Telephone number City (Country) Supervisor (if different from employer) Name and title Telephone number Work address of supervisor City (Country) 13A EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued) Employment code Work hours Full-time Part-time Position title/Military rank Telephone number Name and title Position title Month/Year To Month/Year Supervisor Position title Month/Year To Month/Year Supervisor Explanation/Reason for leaving AdditionaI Periods of Activity with this EmpIoyer Month/Year To Month/Year Position title Supervisor AdditionaI Periods of Activity with this EmpIoyer Month/Year To Month/Year Position title Supervisor Position title Month/Year To Month/Year Supervisor Position title Month/Year To Month/Year Supervisor Explanation/Reason for leaving State ZP Code State ZP Code State ZP Code State ZP Code Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 13B - EmpIoyment Activities - Former FederaI Service YES NO (If NO, proceed to Section 13C) Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report? CompIete the foIIowing if you seIected "Yes" to having former federaI civiIian empIoyment, excIuding miIitary service, NOT indicated previousIy. 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 - EmpIoyment Record Have any of the following happened to you in the Iast 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 SociaI 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) Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR 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 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR 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 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR 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 16) Have you 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?
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 reason for leaving this service. Provide a description of the circumstances of your association with this organization. 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 Country Zip Code Middle name Last name First 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 frequency of contact. Provide the contact's official title. 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 Country Zip Code Middle name Last name First 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) Entry #1 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR 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 reason for leaving this service. Provide a description of the circumstances of your association with this organization. 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 Country Zip Code Middle name Last name First 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 frequency of contact. Provide the contact's official title. Provide the contact's address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City State Country Zip Code Middle name Last name First 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) Entry #2 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR 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 Middle name First name Last 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 Country Zip Code Provide mobile/cell telephone number for this person. Schoolmate Other (Provide explanation) Provide rank/title Friend Neighbor Not applicable Provide full name. I don't know Work associate Day Night Day International or DSN phone number Extension 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 Middle name First name Last 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. Schoolmate Provide rank/title Friend Neighbor Not applicable Provide full name. I don't know Work associate Day Night Day International or DSN phone number Extension Entry #2 Night Middle name First name Last 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 Country Zip Code Provide mobile/cell telephone number for this person. Schoolmate Provide rank/title Friend Neighbor Not applicable Provide full name. I don't know Work associate Day Night Day International or DSN phone number Extension Entry #3 Country Other (Provide explanation) Other (Provide explanation) 17A CURRENT SPOUSE Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page f applicable, complete the following about your current spouse only. f your current spouse was born outside the U.S., provide citizenship information. Last name Date of birth Place of birth (include Country if outside the U.S.) Social Security Number Other names used (specify maiden name, names by other marriages, etc., and show dates used for each name) Country(ies) of citizenship Date married Place married (City, include Country if outside the U.S.) State f separated, date of separation f legally separated, where is the record located? City (Country) State ZP Code Current address of spouse, if different than your current address (Street, City, include Country if outside the U.S.) Telephone number State ZP Code f spouse was born outside the U.S. indicate one type of documentation that he or she possesses and the document numbers. U.S. Passport (current or most recent) Alien registration Naturalization certificate Other (Explain) Document number 17B FORMER SPOUSE(S) Complete the following about your former spouse(s). Use blank sheets if needed. Place of birth (include Country if outside the U.S.) Date of birth State Country(ies) of citizenship Date married Place married (City, include Country if outside the U.S.) State Check one, then give date Widowed f divorced/annulled, where is the record located? City (Country) ZP Code State Last known address of former spouse (Street, City, include Country if outside the U.S.) ZP Code State Explain "Other" Telephone number 17C COHABITANT [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 for reasons of convenience (a roommate)]. f applicable, complete the following about your cohabitant. f your cohabitant was born outside the U.S., provide citizenship information. f cohabitant was born outside the U.S., indicate one type of documentation that he or she possesses and the document numbers. Document number Other names used (specifically maiden names, names by other marriages, etc., and show dates used for each name) Country(ies) of citizenship Date cohabitation began Mark one box to show your current marital status and provide information about your spouse(s) or cohabitant below. f there is not a middle name, enter as "NMN." DS 1350 FS 240 or 545 Citizenship certificate Divorced Annulled Date U.S. Passport (current or most recent) Alien registration Naturalization certificate Other (Explain) DS 1350 FS 240 or 545 Citizenship certificate 17 MARITAL STATUS 1 - Never married 2 - Married (incl. Common Law) 3 - Separated 5 - Divorced 4 - Annulled 6 - Widowed First name Middle name Middle name First name Last name Middle name First name Last name Explain "Other" Place of birth (include Country if outside the U.S.) Date of birth Social Security Number Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Has this relative used any other names? NO YES 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. Middle name Last name Provide your relative's full name. Suffix First name Suffix Middle name Last name First name f 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister. don't know Middle name First name Last name #1 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #2 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #3 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #4 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? 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 - ReIatives Stepfather Brother Sister Stepbrother Stepsister Half-brother Father-in-law Half-sister Mother-in-law Guardian Entry #1 E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI 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. State City Street 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) Provide your relative's APO/FPO address. YES NO don't know s 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 Country Zip Code Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not deceased. E n t r y
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E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI Security Number before going to the next page (Provide explanation) Provide document number Other U.S. Visa U.S. Alien registration Provide type of documentation he or she possesses to support U.S. residence. Provide methods of contact (Check all that apply). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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. E n t r y
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E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Has this relative used any other names? NO YES 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. Middle name Last name Provide your relative's full name. Suffix First name Suffix Middle name Last name First name f 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister. don't know Middle name First name Last name #1 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #2 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #3 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #4 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? 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 - ReIatives - (Continued) Entry #2 E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI 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. State City Street 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) Provide your relative's APO/FPO address. YES NO don't know s 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 Country Zip Code Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not deceased. E n t r y
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E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI Security Number before going to the next page (Provide explanation) Provide document number Other U.S. Visa U.S. Alien registration Provide type of documentation he or she possesses to support U.S. residence. Provide methods of contact (Check all that apply). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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. E n t r y
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E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Has this relative used any other names? NO YES 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. Middle name Last name Provide your relative's full name. Suffix First name Suffix Middle name Last name First name f 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister. don't know Middle name First name Last name #1 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #2 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #3 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #4 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? 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 - ReIatives - (Continued) Entry #3 E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI 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. State City Street 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) Provide your relative's APO/FPO address. YES NO don't know s 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 Country Zip Code Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not deceased. E n t r y
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E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI Security Number before going to the next page (Provide explanation) Provide document number Other U.S. Visa U.S. Alien registration Provide type of documentation he or she possesses to support U.S. residence. Provide methods of contact (Check all that apply). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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. E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Has this relative used any other names? NO YES 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. Middle name Last name Provide your relative's full name. Suffix First name Suffix Middle name Last name First name f 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister. don't know Middle name First name Last name #1 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #2 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #3 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #4 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? 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 - ReIatives - (Continued) Entry #4 E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI 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. State City Street 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) Provide your relative's APO/FPO address. YES NO don't know s 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 Country Zip Code Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not deceased. E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI Security Number before going to the next page (Provide explanation) Provide document number Other U.S. Visa U.S. Alien registration Provide type of documentation he or she possesses to support U.S. residence. Provide methods of contact (Check all that apply). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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. E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Has this relative used any other names? NO YES 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. Middle name Last name Provide your relative's full name. Suffix First name Suffix Middle name Last name First name f 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister. don't know Middle name First name Last name #1 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #2 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #3 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #4 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? 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 - ReIatives - (Continued) Entry #5 E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI 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. State City Street 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) Provide your relative's APO/FPO address. YES NO don't know s 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 Country Zip Code Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not deceased. E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI Security Number before going to the next page (Provide explanation) Provide document number Other U.S. Visa U.S. Alien registration Provide type of documentation he or she possesses to support U.S. residence. Provide methods of contact (Check all that apply). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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. E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Has this relative used any other names? NO YES 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. Middle name Last name Provide your relative's full name. Suffix First name Suffix Middle name Last name First name f 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister. don't know Middle name First name Last name #1 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #2 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #3 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? YES NO Middle name First name Last name #4 From (Month/Year) To (Month/Year) Suffix Est. Est. Present Maiden name? 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 - ReIatives - (Continued) Entry #6 E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI 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. State City Street 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) Provide your relative's APO/FPO address. YES NO don't know s 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 Country Zip Code Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not deceased. E n t r y
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Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Section 18 - ReIatives - (Continued) Enter your SociaI Security Number before going to the next page (Provide explanation) Provide document number Other U.S. Visa U.S. Alien registration Provide type of documentation he or she possesses to support U.S. residence. Provide methods of contact (Check all that apply). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, 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, ChiId (incIuding adopted/foster), StepchiId, Brother, Sister, Stepbrother, Stepsister, HaIf-brother, HaIf-sister, Father-in-Iaw, Mother-in-Iaw, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) n person Written correspondence Other Provide approximate frequency of contact. Monthly Annually Daily Weekly (Provide explanation) Other Quarterly Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name 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 Country Zip Code don't know (Provide explanation) s this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? NO YES 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. E n t r y
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Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 (If NO, proceed to Section 20A) YES Provide place of birth. 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 Suffix Middle name Last name First name 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) In person Written correspondence (Provide explanation) Other Daily Weekly Monthly Quarterly Annually Other (Provide explanation) Provide the nature of relationship (Check all that apply). (Provide explanation) Other Personal (Such as family ties, friendship, affection, common interests, etc) Professional or Business (Provide explanation) Obligation Last name First name Middle name Suffix Provide other names and/or nicknames, as appropriate. Est. Provide date of birth. (Month/Day/Year) Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Street City State Country Zip Code 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 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 Country Zip Code Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service? YES NO Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service. Zip Code NO YES Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address. Address APO or FPO APO/FPO State Code Country (If country unknown, requires explanation) City Provide approximate frequency of contact. Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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. Provide country(ies) of citizenship. Country #1 Country #2 Suffix Middle name Last name First name 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) In person Written correspondence (Provide explanation) Other Daily Weekly Monthly Quarterly Annually Other (Provide explanation) Provide the nature of relationship (Check all that apply). (Provide explanation) Other Personal (Such as family ties, friendship, affection, common interests, etc) Professional or Business (Provide explanation) Obligation Last name First name Middle name Suffix Provide other names and/or nicknames, as appropriate. Est. Provide date of birth. (Month/Day/Year) Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Street City State Country Zip Code 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 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 Country Zip Code Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service? NO YES Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service. NO YES Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address. Country (If country unknown, requires explanation) City Provide approximate frequency of contact. Zip Code Address APO or FPO APO/FPO State 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 Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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. Provide country(ies) of citizenship. Country #1 Country #2 Suffix Middle name Last name First name 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). Telephone Electronic (Such as e-mail, texting, chat rooms, etc) In person Written correspondence (Provide explanation) Other Daily Weekly Monthly Quarterly Annually Other (Provide explanation) Provide the nature of relationship (Check all that apply). (Provide explanation) Other Personal (Such as family ties, friendship, affection, common interests, etc) Professional or Business (Provide explanation) Obligation Last name First name Middle name Suffix Provide other names and/or nicknames, as appropriate. Est. Provide date of birth. (Month/Day/Year) Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Street City State Country Zip Code 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 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 Country Zip Code Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service? NO YES Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service. NO YES Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address. Country (If country unknown, requires explanation) City Provide approximate frequency of contact. Zip Code Address APO or FPO APO/FPO State 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 Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 20A.2) 20A.1 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 Country Zip Code Suffix Middle name Last name First name 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.) Dependent children Cohabitant Spouse Yourself Specify (Check all that apply): 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. Est. Date 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 Provide full name of co-owner. #1 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 Country Zip Code Provide full name of co-owner. Suffix Middle name Last name First name Provide the nature of your relationship with the co-owner. #2 Est. Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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. Suffix Middle name Last name First name Provide the full name of co-owner. #2 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 Country Zip Code 20A.2 Entry #1 NO (If NO, Proceed to 20A.3) YES 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? Dependent children Cohabitant Spouse Yourself Specify: (Check all that apply): 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. Suffix Middle name Last name First name 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 Country Zip Code 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. Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Suffix Middle name Last name First name Provide the full name of co-owner. #1 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 Country Zip Code 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) Suffix Middle name Last name First name Provide the full name of co-owner. #2 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 Country Zip Code 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. Provide the nature of your relationship with the co-owner. 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 owned, or anticipate owning, or planning to purchase real estate in a foreign country. Section 20A - Foreign Activities - (Continued) 20A.3 Dependent children Cohabitant Spouse Yourself Specify (Check all that apply): 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. City Street Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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? Dependent children Cohabitant Spouse Yourself Specify (Check all that apply) 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 Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Country Zip Code Suffix Middle name Last name First name 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 Country Zip Code Suffix Middle name Last name First name 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 Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page 4. Have you 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.)?
f "Yes," provided additional information. 5. Have you attended or participated in any coferences, trade shows, seminars, or meetings outside the U.S.? 20B Foreign Business, ProfessionaI Activities, and Foreign Government Contacts Respond for the time frame of the last 7 years, unless otherwise noted. ndicate if activity was on official U.S. Government business. f "Yes" AND the activity was outside of official U.S. Government business, describe advice/support provided, name(s) of foreign national and/or organization(s) to which it was provided, the name(s) of foreign country(ies), timeframe(s), and if compensation was provided. Have you provided advice or support to to any individual associated with a foreign business or other foreign organization that you have not previously listed as a former employer?
6. Have you had any contact with foreign government, its establishment or its representatives, whether inside or outside the U.S.? f "Yes," provide the name(s), county of citizenship for contact(s). 7. Have you sponsored any foreign national to come to the U.S. as a student, for work, or for permanent residence? f "Yes" (Name, DOB, Citizenship, Address, Timeframe)?
f "Yes," provide additional information. 1. 2. Have you or any immediate family member been asked to provide advice by any foreign government official or agency? f "Yes," provided additional information. 3. Has any foreign national offered you a job, asked you to work as a consultant, or consider employment with them?
f "Yes," provided additional information. NO YES OfficiaI Govt. Business 8. Have you EVER held political office in a foreign country? 9. Have you EVER voted in the election of a foreign country? Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 (If NO, proceed to Section 21) YES 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 Trade shows, conferences, and seminars Education Tourism Volunteer activities Business/Professional conference Provide the purpose of the travel to this country (Check all that apply). Other NO YES Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Trade shows, conferences, and seminars Education Tourism Volunteer activities Business/Professional conference Provide the purpose of the travel to this country (Check all that apply). Other NO YES Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Complete the following if you responded 'Yes' to having traveled outside the U.S. in the Iast 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 TraveI - (Continued) Entry #4 Provide the dates of your travel to this country. From Date Est. To Date Present Est. (Month/Year) (Month/Year) f 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? f yes, provide explanation. NO YES While traveling to or in this country, were you involved in any encounter with the police? f 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? f yes, provide explanation. NO YES While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported? f 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? f 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? f 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 Trade shows, conferences, and seminars Education Tourism Volunteer activities Business/Professional conference Provide the purpose of the travel to this country (Check all that apply). Other Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Country Zip Code 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 Country Zip Code Same as above From Date (Month/Year) Est. To Date (Month/Year) Present Est. NO YES 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 Country Zip Code 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 Country Zip Code Same as above From Date (Month/Year) Est. To Date (Month/Year) Present Est. NO YES 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 Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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 Country Zip Code 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 Country Zip Code 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 Country Zip Code 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 Country Zip Code 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 Country Zip Code 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 Country Zip Code Provide the final disposition. Entry #2 22 POLICE RECORD n the last 7 years, have you received counseling or treatment or have you been ordered, advised, or asked to seek counseling or treatment as a result of your use of drugs? f you answered "Yes," provide date(s) of treatment and name(s) and address(es) of provider(s). You will be asked to sign an additional release if information is needed concerning any treatment. The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful responses nor information derived from your responses will be used as evidence against you in any subsequent criminal proceeding. f you answered "Yes" to any question above, explain below, providing information for each and every offense. #2 #1 Month/Year Offense Action Taken Law Enforcement Authority/Court City and Country (if outside U.S.) State ZP Code Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Have youbeen involved in the illegal purchase, manufacture, cultivation, trafficking, production, transer, shipping, receiving, handling or sale of any drug or controlled substance? 23 ILLEGAL USE OF DRUGS OR DRUG ACTIVITY NO YES 1 n the last 7 years, have you illegally used any controlled substance, for example, cocaine, crack cocaine, THC (marijuana, hashish, etc.), narcotics (opium, morphine, codeine, heroin, etc.), stimulants (amphetamines, speed, crystal methamphetamine, Ecstacy, ketamine, etc.), depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), steroids, inhalants (toluene, amyl nitrate, etc.) or prescription drugs (including painkillers)? Use of a controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise consuming any controlled substance. 2 Have you EVER illegally used or otherwise been involved with a drug or controlled substance while possessing a security clearance other than previously listed? Dates of Use/Activity Month/Year To Month/Year Type of Controlled Substance(s) Explain (nature of use/activity, frequency of activity and number of times used) #1 #2 3 Enter your SociaI Security Number before going to the next page Has your use of alcohol 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? (If "Yes," explain.) Month/Year To Month/Year YES NO 1 2 Have you been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol? 3 Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol?
4. Have you EVER received counseling or treatment as a result of alcohol use in addition to what you have already listed on this form?
Name/Address of Counselor or Doctor #1 #2 24 USE OF ALCOHOL Respond for the time frame of the last 7 years. NO YES 5. Have you EVER been charged with any offense(s) related to alcohol or drugs? 4. Have you EVER been charged with a firearms or explosives offense? 3. s there currently a domestic violence protective order or restraining order issued against you? 2. Have you been arrested by any police officer, sheriff, marshal, or any other type of law enforcement officer? Charged with a felony? 1. Have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you; are you on trial or awaiting a trial on criminal charges; or are you currently awaiting sentencing for a criminal offense? For questions a and b, respond for the timeframe of the last 7 years (if an SSB go back 10 years). Exclude any fines of less than $300 for traffic offenses that do not involve alcohol or drugs. For this item, 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. State ZP Code
4 f you answered "Yes" to a - d above, provide the date(s) of use or activity, identify the controlled substance(s), and explain the use or activity. Foreign Government or Other Agency (If necessary) Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Enter your SociaI Security Number before going to the next page Has the U.S. Government or a foreign government EVER investigated your background and/or granted you a security clearance? f "Yes," use the codes that follow to provide the requested information below. f "Yes," but you can't recall the investigating agency and/or the security clearance received, enter the code for "Unknown." f your response is "No," or you don't know or can't recall if you were investigated and cleared, check the "No" box. NO YES Month/Year 1 Investigating Agency Codes 1 - Defense Department 2 - State Department 3 - Office of Personnel Management 5 - Treasury Department 6 - Department of Homeland Security 7 - Foreign government (Specify country) 9 - Other (Explain below) Security CIearance Codes 0 - Not Required 1 - Confidential 2 - Secret 3 - Top Secret 4 - Sensitive Compartmented nformation 5 - Q 6 - L 7 - ssued by foreign country (specify country) 8 - Unknown Agency Code Clearance Code #1 #2 #3 #4 25 INVESTIGATIONS AND CLEARANCE RECORD Month/Year Department or Agency Taking Action Circumstances #1 #2 h - you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? 5 Are you currently utilizing, or seeking assistance from a credit counseling service to resolve your financial difficulties? 6 Have ever had any of the following happen to you? 26 FINANCIAL RECORD For the following, answer for the last 7 years, unless otherwise specified in the question. Disclose all financial obligations, including those for which you are a cosigner or guarantor, on the following page. YES NO 1 Have you filed a petition under any chapter of the bankruptcy code? f "Yes," indicate type. 2 Have you ever experienced financial problems due to gambling? 3 Have you failed to file or pay Federal, State, or other taxes when required by law or ordinance? 4 Have you been counseled, warned, or disciplined for violating the terms of agreement for a credit card provided by your employer? a - you have been delinquent on alimony or child support payments? b - you had a judgment entered against you? c - you had a lien placed against your property for failing to pay taxes or other debts? d - you are currently delinquent on any Federal debt? e - you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? f - you defaulted on any type of loan? g - you had bills or debts turned over to a collection agency? i - you were evicted for non-payment? To your knowledge, have you EVER had a clearance or access authorization denied, suspended, or revoked; or been debarred from government employment? f "Yes," give the action(s), date(s) of action(s), agency(ies), and circumstances. Note: An administrative downgrade or termination of a security clearance is not a revocation. j - you had your wages, benefits, or assets garnished or attached for any reason? NO YES 2 4 - Federal Bureau of nvestigation 8 - Unknown 9 - Other (Explain below) Amount of Property Value nvolved 26 FINANCIAL RECORD (Continued) Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 ndicate (a-p) Date Satisfied Month/Year Amount of Property Value nvolved Loan/Account Number/ Bankruptcy Type Names of Agency/Organization/ndividual to Whom Debt is/was Owed Name/Address of Company, Court, or Agency Handling Case Name Action/Debt is Recorded Under Status of Action or Debt #1 1 n the last 7 years, have you illegally or without authorization modified, destroyed, manipulated, or denied others access to information residing on an information technology system? 2 n the last 7 years, have you illegally or without proper authorization entered into any information technology system? Enter your SociaI Security Number before going to the next page 27 USE OF INFORMATION TECHNOLOGY SYSTEMS YES NO The following questions ask about your use of information technology systems. nformation technology systems include all related computer hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage, or protection of information. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful responses nor information derived from your responses will be used as evidence against you in any subsequent criminal proceeding. For the following, answer for the last 7 years, unless otherwise specified in the question. Disclose all financial obligations, including those for which you are a cosigner or guarantor. f you answered "Yes" on the previous page (a-p), provide the information requested below. For each "Yes" answer, provide the corresponding letters. 3 n the last 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? ndicate (a-p) Date Satisfied Month/Year Loan/Account Number/ Bankruptcy Type Names of Agency/Organization/ndividual to Whom Debt is/was Owed Name/Address of Company, Court, or Agency Handling Case Name Action/Debt is Recorded Under Status of Action or Debt #2 ndicate (a-p) Date Satisfied Month/Year Amount of Property Value nvolved Loan/Account Number/ Bankruptcy Type Names of Agency/Organization/ndividual to Whom Debt is/was Owed Name/Address of Company, Court, or Agency Handling Case Name Action/Debt is Recorded Under Status of Action or Debt #3 ndicate (a-p) Date Satisfied Month/Year Amount of Property Value nvolved Loan/Account Number/ Bankruptcy Type Names of Agency/Organization/ndividual to Whom Debt is/was Owed Name/Address of Company, Court, or Agency Handling Case Name Action/Debt is Recorded Under Status of Action or Debt #4 State ZP Code State ZP Code State ZP Code State ZP Code Date of ncident (Month/Year) Nature of ncident/Offense Location ncident Took Place Action Taken #1 #2 #3 #4 #5 #6 #7 Have you EVER been an officer or a member of, or made a contribution to, an organization that unlawfully advocates or practices the commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the U.S. with the specific intent to further such unlawful activities? 29 ASSOCIATION RECORD Enter your SociaI Security Number before going to the next page YES NO 1 2 Have you EVER been an officer or a member of, or made a contribution to, an organization dedicated to the use of violence or force to overthrow the U.S. Government, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal activities? 3 f you answered "Yes" to any of the questions above, explain below. Use the continuation sheet(s) (SF 86A) for additional answers for items 11, 12, and 13. Use the space below to continue answers to all other items and to provide any information you would like to add. f more space is needed than is provided below, use a blank sheet(s) of paper. Start each sheet with your name and SSN. Before each answer, identify the number of the item and try to maintain question format. After compIeting this form and any attachments, you shouId review your answers to aII questions to make sure the form is compIete and accurate, and then sign and date the foIIowing certification and the attached reIease(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. have carefully read the foregoing instructions to complete this form. 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). 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 Date (mm/dd/yyyy) CONTINUATION SPACE Form approved: OMB No. 3206 0005 NSN 7540-00 634-4036 86-111 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Court nformation 28 INVOLVEMENT IN NON-CRIMINAL COURT ACTIONS YES NO n the last 7 years (if an SSB go back 10 years), have you been a party to any public record civil court action(s) not listed elsewhere on this form? f you answered "Yes," provide the information about each public record civil court action(s) requested below. Name of Principal Parties nvolved (if more space is needed, use Continuation Space on page 17) Result of Action Nature of Action Month/Year #1 #2 Court name Court name Street address Street address City State ZP Code City State ZP Code The following questions 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 decision or action against you. 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.
Have you EVER been an officer or a member of, or made a contribution to, an organization dedicated to terrorism, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal activities? 4 Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force with the specific intent to incite others to unlawful action in furtherance of such aims? Have you EVER knowingly engaged in any activities designed to overthrow the U.S. Government by force? 5 Have you EVER knowingly engaged in any acts of terrorism? Neither your truthful response nor information derived from your response to this question will be used as evidence against you in any subsequent criminal proceeding. 6 7 Have you EVER participated in militias (not including official state government militias) or paramilitary groups? Continuation Space Enter your Social Security Number before going to the next page Form approved: OMB No. 3206 0005
QUESTIONNAIRE FOR 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.