General Electronic Form Notes/Notices (all Sections)
This document is for reference only and is not a form for completion. Individuals will be invited
into the applicable eApplication system to complete the form. The questions/content captured in
this document are intended to display what data will be captured from the individual and the
additional questions (Branch questions) to be presented based on the individual responses to
previous questions during data capture.
Question numbering and “electronic form navigation notes” have been made throughout this
form to help facilitate review and navigation. These items are subject to change based on the data
collection or processing systems this form may be implemented in.
Additionally numbering and electronic form notes are not to be considered part of the content of
the form. Only the section numbers are applicable as the official numbering for this form.
Screens may vary based on html style formatting, java scripting, data capture formatting, system
functionality, validation, and navigation.
Systems that are used for the collection of the “Questionnaire for Non-Sensitive Positions (SF
85)” data for investigative purposes are subject to OMB review and approval.
Standard Form 85
Revised November 2021
U.S. Office of Personnel Management
5 CFR parts 731 and 736
Form approved:
OMB No. 3206-0261
Office of Personnel Management
Questionnaire for Non-Sensitive Positions, SF 85
Questionnaire for Non-Sensitive Positions
Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the office that provided you the form.
All questions on this form must be answered completely and truthfully in order that the Government may make the determinations described below on a complete record. Penalties for
inaccurate or false statements are discussed below. If you are a current civilian employee of the federal government: failure to answer any questions completely and truthfully could
result in an adverse personnel action against you, including loss of employment; with respect to Sections 17 and 20, however, neither your truthful responses nor information derived
from those responses will be used as evidence against you in a subsequent criminal proceeding.
Purpose of this Form
This form will be used by the United States (U.S.) Government in conducting background investigations and reinvestigations of persons under consideration for, or retention of, non-
sensitive low risk positions as defined in 5 CFR 731. It is also used for determining fitness of individuals under consideration for, or retention in positions in the excepted service when
the duties to be performed are equivalent to a low risk position. This form may also be used by agencies in determining whether a subject should be issued a Federal credential for access
to federally controlled facilities and information systems . For applicants, this form is to be used only after a conditional offer of employment has been made, unless OPM has provided
for an exception. This form is not to be used for National Security sensitive positions.
Providing this information is voluntary. If you do not provide each item of requested information, however, we will not be able to complete your investigation, which will adversely
affect your eligibility for a position or your ability to obtain or retain Federal or contract employment, or logical or physical access. It is imperative that the information provided be true
and accurate, to the best of your knowledge. Any information that you provide is evaluated on the basis of its currency, seriousness, relevance to the position and duties, and consistency
with all other information about you. Withholding, misrepresenting, or falsifying information may affect your eligibility for positions, physical and /or logical access required to perform
duties, or your ability to obtain or retain Federal or contract employment. In addition, withholding, misrepresenting, or falsifying information may affect your eligibility for physical and
logical access to federally controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also negatively affect your employment prospects
and job status, and the potential consequences include, but are not limited to, removal, debarment from Federal service, or prosecution.
This form may become a permanent document that may be used as the basis for future investigations, determinations of suitability or fitness for Federal employment, fitness for contract
employment, or eligibility for physical and logical access to federally controlled facilities or information systems. Your responses to this form may be compared with your responses to
previous questionnaires.
The investigation conducted on the basis of information provided on this form may be selected for studies and analyses in support of evaluating and improving the effectiveness and
efficiency of the investigative and adjudicative methodologies. All study results released to the general public will delete personal identifiers such as name, Social Security Number, and
date and place of birth.
Authority to Request this Information
Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under Executive Orders13764, 13741, 10577, 13467, and 13488, as
amended; sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 6, 731, and 736 of title 5, Code of Federal Regulations (CFR), Homeland Security
Presidential Directive (HSPD) 12, and Federal information processing standards.
Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or
delay the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397, as amended by EO 13478.
The Investigative Process
Background investigations for non-sensitive positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and will
not present an unacceptable risk,. The information that you provide on this form and your Declaration for Federal Employment (OF 306) may be confirmed during the investigation.
The investigation may extend beyond the time covered by this form, when necessary to resolve issues. Your current employer may be contacted as part of the investigation, although
you may have previously indicated on applications or other forms that you do not want your current employer to be contacted. If you have a security freeze on your consumer or
credit report file and a credit report is required by the agency requesting your investigation, then we may not be able to complete your investigation, which can adversely affect your
eligibility for positions, physical and /or logical access required to perform duties, or your ability to obtain Federal or contract employment. To avoid such delays, you must request
that the consumer reporting agencies lift the freeze in these instances.
In addition to the questions on this form, inquiry also is made about your adherence to security requirements, your honesty and integrity, falsification, misrepresentation, and any other
behavior, activities, or associations that tend to demonstrate a person is not reliable or trustworthy, or poses an unacceptable risk to the life, safety, or health of employees, contractors,
vendors or visitors to a Federal facility; the Government’s physical assets or information systems; personal property; records, or, the privacy of the individuals whose data the
Government holds in its systems. After an eligibility determination is made, you may also be subject to reinvestigations to ensure your continuing suitability for employment.
The information you provide on this form may be confirmed during the investigation, and may be used for identification purposes throughout the investigation process.
Your Personal Interview
Some investigations may include an interview with you as needed as part of the investigative process. The investigator may ask you to explain your answers to any question on this
form. This provides you the opportunity to update, clarify, and explain information on your form more completely, which often assists in completing your investigation. If contacted, it
is imperative that the interview be conducted as soon as possible after contact is made by the investigator. Postponements will delay the processing of your investigation, and declining
to be interviewed may result in your investigation being delayed or canceled.
For the interview, you will be required to provide photo identification, such as a valid state driver's license. You may be required to provide other documents to verify your identity, as
instructed by your investigator. These documents may include certification of any legal name change, Social Security card, passport, and/or your birth certificate. You may also be
asked to provide documents regarding information that you provide on this form, or about other matters requiring specific attention.
Instructions for Completing this Form
1. Follow the instructions provided to you, by the office that gave you this form and any other clarifying instructions, provided by that office, to assist you with completion of this form.
You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.
2. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box, unless otherwise
noted.
3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the country dropdown
feature.
4. When entering a U.S. address or location, select the state or territory from the "States" dropdown list that will be provided. For locations outside of the U.S. and its territories, select
the country in the "Country" dropdown list and leave the "State" field blank.
5. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes.
6. For telephone numbers in the U.S., ensure that the area code is included.
7. All dates provided in this form must be in Month/Day/Year or Month/Year format. The month and day should be entered as a two character numbers (i.e., 01 for January and 29 for
29
th
day of the month). The year should be entered as a four character number (i.e., 1978 or 2001). If you are unable to report an exact date, approximate or estimate the date to the
best of your ability, and indicate this by checking the "Estimated." box.
Final Determination on Your Eligibility
Final determination on your eligibility for a position and/or physical or logical access to federal facilities and information is the responsibility of the Office of Personnel Management or
the Federal agency that requested your investigation. You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made, if an
unfavorable decision is considered. The United States Government does not discriminate on the basis of prohibited categories, including but not limited to race, color, religion, sex
(including pregnancy and gender identity), national origin, disability, and sexual orientation, when making determinations of eligibility for non-sensitive positions, physical and/or
logical access required to perform duties.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a felony which may result in fines and/or up to five (5) years
imprisonment. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent
record for future placements. Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any
information you provide on this form and to make your comments part of the record.
Disclosure Information
The information you provide is for the purpose of investigating you for a position, and the information will be protected from unauthorized disclosure. The collection, maintenance,
and disclosure of background investigative information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation
have published notices in the Federal Register describing the systems of records in which your records will be maintained. The information you provide on this form, and information
collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C.
552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register. You will not receive prior notice of such disclosures under a routine use. The
Defense Counterintelligence and Security Agency, the Government's primary investigative service provider, has established its routine uses in the Federal Register at the following
address: Federal Register. If another agency is conducting your investigation, it will inform you of its routine uses.
f.
Public Burden Information
Public burden reporting for this collection of information is estimated to average 120 minutes per response, including time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to U.S. Office of Personnel Management, Attn: Forms
Manager, OMB Number 3206-0261 1900 E Street, NW, Washington, DC 20415. The OMB clearance number, 3206-0261, is currently valid. OPM may not collect this information,
and you are not required to respond, unless this number is displayed.
--------------------End of Instructions Pages -------------------
Persons Completing This Form Should Begin After Carefully Reading The Preceding Instructions.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the
penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), or removal and debarment from Federal
Service.
YES NO
Agency Use Block “AUB”
Investigating agency user only Codes: (FIPC CODES) Case Number:
For Competitive Service initial appointments only: As a reminder, agencies are responsible for reviewing information provided on the
OF 306, resume, and other documentation provided as part of the hiring process to identify possible discrepancies with information
provided on the standard form questionnaire. Agencies must notify their Investigative Service Provider of any discrepancies that may
exist between the forms, and request resolution of the conflict through the investigation process.
In this situation the discrepant documents must be forwarded with the questionnaire to OPM for Action.
A – Type of Investigation B – Extra coverage / advanced results C –Risk level
D – Nature of action code E – Date of action F – Geographic location G – Position code
H – Position title I – SON (Submitting Office Number )
J – Location of Official Personnel Folder _ None _ NPRC _ At SON _e-OPF _ Other Other address / web address of e-OPF Zip Code
K – SOI (Security Office Identifier)
L – Location of Security Folder _ None _ NPI _ At SOI __ Other Other address Zip Code
M – IPAC N – TAS O – Obligating document number P - BETC Q – Accounting data and /or Agency case number
R – Investigative requirement _Initial _Reinvestigation S – Requesting Official: Name, Title, Signature, Email Address, Telephone, Date
T – Secondary Requesting Official: Name, Title, Email Address, Telephone Number
U – Applicant Affiliation _ FED CIV _ CON _ MIL _ Other
V – Deployment/PCS (if Imminent):
From Est.-To Dates, Est., Permanent Relocation, Reason(s) for temporary duty assignment or PCS, point of contact at location, Telephone number
(Include Ext.), Address/Unit/Duty location (Include City or Post Name)
Agency Special Instructions for the Investigative Service Provider: Cage Code Contracting Number
For Reference Only
_ _ _
Section 1 – Full Name
Provide your full name. If you have only initials in your name, provide them and indicate “Initial only”. If you
do not have a middle name, indicate “No Middle Name”. If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Last First Middle Suffix
Section 2 – Date of Birth
Provide your date of birth. Date _ _-_ _-_ _ _ _ Est. □
Section 3 – Place of Birth
Provide your Place of birth. City County State Country
Section 4 – SSN
Provide your U.S. Social Security Number. □ Not applicable _ _ _-_ _-_ _ _ _
Section 5 – Other Names Used
Provide your other names used and the period of time you used them (for example: your maiden name, name(s) by a former marriage (s), former name(s),
alias (es), or nickname(s)).
Have you used any other names? YES NO
Branch
If Yes to
“Other
Names”
(Multiple
Entries
Allowed)
Provide your other name used and the period of time you used it [for example: your maiden name, name by a former marriage, former
name, alias, or nickname]. If you have only initials in your name, provide them and indicate “Initial only.” If you do not have a middle
name, indicate “No Middle Name” (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Provide other name used. Last First Middle Suffix Maiden name? Yes No
Provide dates used. From Date (Estimated) To Date (Estimated/Present)
Provide the reason(s) why the name changed. Reason: (Free Text)
Do you have additional names to enter? Yes (Yes adds another entry) No (Required to pass validation)
Section 6 – Your Identifying Information
Provide your Identifying Information Height (feet) (inches) Weight (in pounds) Hair Color Eye Color Sex (M/F)
Section 7 – Your Contact Information
Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your background
investigation.
Provide your contact information.
Email addresses may be used as a
contact method, and identify subject
in records.
Home email address Email (Free Text) Work email address Email (Free Text)
Home telephone number
Extension Time Day Night Both
_ Check box if International or DSN
phone number
Work telephone number
Extension Time Day Night Both
_ Check box if International or DSN
phone number
Mobile/Cell telephone number
Extension Time Day Night Both
_ Check box if International or DSN
phone number
Section 8 – U.S. Passport Information
Do you possess a U.S. passport (current or expired)? YES NO
Branch
If Yes to
“passport”
Provide the following information for the most recent U.S. passport you currently possess:
Provide your U.S. passport number Passport (Free Text)
Click here for U.S. State Department passport help.
Provide the issue date of passport. Date (Estimated) Provide the expiration date of passport. Date (Estimated)
Provide the name in which passport was first issued. Last
name:
First name: Middle name: Suffix
Section 9 – Citizenship
Select the box that reflects your current citizenship status and click Save.
Provide your current citizenship status: □ I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
□ I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country. □ I am a naturalized U.S. citizen. □ I am a derived U.S. citizen. □ I
am not a U.S. citizen.
Provide your Mother’s Maiden Name Last Name/First Name/ Middle Name/Suffix
Branch
Foreign Born
to U.S. Parents
in a Foreign
Country
You answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.
Provide type of documentation of U.S. citizen born abroad.
FS 240, DS 1350, FS 545, Other (Provide explanation)
Explanation
Provide document number for U.S. citizen born abroad: Document Number (Free Text)
Provide the date the document was issued. Date __-__-____ Estimated □
Provide the place of issuance. City State Country
Provide the name in which document was issued. Last name: First
name:
Middle
name:
Suffix
Provide your Certificate of Citizenship number. Certificate Number (Free Text)
Provide the date the certificate was issued.
Date __-__-____ Estimated □
Provide the name in which the certificate was issued. Last name: First
name:
Middle
name:
Suffix
Were you born on a U.S. military installation? YES NO
Branch If Yes
You answered that you were born on a U.S. military installation.
Provide the name of the base. Name (Free Text)
Branch
Citizenship
Naturalization
U.S Citizen
You answered that you are a naturalized U.S. citizen.
Provide the date of entry into the U.S. Date __-__-____ Estimated □
Provide the location of entry into the U.S. City State
Provide country(ies) of prior citizenship. Country (Allows for Multiples)
Do/did you have a U.S. alien registration number? YES NO
Branch If Yes Provide your U.S. alien registration number on
Certificate of Naturalization-utilize USCIS,
CIS, or INS registration number, I-551, I-766.
Alien Registration Number (Free Text)
Provide your Certificate of Naturalization number (N550 or N570). Certificate of Naturalization Number (Free Text)
Provide the name of the court that issued the Certificate of Naturalization Court (Free Text)
Provide the address of the court that issued the
Certificate of Naturalization
Street City State Zip
Provide the date the Certificate of Naturalization was issued. Date __ -__-____ Estimated □
Provide the name in which the Certificate of Naturalization was issued. Last
name:
First
name:
Middle
name:
Suffix
Provide the basis of naturalization. - Based on my own individual naturalization application,
- Other (Provide explanation)
Explanation
Branch
Citizenship
Derived
You answered that you are a derived U.S. citizen.
Provide your alien registration number (on Certificate of Citizenship — utilize USCIS, CIS or INS registration number) Alien
Registration Number (Free Text)
Provide your Permanent Resident Card number (I-551)
Permanent Resident Card number (I-551) (Free Text)
Provide your Certificate of Citizenship number (N560 or N561)
Certificate of Citizenship number (N560 or N561) (Free Text)
Provide the name in which the document was issued. Last name: First name: Middle name: Suffix:
Provide the date document was issued Date __-__-___ Estimated __
Provide the basis of derived citizenship. -By operation of law through my U.S. citizen parent .-Other (Provide explanation)
Explanation
Branch
Citizenship
Not a U.S.
citizen
Not a U.S. Citizen
Provide your residence status. Status (Free
Text)
Provide your date of entry into the
U.S.
Date __ -__-____ Estimated □
Provide your country (ies) of citizenship. Allow
multiple
Provide your place of entry in the U.S. City (Free Text) State
Provide your alien registration number. (I-1551, I-766) Registration Number (Free Text)
Provide document expiration date (I-766 ONLY). Date__-__-____ Estimated □
Provide type of document issued. (I-94, U.S. Visa-red
foil number, I-20, DS-2019, etc.)
I-94, U.S. Visa (red foil number), I-20, DS-2019,
Other (Provide explanation)
Explanation
Provide document number: Document Number (Free Text)
Provide the name in which the document was issued. Last name: First
name:
Middle
name:
Suffix
Provide the date document was issued. Date
Estimated
_-__-____
□
Provide document expiration
date.
Date
Estimated
_-__-____
□
Section 10 – Dual/Multiple Citizenship
Do you now or have you EVER held dual/multiple citizenships? YES NO
Branch
Dual/Multiple
Citizenship
(Multiple
Entries
Allowed)
You answered “Yes” to having EVER held dual/multiple citizenship
Provide country of citizenship 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
(Estimated)
To Date (Estimated/Present)
How did you acquire this non-U.S. citizenship you now have or previously had? How (Free Text)
Branch
If Present/Current
Do you currently hold citizenship with this country? YES NO
Provide explanation:
Summary of dual/multiple citizenships you have listed: Allow multiple
Select Country Value Dates of Citizenship Actions
Do you have an additional citizenship to provide? YES (Yes adds another entry) NO (Required to validate)
Section 11 – Where You Have Lived
Enter residence information. (Multiple Entries Allowed)
Provide dates of residence. From Date (Estimated ) To Date
(Estimated /Present)
Is/was this residence: □ Owned by you □ Rented or leased by you □ Military housing □ Other (Provide explanation) Explanation (Free Text)
List the places where you have lived beginning with your present residence and working back 5 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 for residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for periods of residence.
Provide the street address. Street address and City
Provide the country if outside the United States; otherwise provide
State and Zip Code
State Zip Code Country
Branch
Physical
Location
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country
location or home port/fleet headquarter. Provide physical location data:
Street Address/Unit/Duty Location: City or Post Name
Provide State for ports in United States, or Country location. State and Zip Code or Country
Branch
APO/FPO
Address
You have indicated an address outside of the United States.
Do/did you have an APO/FPO address while at this location? Yes No
Branch You have indicated that you have or had and APO/FPO while at this location.
Provide APO/FPO address: Address APO or FPO APO/FPO State Code Zip Code
Branch
Person Who
Knew you
(if address
dates within
last 3 years)
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
Provide the full name:
Last
name:
First
name:
Middle
name:
Suffix Provide date of last contact: Date MM-YYYY_ Estimated
□
Provide your relationship to this person (select all that apply) □ Neighbor □ Friend □ Landlord □ Business associate
□ Other (Provide explanation) Explanation (Free Text)
Provide the following contact information for this person :
Provide evening phone number for this
person:
Number/Extension
__Check box
if International or
DSN phone
number
_I don’t
know
Provide daytime phone number for this person: Number/Extension
__Check box if
International or
DSN phone number
_I don’t
know
Provide cell/mobile phone number for this person:
Number/Extension Time __Day __Night__Both
__Check box if International or DSN phone
number _I don’t know
Provide e-mail address for this person: Email (Free Text) _I don’t know
Provide street address for this person (including apartment
number).
Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code
State Zip Code Country
Branch
Physical
Location
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and
country location or home port/fleet headquarter. Provide physical location data:
Street Address/Unit/Duty Location: City or Post Name
Provide State for ports in United States, or Country location. State and Zip Code or Country
Branch
APO/FPO
Address
You have indicated an address outside of the U.S.
Does the person who knew you have an APO/FPO address? YES NO
Branch If Yes Provide APO/FPO address: Address APO or FPO APO/FPO State Code Zip Code
Do you have an additional residence to report? YES (Yes adds another entry) NO (Required to validate)
Section 12 – Where You Went to School
Do not list education before your 18th birthday, unless to provide a minimum of two years education history. (Multiple Entries Allowed)
Have you attended any schools in the last 5 years? YES NO
Branch
If Yes to
Attending
Schools
Have you received a degree or diploma more than 5 years ago? YES NO
Branch
If Yes to
Receiving
Degree
Provide the dates of attendance. From Date (Estimated) To Date (Estimated/Present)
Select the most appropriate box to describe your school. □ High School □ College/University/Military College
□ Vocational/Technical/Trade School □ Correspondence/Distance/Extension/Online School
Provide the name of the school: Name (Free Text)
Provide the street address of the school. For correspondence/distance/
extension/online schools, provide the address where the records are
maintained. For assistance determining the school address, refer to
Accreditation Records
Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code
State Zip Code Country
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
Provide the name of person who knows/knew you at school: □ I don’t know Last
name:
First
name:
Initial Only □
No First Name □
Provide current address for this person (including apartment number). Street City
Provide Country if outside the United States; otherwise, provide State and Zip
Code
State Zip Code Country
Provide telephone number for this person. Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
___ I don’t know
Provide email address for this person: □ I don’t know Email (Free Text)
Did you receive a degree/diploma? YES NO
Branch
If Yes to
Receiving Degree
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
Other Degree (Free Text)
Month / Year Date
Estimated
__-__-____
□
Do you have additional education to enter (include education within the last 5
years, as well as degrees or diplomas more than 5 years ago)?
YES (Yes adds
another entry)
NO (Required to
validate)
Section 13a – Employment Activities – Employment & Unemployment Record
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 5 years. The entire
period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of
military duty station. Provide separate entries for employment activities with the same employer but having different physical
addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.
(Multiple Entries Allowed)
Select your employment activity: □ Active military duty station □ National Guard/Reserve □ USPHS Commissioned Corps
□ Other Federal employment □ State Government (Non-Federal employment) □ Self-employment □ Unemployment
□ Federal Contractor □ Non-government employment (excluding self-employment) □ Other (Provide explanation)
Other Type Explanation (Free Text) Provide dates of employment. From Date (Estimated) To Date (Estimated/Present)
Branch
If Employment
Type is Active
Duty, National
Guard/Reserve,
or USPHS
Commissioned
Corps
Active Duty, National Guard/Reserve, or USPHS Commissioned Corps
Select the employment status for this position: □ Full-time □ Part-time
Provide your assigned duty
station during this period.
Duty station (Free Text) Provide your most recent
rank/position title.
Rank/position (Free Text)
Provide address of duty station. Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code.
State Zip Code Country
Telephone number Number/Extension Time Day Night Both
__Check box if International or DSN phone number
Branch
Physical
Location
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
unit, and country location or home port/fleet headquarter. Provide physical location data:
Street Address/Unit/Duty Location: City or Post Name:
Provide state for ports in the United States, or country location. State Zip
Code
Country
Branch
APO/FPO
Address
You have indicated an address outside of the United States. Do you or did you have an APO/FPO
address while at this location?
YES NO
Branch If Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code
Provide the name of your supervisor. Supervisor name (Free Text)
Provide the rank/position title of your supervisor. Supervisor rank/position (Free Text)
Provide the email address of your supervisor. □ I don’t know Supervisor email (Free Text)
Provide the physical work location of your supervisor. Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code
State Zip Code Country
Provide supervisor telephone number Number/Extension Time Day Night Both
__Check box if International or DSN phone number
Branch
Physical
Location
You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address,
base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your
supervisor:
Street Address/Unit/Duty Location: City or Post Name:
Provide state for ports in the United States, or country location. State and Zip Code or Country
Branch
APO/FPO
Address
You have indicated an address outside of the United States. Did/does your supervisor have an
APO/FPO address while at this location?
YES NO
Branch if Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code
Branch
If Employment
Type is Other
Federal
employment,
State
Government,
Federal
Contractor, Non-
government
employment, or
Other
Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other
Provide most recent position title. Position (Free Text)
Select the employment status for this position: □ Full-time □ Part-time
Provide the name of your employer Employer name (Free Text)
Provide the address of employer Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code
State Zip Code Country
Provide telephone number Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than
one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of
time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and
supervisors for the two previous periods of employment as entries below). Not Applicable □ (Multiple Entries Allowed)
Dates of employment From Date (Estimated) To Date (Estimated/Present)
Position title Position (Free Text) Supervisor Supervisor (Free Text)
Is/was your physical work address different than your employer’s address? YES NO
Branch
Physical
Location
Provide the work address where you are/were physically located. Street Address City
Provide Country if outside the United States; otherwise
provide State and Zip Code
State Zip Code Country
Provide the telephone number Number/Extension Time Day Night Both
__Check box if International or DSN phone number
Branch
Physical
Location
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
unit, and country location or home port/fleet headquarter. Provide physical location data:
Street Address/Unit/Duty Location: City or Post Name:
Provide state for ports in the United States, or country location. State Zip Code Country
Branch
APO/FPO
You have indicated an address outside of the United States. Do you or did you have an APO/FPO
address while at this location?
YES NO
Address Branch if Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code
Provide the name of your supervisor. Supervisor name (Free Text)
Provide the position title of your supervisor. Supervisor position (Free Text)
Provide the email address of your supervisor. □ I don’t know Supervisor email (Free Text)
Provide the physical work location of your supervisor. Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code
State Zip Code Country
Provide the telephone number for this supervisor. Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
Branch
Physical
Location
You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address,
base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your
supervisor:
Street Address/Unit/Duty Location: City or Post Name:
Provide state for ports in the United States, or country location. State and Zip Code or Country
Branch
APO/FPO
Address
You have indicated an address outside of the United States. Did/does your supervisor have an
APO/FPO address while at this location?
YES NO
Branch if Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code
Branch
If Employment
Type is Self-
Employment
Self-Employment
Provide most recent position title. Position (Free Text)
Select the employment status for this position: □ Full-time □ Part-time
Provide the name of your employment Employment name (Free Text)
Provide the address of employment Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code
State Zip Code Country
Provide telephone number Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
Is your physical work address different than your employment address? YES NO
Branch
Physical
Location
Provide the work address where you are/were physically
located.
Street address City
Provide Country if outside the United States; otherwise, provide State and Zip
Code
State Zip
Code
Country
Provide telephone number Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
Branch
Physical
Location
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
unit, and country location or home port/fleet headquarter. Provide physical location data:
Street Address/Unit/Duty Location: City or Post Name:
Provide state for ports in the United States, or country location. State Zip Code Country
Branch
APO/FPO
Address
You have indicated an address outside of the United States. Do you or did you have an APO/FPO
address while at this location?
YES NO
Branch if Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code
Provide the name of someone that can verify your self-employment. Last First
Provide the address of this verifier. Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code
State Zip Code Country
Provide the telephone number for this person Number/Extension Time Day Night Both
__Check box if International or DSN phone number
Branch
Verifier
Physical
Location
You have indicated an APO/FPO address for your self-employment verifier; provide physical location data with either
street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location
data for this person
Street Address/Unit/Duty Location: City or Post Name:
Provide state for ports in the United States, or country location. State Zip Code Country
Branch
Verifier
APO/FPO
Address
You have indicated an address outside of the United States. Does your self-employment verifier
have an APO/FPO address?
YES NO
Branch if Yes
Provide APO/FPO address for this person: Address APO/FPO
APO/FPO State Zip Code
Branch
If Employment
Type is
Unemployment
Unemployment
Provide the name of someone who can verify your unemployment activities and means of support Last
name:
First name:
Provide the address of this verifier. Street address City
Provide Country if outside the United States; otherwise,
provide State and Zip Code
State Zip Code Country
Provide the telephone number for this person Number/Extension Time Day Night Both _Check box if
International or DSN phone number
Branch
Verifier
Physical
Location
You have indicated an APO/FPO address for your unemployment verifier; provide physical location data with either
street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location
data for this person:
Street Address/Unit/Duty Location: City or Post Name:
Provide state for ports in the United States, or country location. State Zip Code Country
Branch
You have indicated an address outside of the United States. Does your unemployment verifier YES NO
Verifier
APO/FPO
Address
have an APO/FPO address?
Branch if Yes
Provide APO/FPO address for this person: Address APO/FPO
APO/FPO State Zip Code
Provide the reason for leaving the employment activity. Reason (Free Text)
Branch
If Employment
Type is Active
Duty, National
Guard/Reserve,
USPHS
Commissioned
Corps, Other
Federal
employment,
State
Government,
Federal
Contractor, Non-
government
employment,
Self-
Employment,
Unemployment,
or Other
For this employment have any of the following happened to you in the last five (5) years? YES NO
• Fired • Quit after being told you would be fired • Left by mutual agreement following charges or
allegations of misconduct • Left by mutual agreement following notice of unsatisfactory performance
Branch
If Fired, Quit,
Left by Mutual
Agreement, or
Left After
Unsatisfactory
Performance
(Multiple
Entries
Allowed)
Select the type of incident: • Fired • Quit after being told you would be fired
• Left by mutual agreement following charges or allegations of misconduct
• Left by mutual agreement following notice of unsatisfactory performance
Branch
If Fired
Provide the reason for being fired. Reason (Free Text)
Provide the date you were fired. Date (Estimated)
Branch
If Quit
Provide the reason for quitting. Reason (Free Text)
Provide the date you quit after being told you would
be fired.
Date (Estimated)
Branch
Provide the charges or allegations of misconduct. Charges (Free Text)
Provide the date you left following charges or
allegations of misconduct.
Date (Estimated)
If Left after Charges
Branch
If Left Unsatisfactory
performance
Provide the reason(s) for unsatisfactory performance. Reason (Free Text)
Provide the date you left by mutual agreement following
a notice of unsatisfactory performance.
Date (Estimated)
In the last five (5) years do you have another reason for leaving
to report for this employment?
YES (Yes adds
another entry)
NO (Required to
validate)
For this employment, in the last five (5) years have you received a written warning, been officially
reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?
YES NO
Branch
If Disciplined,
Warned,
Reprimanded, or
Suspended
(Multiple Entries
Allowed)
Officially reprimanded, suspended, or disciplined for misconduct.
Provide the month and year you were warned, reprimanded, suspended or
disciplined.
Date/ Estimated □
Provide the reason(s) for being warned, reprimanded, suspended or disciplined Reason (Free Text)
Do you have another instance of discipline or a warning
to provide? another entry)
YES (Yes adds NO (Required to
validate)
Do you have an additional employment activity to enter? YES (Yes adds another entry) NO (Required to validate)
Section 13b – Employment Record
Have any of the following happened to you in the last five (5) years at employment activities that you have not previously listed? (If Yes, you will be
required to add an additional employment in Section 13a) • 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?
YES NO
Section 14 – Selective Service Record
Were you born a male after December 31, 1959? YES NO
Branch
If Yes to Born
Male After
12/31/1959
Selective Service Registration
Have you registered with the Selective Service System (SSS)? I don’t know YES NO
Branch
If Yes
The Selective Service website can help provide the registration number for persons who have
registered. Note: Selective Service Number is not your Social Security Number
Provide registration number: Registration number (Free Text)
Branch
If No
You responded 'No' to having registered with the Selective Service System (SSS)
Provide explanation Explanation (Free Text)
Branch
If I Don’t Know
You responded 'I don't know' to having registered with the Selective Service System (SSS)
Provide explanation Explanation (Free Text)
Section 15 – Military History
Have you EVER served in the U.S. Military? YES NO
Branch
If Yes to
Serving in
the U.S.
Military
(Multiple
Entries
Allowed)
You responded ‘Yes’ to having served in the U.S. Military:
Provide the branch of service you served in: State of service, if
National Guard
Provide your status
Officer or enlisted:
Not Applicable
Officer
Enlisted
Provide your service number
(Free Text)
Number (Free Text)
□
□
□ Army □ Army National Guard
□ Navy □ Air Force □ Air National
Guard □ Marine Corps □ Coast Guard □
□ Active Duty □ Active
Reserve □ Inactive Reserve
Provide your dates of service From Date (Estimated) To Date (Estimated/Present)
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard? YES NO
Branch
If Yes to
Discharged
You responded ‘Yes’ to being discharged from U.S. military service, to include Reserves
or National Guard.
Provide the type of discharge you received: □ Honorable □ Dishonorable □ Under Other than Honorable Conditions
□ General □ Bad Conduct □ Other (provide type)
Provide other discharge type: Discharge explanation (Free Text)
Provide the date of discharge listed above Date (Estimated)
Branch If Discharge Not Honorable Provide the reason(s) for the discharge. Reason(s) (Free Text)
Do you have additional military service to report? YES (Yes adds
NO (Required
to
another entry) validate)
In the last 5 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,
YES NO
Article 135 Court of Inquiry, etc?
Branch
If Yes to
Military
Discipline
You responded ‘Yes’ to having 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 in the last 5 years.
Provide the date of the court martial or other disciplinary procedure. Date (Estimated)
Provide a description of the Uniform Code of Military Justice (UCMJ) offense(s) for which you
were charged.
Description (Free
Text)
Provide the name of the disciplinary procedure, such as Court Martial, Article 15, Captain’s mast,
Article 135 Court of Inquiry, etc.
Name
(Free Text)
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).
Description
(Free Text)
Provide the description of the final outcome of the disciplinary procedure, such as found guilty,
found not guilty, fine, reduction in rank, imprisonment, etc.
Description
(Free Text)
In the last 5 years do you have an additional
instance of military discipline to report?
YES (Yes adds another entry) NO (Required to validate)
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?
YES NO
Branch
If Yes to
Serving in a
Foreign
Military
(Multiple
Entries
Allowed)
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.
During your foreign service, which organization were you serving under: □ Military (Army, Navy, Air Force, Marines, etc.), Specify
□ Intelligence Service □ Diplomatic Service □ Security Forces □ Militia □Other Defense Forces, Specify □ Other Government Agency,
Specify
Provide the name of the foreign organization. Name (Free Text)
Provide your period of service From Date (Estimated) To Date (Estimated/Present)
Provide the name of the country Provide your highest position/rank
held
Position held (Free Text)
Provide the division/department/office in which you served. Division (Free Text)
Provide a description of the circumstances of your association with this organization. Description (Free Text)
Provide a description of the reason for leaving this service. Description (Free Text)
Do you have an additional foreign military service to report? YES (Yes adds NO (Required to
validate) another entry)
Section 16 – Police Record
For this section report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or
the charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an
expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.
Have any of the following happened? (If yes, you will be asked to provide details for each offense that pertains to the actions that are identified below.)
YES NO
• In the last five (5) years have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you? (Do not check if all
the citations involved traffic infractions where the fine was less than $300 and did not include alcohol or drugs.)
• In the last five (5) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
• In the last five (5) years have you been charged with, convicted of, or sentenced for a crime in any court? (Include all qualifying charges, convictions or
sentences in any Federal, state, local, military, or non-U.S. court, even if previously listed on this form).
• In the last five (5) years have you been or are
you currently on probation or parole?
• Are you currently on trial or awaiting a trial on criminal charges?
Branch
If Yes to the
Above
Happening
(Multiple
Entries
Allowed)
Provide the date of offense. Date (Estimated) Provide a description of the
specific nature of the offense.
Description (Free Text)
Provide the location where the offense occurred. Street address and city State and Zip Code or Country
Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police
officer, sheriff, marshal or any other type of law enforcement official?
YES NO
Branch
If Yes to Being
Arrested/Cited/
Summoned
Arresting/citing/summoning agency
Provide the name of the law enforcement agency that arrested/cited/summoned you. Name (free Text)
Provide the location of the law
enforcement agency.
Street address and city, County State and Zip Code or Country
As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court
in a criminal proceeding against you?
YES NO
Branch - If No
to Charged or
Convicted
You responded ‘No’ to “As a result of this offense were you charged, convicted, currently awaiting trial, and/or
ordered to appear in court in a criminal proceeding against you?”
Provide Explanation Explanation (Free Text)
Branch
If Yes to
Charged or
Convicted
Court information
Provide the name of the court. Name of court (Free Text)
Provide the location of the court. Street address and city State and Zip Code or Country
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found
guilty, found not-guilty, charge dropped or “nolle pros,” etc). If you were found guilty of or pleaded guilty to a lesser
offense, list separately both the original charge and the lesser offense.
Felony/Misdemeanor Felony, Misdemeanor, Other Charge Charge (Free Text)
Outcome Outcome (Free Text) Date (Month/Year) Date
(Est.)
Were you sentenced as a result of this offense? YES NO
Branch
If Yes to
Being
Sentenced
Conviction detail
Provide a description of the sentence.
If the conviction resulted in imprisonment, provide the dates
that you actually were incarcerated.
From Date (Estimated)
(Not Applicable ) □
To Date (Estimated/Present)
If conviction resulted in probation or parole, provide the From Date (Estimated)
dates of probation or parole. (Not Applicable □ ) To Date (Estimated/Present)
Branch
If No to
Being
Sentenced
Trial detail
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal
charges for this offense?
YES NO
Provide Explanation Explanation (Free Text)
Do you have any other offenses where any of the following has happened to you? YES
(Yes adds
another entry)
NO
(Required
to validate)
• In the last five (5) years have you been issued a summons, citation, or ticket to appear in
court in a criminal proceeding against you? (Do not include citations involving traffic
infractions where the fine was less than $300 and did not include alcohol or drugs)
• In the last five (5) years have you been arrested by any police officer, sheriff, marshal or
any other type of law enforcement official?
• In the last five (5) years have you been charged with, convicted of, or sentenced for a crime
in any court? (Include all qualifying charges, convictions, or sentences in a Federal, state,
local, military, or non-U.S. court even if previously listed on this form.)
• In the last five (5) years have you been or are you currently on probation or parole?
• Are you currently on trial or awaiting a trial on criminal charges?
Is there currently a domestic violence protective order or restraining order issued against you? YES NO
Branch
If Yes to
Domestic
Violence
(Multiple
Entries
Allowed)
You responded ‘Yes’ to currently having a domestic violence protective order or restraining order issued against you.
Provide explanation: Explanation (Free Text)
Provide the date the order was issued. Date (Estimated)
Provide the name of the court or agency that issued the order. Name of court (Free Text)
Provide the location of the court or agency that issued the order. Street address and city State and Zip Code or Country
Do you have another domestic violence protective order or
restraining order currently issued against you to report?
YES
(Yes adds another entry)
NO
(Required to validate)
Section 17 – Illegal Use of Drugs and Drug Activity
We note, with reference to this section, that neither your truthful responses nor information derived from your responses to this section will be used as
evidence against you in a subsequent criminal proceeding. This particular section applies whether or not you are currently employed by the Federal
government. The following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance activity not in accordance
with Federal laws, even if permissible under state laws.
In the last year have you illegally used any drugs or controlled substances? Use of a drug or controlled substance includes injecting,
snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug or controlled substance.
YES NO
Branch
If Yes to
Illegally Using
Drugs or
Controlled
Substances
(Multiple
Entries
Allowed)
You answered ‘Yes’ to in the last year having illegally used a drug or controlled substance.
Provide the type of drug or controlled substance. Explanation if other (Free Text)
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Other (Provide explanation):
Provide an estimate of the
month and year of first use.
Date (Estimated) Provide an estimate of the month
and year of most recent use.
Date (Estimated)
Provide nature of use, frequency, and number of times used. Nature of use (Free Text)
Do you have an additional instance(s) of illegal use of a drug or controlled
substance to enter?
YES
(Yes adds another entry)
NO
(Required to validate)
In the last year, have you been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping,
receiving, handling or sale of any drug or controlled substance?
YES NO
Branch
If Yes to
Illegal Drug
Activity
(Multiple
Entries
Allowed)
You answered ‘Yes’ to in the last year having been involved in the illegal purchase, manufacture, cultivation, trafficking, production,
transfer, shipping, receiving, handling or sale of a drug or controlled substance.
Provide the type of drug or controlled substance.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Other (Provide explanation free text):
Provide an estimate of the month
and year of first involvement.
Date
(Estimated)
Provide an estimate of the month and
year of most recent involvement.
Date (Estimated)
Provide nature of and frequency of activity. Nature of activity (Free Text)
Provide the reason(s) why you engaged in the activity. Reason(s) (Free Text)
Do you have an additional instance(s) of having been involved in the illegal purchase,
manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale
of a drug or controlled substance to enter?
YES
(Yes adds
another entry)
(Required to
validate)
NO
In the last year have you intentionally engaged in the misuse of prescription drugs, regardless of whether or not the drugs were
prescribed for you or someone else?
YES NO
Branch
If Yes to
Misuse of
Prescription
Drugs
(Multiple
Entries
Allowed)
You responded ‘Yes’ to in the last year having intentionally engaged in the misuse of prescription drugs, regardless of whether the drugs
were prescribed for you or someone else.
Provide the name of the prescription drug that you misused. Drug names (Free Text)
Provide the dates of involvement in the above. From Date (Estimated) To Date (Estimated/Present)
Provide the reason(s) for and circumstances of the misuse of the prescription drug. Reasons (Free Text)
Do you have an additional instance(s) of intentionally engaging in the misuse
of prescription drugs in the last year to enter?
YES
(Yes adds another entry)
NO
(Required to validate)
In the last year have you been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or
controlled substances?
YES NO
Branch
If Yes to
Being Ordered
Treatment for
the Misuse of
Drugs
(Multiple
Entries
Allowed)
You responded ‘Yes’ to having in the last year, been ordered, advised, or asked to seek counseling or treatment as a result of your illegal
use of drugs or controlled substances
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or
controlled substances? (Select all that apply)
□ An employer, military commander, or employee assistance program □ A medical professional
□ A mental health professional □ A court official / judge
□ I have not been ordered, advised, or asked to seek counseling or treatment by any of the above.
Provide explanation Explanation (Free Text) Did you take action to receive counseling or treatment? YES NO
Branch If No
to Action Taken
You have indicated that you did not receive treatment. Provide explanation. Explanation (Free Text)
Provide the type of drug or controlled substance for which you were treated.
Branch
If Yes to Action
Taken
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Explanation (Free Text) Provide the name of the treatment
provider. (Last name, First name)
Name (Last name, First name)
Provide the address for this treatment provider. Street address and city State and Zip Code or Country
Provide a telephone number for the treatment provider. Number/Ext. Extension Time Day
Night Both _Check box if
International
Provide the dates of treatment. Date From (Estimated) Date To (Estimated/Present)
Did you successfully complete the treatment? YES NO
Branch If No
to Successful
Treatment
You have indicated that you did not successfully
complete the treatment. Provide explanation.
Explanation (Free Text)
Do you have another instance of having been ordered, advised, or asked
to seek drug or controlled substance counseling or treatment to enter?
YES
(Yes adds another entry)
NO
(Required to validate)
In the last year have you voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance? YES NO
Branch
If Yes to
Voluntarily
Seeking
Treatment for
the Misuse of
Drugs
(Multiple
Entries
Allowed)
Voluntary treatment detail
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Other (Provide explanation free text)
Provide the name of the treatment provider. (Last name, First name) Name (Free Text)
Provide the address for this treatment provider. Street address and city State and Zip Code or Country
Provide a telephone number for the treatment provider. Number/Extension Time Day Night
Both _ Check box if International
Provide the dates of treatment. Date From (Estimated) Date To (Estimated/Present)
Did you successfully complete the treatment? YES NO
Branch If No to
Successful Treatment
You have indicated that you did not successfully complete the
treatment. Provide explanation.
Explanation (Free Text)
Do you have another instance of voluntarily seeking counseling or
treatment as a result of your use of a drug or controlled substance in the
last year?
YES
(Yes adds another entry)
NO
(Required to validate)
Section 18 – Investigations and Clearance Record
Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a security clearance
eligibility/access?
YES NO
Branch
If Yes to Having
Ever Been
Investigated
(Multiple Entries
Allowed)
You responded ‘Yes’ to the U.S. Government (or a foreign government) having investigated your background and/or having granted
you a security clearance eligibility/access.
Provide the investigating agency: □ U.S. Department of Defense □ U.S. Department of State
□ U.S. Office of Personnel Management □ Federal Bureau of Investigation
□ U.S. Department of Treasury (Provide name of bureau)
□ U.S. Department of Homeland Security
□ Foreign government (Provide name of government) I don’t know □
□ Other (Provide explanation)
Explanation or name of government or
bureau. (Free Text)
Date the investigation was completed. □ I don’t know Date (Estimated)
Was a clearance eligibility/access granted? Yes No
If yes, to having
clearance
eligibility/access
granted
(Multiple Entries
Allowed)
Provide the name of agency that issued the clearance eligibility/access if
different from the investigating agency.
Name (Free Text)
Provide the date clearance eligibility/access was granted. □ I don’t
know
Date (Estimated)
□ □ □ □
□ □ □ □
know
□ □
1E a
Provide the level
of clearance
eligibility/access
granted.
None Confidential Secret Top Secret
Sensitive Compartmented Information (SCI) Q L I don’t
Issued by foreign country Other (Provide explanation)
Explanation
(Free Text)
Do you have another investigation to enter? YES (Yes adds another entry) NO (Required to validate)
In the last five (5) years have you had a security clearance eligibility/access authorization denied, suspended, or revoked? (Note: An
administrative downgrade or administrative termination of a security clearance is not a revocation.)
YES NO
Branch
If Yes to Denied
(Multiple Entries
Allowed)
You responded ‘Yes’ to having a security clearance eligibility/access authorization denied, suspended, or revoked within the last five
(5) years.
Provide the date security clearance eligibility/access authorization was denied, suspended or revoked. Date (Estimated)
Provide the name of the agency that took the action. Name (Free Text)
Provide an explanation of the circumstances of the denial, suspension or revocation action. Explanation (Free Text)
Do you have another denied, revoked or suspended security
clearance eligibility/access authorization to enter?
YES
(Yes adds another entry)
NO
(Required to validate)
In the last five (5) years have you been debarred from government employment? YES NO
Branch
If Yes to
Debarment
(Multiple Entries
Allowed)
You responded ‘Yes’ to in the last 5 years having been debarred from government employment.
Provide the name of the government agency taking debarment action. Agency name
Provide the date the debarment occurred. Date (Estimated)
Provide an explanation of the circumstances of the debarment Circumstances (Free text)
Do you have another Government debarment to enter? YES (Yes adds another entry) NO (Required to validate)
Section 19 – Financial Record
In the last five (5) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance? YES NO
Branch
If Yes to
Failing to
File/Pay Taxes
(Multiple
Entries
Allowed)
You responded ‘Yes’ to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.
Did you fail to file, pay as required, or both? File Pay Both □ □ □
Provide the year you failed to file or pay your Federal, state or other taxes. Est.
Provide the reason(s) for your failure to file or pay required taxes. Reasons (Free Text)
Provide the Federal, state or other agency to which you failed to file or pay taxes. Agency (Free Text)
Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.). Tax Type (Free Text)
Provide the amount (in U.S. dollars) of the taxes. Estimated □ Amount (Free Text)
Provide date satisfied. Not applicable □ Date (Estimated)
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.
Description (Free Text)
Are there any other instances in the last five (5) years where you failed to
file or pay Federal, state or other taxes when required by law or ordinance?
YES
(Yes adds another entry)
NO
(Required to validate)
Other than previously listed, has the following happened to you? (You will be asked to provide details about each financial obligation that pertains to the
items identified below).
• You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for which you are a
c
osigner or guarantor).
YES NO
Provide the associated loan / account number(s) involved Loan / account number (Free Text)
Identify/describe the type of property involved (if any). Property type (Free Text)
Provide the amount (in U.S. dollars) of the financial issue. □ Estimated Amount (Free Text)
Provide the reason(s) for the financial issue. Reasons (Free Text)
Provide the current status of the financial issue. Status (Free Text)
Provide the date the financial issue began. Date (Estimated)
Provide date the financial issue was resolved. Not resolved □ Date (Estimated)
Provide the name of the court involved. Court name (Free Text)
Provide the address of the court involved. Street address and City State and Zip Code or Country
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.
Description (Free Text)
Other than previously listed, are there any other instances of the following occurrence?
• You are currently delinquent on any Federal debt. (Include financial obligations for which you are the sole debtor, as well as those for
which you are a cosigner or guarantor).
□ YES (Yes adds another entry)
□ NO (Required to validate)
Section 20 – Association Record
The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an
adverse employment or credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are
dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or
coercion or to affect the conduct of a government by mass destruction, assassination or kidnapping.
Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an awareness of the
organization’s dedication to that end, or with the specific intent to further such activities?
YES NO
Branch
If Yes to Being a
You responded ‘Yes’ to being or EVER having been a member of an organization dedicated to terrorism, either with an awareness of
the organization’s dedication to that end, or with the specific intent to further such activities.
Provide the full name of the organization. Organization name (Free Text)
Member of a
Terrorist
Organization
(Multiple Entries
Allowed)
Provide the address/location of the organization. Street address and City State and Zip Code or Country
Provide the dates of your involvement with the organization. From Date (Estimated) To Date (Estimated/Present)
Provide all positions held in the organization, if any. □ No positions held Positions (Free Text)
Provide all contributions made to the organization, if any. □ No contributions made Contributions (Free Text)
Provide a description of the nature of and reasons for your involvement with the organization. Involvement (Free Text)
Do you have any other instances of being a member of an organization dedicated to
terrorism, either with an awareness of the organization’s dedication to that end, or with the
specific intent to further such activities to report?
YES
(Yes adds
another entry)
NO
(Required to
validate)
Have you EVER knowingly engaged in any acts of terrorism? YES NO
To Date (Estimated/Present)
Branch If Yes
Engaging in
Terrorism
(Multiple Entries
Allowed)
You responded ‘Yes’ to EVER having knowingly engaged in any acts of terrorism.
Describe the nature and reasons for the activity. Nature and reasons (Free Text)
Provide the dates for any such activities From Date (Estimated)
Do you have any other instances of knowingly engaging in acts of
terrorism to report?
YES
(Yes adds another entry)
NO
(Required to validate
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force?
YES
NO
Branch
If Yes to
Advocating
(Multiple Entries
Allowed)
You responded ‘Yes’ to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by
force.
Provide the reason(s) for advocating acts of terrorism. Reasons (Free Text)
Provide the dates of advocating acts of terrorism From Date (Estimated) To Date (Estimated/Present)
Do you have any other instances of advocating acts of terrorism or activities
designed to overthrow the U.S. Government by force to report?
YES (Yes adds
another entry)
NO (Required to
validate)
Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States
Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or with the
specific intent to further such activities?
YES NO
Branch
You responded ‘Yes’ to having EVER been a member of an organization dedicated to the use of violence or force to overthrow the
United States Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or
with the specific intent to further such activities.
If Yes to being
Member of
Organization
Using Violence
to Overthrow the
U.S. Govt.
Provide the full name of the organization. Organization name (Free Text)
Provide the address/location of the organization. Street address and City State and Zip Code or Country
Provide the dates of your involvement with the organization From Date (Estimated) To Date (Estimated/Present)
Provide all positions held in the organization, if any. □ No positions held Positions (Free Text)
Provide all contributions made to the organization, if any. □ No contributions made Contributions (Free Text)
Provide a description of the nature of and reasons for your involvement with the organization. Description (Free Text)
(Multiple Entries
Allowed)
Do you have any other instances of being a member of an organization dedicated to the use
of violence or force to overthrow the United States Government, which engaged in
activities to that end with an awareness of the organization’s dedication to that end or with
the specific intent to further such activities to report?
YES
(Yes adds
another entry)
NO
(Required to
validate)
Have you EVER been a member of an organization that advocates or practices commission of acts of force or violence to
discourage others from exercising their rights under the U.S. Constitution or any state of the United States with the specific intent to
further such action?
YES NO
Branch
If Yes to Being a
Member of
Organization
Using Violence
(Multiple Entries
Allowed)
You responded ‘Yes’ to being or EVER having been a member of an organization that advocates or practices commission of acts of
force or violence to discourage others from exercising their rights under the U.S. Constitution or that of any state of the U.S. with the
specific intent to further such action.
Provide the full name of the organization. Organization Name (Free Text)
Provide the address/location of the organization. Street address and City State and Zip Code or Country
Provide the dates of your involvement with the organization From Date (Estimated) To Date (Estimated/Present)
Provide all positions held in the organization, if any. □ No positions held Positions (Free Text)
Provide all contributions (in U.S. dollars) made to the organization, if any. □ No contributions
made
Contributions (Free Text)
Provide a description of the nature of and reasons for your involvement with the organization. Involvement (Free Text)
Do you have any other instances of being a member of an organization that advocates or
practices commission of acts of force or violence to discourage others from exercising
their rights under the U.S. Constitution or any state of the United States with the specific
intent to further such action to report?
YES
(Yes adds
another entry)
NO
(Required to
validate)
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force? YES NO
Branch If Yes to
Activities to
Overthrow
(Multiple Entries
Allowed)
You responded ‘Yes’ to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.
Describe the nature and reasons for the activity. Reasons (Free Text)
Provide the dates of such activities. From Date (Estimated) To Date Estimated/Present)
Do you have any other instances of having knowingly engaged in activities
designed to overthrow the U.S. Government by force to report?
YES
(Yes adds another entry)
NO
(Required to validate)
Have you EVER associated with anyone involved in activities to further terrorism? YES NO
Branch If Yes to
Having
Terrorism
Association
Terrorism Association Detail
Provide Explanation Explanation (Free Text)
Additional Comments
After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate,
and then sign and date the fol
lowing certification and the attached release(s).
Certification
My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in
good faith. I have carefully re
ad the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this
form can be punished by fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or
falsifying information may have a negative effect on my employment prospects, or job status, or my removal and debarment from Federal
service
Signature (Sign in ink)
Date (mm/dd/yyyy)
Standard Form 85 Revised
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
OMB No. 3206-0261
Questionnaire For Non-Sensitive Positions
United States of America
Authorization For Release of Information
Carefully read this authorization to release information about you, then sign and date.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation or reinvestigation to obtain any information relating to my activities, conduct, and
character from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus,
consumer reporting agencies, collection agencies, retail business establishments, or other sources of information. This
information may include, but is not limited to current and historic academic, residential, achievement, performance,
attendance, disciplinary, employment, criminal, financial, and credit information, and publicly available social media
information. I authorize the Federal agency conducting my investigation to disclose the record of investigation or ongoing
evaluation to the requesting agency for the purpose of making a determination of suitability or eligibility for a non-sensitive
position and/or for physical or logical access to federal facilities and information systems.
I Understand that, for these purposes, publicly available social media information includes any electronic social media
information that has been published or broadcast for public consumption, is available on request to the public, is accessible
on-line to the public, is available to the public by subscription or purchase, or is otherwise lawfully accessible to the
public. I further understand that this authorization does not require me to provide passwords; log into a private account; or
take any action that would disclose non-publicly available social media information.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social
Security Number, and date of birth with information in SSA records and provide the results of the match) to the United
States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my investigation for the
purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the other Federal agency
requesting or conducting my investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other
sources of information, separate specific release may be needed, and I may be contacted for such releases at a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of
Investigation, the Department of Defense, the Department of Homeland Security, the Office of the Director of National
Intelligence, Department of State, and any other authorized Federal agency, to request criminal record information about
me from criminal justice agencies for the purpose of determining my suitability or eligibility for appointment to, or
retention in, a non-sensitive position, in accordance with 5 U.S.C. 9101 or my eligibility for logical or physical access. I
understand that I may request a copy of such records as may be available to me under the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information upon
request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above
regardless of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by the
Federal Government only for the purposes provided in this Standard Form 85, and that it may be disclosed by the
Government only as authorized by law.
I Authorize the information to be used to conduct officially sanctioned and approved suitability-related studies and
analyses, which will be maintained in accordance with the Privacy Act.
Photocopies of this authorization with my signature are valid. This authorization is valid for five (5) years from the
date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink) Full name (Type or print legibly) Date signed (mm/dd/yyyy)
Other names used Date of birth Social Security Number
Current street address Apt. # City (Country) State ZIP Code
Telephone number
Standard Form 85
Revised
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
OMB No. 3206-0261
SF 85 Questionnaire For Non-Sensitive Positions
United States of America
Fair Credit Reporting Disclosure and Authorization
Disclosure
One or more reports from consumer reporting agencies may be obtained for employment
purposes pursuant to the Fair Credit Reporting Act, codified at 15 U.S.C. § 1681 et seq.
Purpose
Depending on circumstances within your background, the Federal government may require
information from one or more consumer reporting agencies in order to obtain information in
connection with a background investigation, reinvestigation, or ongoing evaluation (i.e.
continuous evaluation) for positions designated as low risk, non-sensitive, and for physical and
logical access. The information obtained may be disclosed to other Federal agencies for the
above purposes in fulfillment of official responsibilities to the extent that such disclosure is
permitted by law. Information from the consumer report will not be used in violation of any
applicable Federal or state equal employment opportunity law or regulation.
Authorization
I hereby authorize any investigator, special agent, or other duly accredited representative of the
authorized Federal agency conducting my initial background investigation, reinvestigation, or
ongoing evaluation (i.e. continuous evaluation) for positions designated as low risk, non-
sensitive, and for physical and logical access to request, and any consumer reporting agency to
provide, such reports for the purposes described above.
Note: If you have a security freeze on your consumer or credit report file, we will not be able to
access the information necessary to complete your investigation, which can adversely affect your
eligibility for a non-sensitive position. To avoid such delays, you should expeditiously respond
to any request made to release the credit freeze for the purposes as described above.
Photocopies of this authorization with my signature are valid. This authorization shall remain in
effect so long as I occupy a non-sensitive position.
Print name Social Security Number
Signature (Sign in ink) Date (mm/dd/yyyy)
