Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 QUESTIONNAIRE FOR NATIONAL SECURITY 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 23, 27, and 29, 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, reinvestigations, and continuous evaluations of persons under consideration for, or retention of, national security positions as defined in 5 CFR 732, and for individuals requiring eligibility for access to classified information under Executive Order 12968. This form may also be used by agencies in determining whether a subject performing work for, or on behalf of, the Government under a contract should be deemed eligible for logical or physical access when the nature of the work to be performed is sensitive and could bring about an adverse effect on the national security . 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 national security position, eligibility for access to classified information, 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 access to classified information, eligibility for a sensitive position, 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, loss of eligibility for access to classified information, or prosecution. This form is a permanent document that may be used as the basis for future investigations, eligibility determinations for access to classified information, or to hold a sensitive position, 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 SF-86 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 Orders 10450, 10865, 12333, and 12968; sections 3301, 3302, and 9101 of title 5, United States Code (U.S.C.); sections 2165 and 2201 of title 42, U.S.C.; chapter 23 of title 50, U.S.C.; and parts 2, 5, 731, 732, and 736 of title 5, Code of Federal Regulations (CFR). 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. Form approved: OMB No. 3206 0005 The Investigative Process Background investigations for national security positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and loyal to the U.S. The information that you provide on this form 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, then we may not be able to complete your investigation, which can adversely affect your eligibility for a national security position. To avoid such delays, you should 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, honesty and integrity, vulnerability to exploitation or coercion, falsification, misrepresentation, and any other behavior, activities, or associations that tend to demonstrate a person is not reliable, trustworthy, or loyal. Federal agency records checks may be conducted on your spouse, cohabitant(s), and immediate family members. After an eligibility determination has been completed, you also may be subject to continuous evaluation, which may include periodic reinvestigations, to determine whether retention in your position is clearly consistent with the interests of national security. Your Personal Interview Some investigations will include an interview with you as a routine 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. It is imperative that the interview be conducted immediately after you are contacted. 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. These matters include (a) alien registration or naturalization documents; (b) delinquent loans or taxes, bankruptcies, judgments, liens, or other financial obligations; (c) agreements involving child custody or support, alimony, or property settlements; (d) arrests, convictions, probation, and/or parole; or (e) other matters described in court records. 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. Type or legibly print your answers in ink. If the form is not legible, it will not be accepted. You may also be asked to submit your form using the approved electronic format. 3. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form with "N/A," unless otherwise noted. 4. Any changes that you make to this form, after you sign it, must be initialed and dated by you. Under extremely limited circumstances, agencies may modify your response(s) with your consent. 5. You must use the Location codes (abbreviations), immediately following the Privacy Act Routine Uses, when you fill out this form. Do not abbreviate the names of cities or foreign countries. 6. Place of birth requires Country entry, even if in the U.S. 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 7. 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. records by the Department of Justice is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records. 8. For telephone numbers in the U.S., ensure that the area code is included. 2. To a court or adjudicative body in a proceeding when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such records is therefore deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the records. 9. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use numbers (01-12) to indicate months. For example, July 29, 1968, should be written as 07/29/1968. If you are unable to report an exact date, approximate or estimate the date to the best of your ability, and indicate "APPROX." or "EST" in the field. 10. If additional space is required for an explanation or to list your residences, employment/self- employment/unemployment, or education, you should use a continuation sheet, SF 86A, located at http://www.opm.gov/forms, select standard forms. If additional space is required to answer other items, use the Continuation Space, on page 121, or a blank sheet(s) of paper. Include your name and SSN at the top of each blank sheet (s) used. Final Determination on Your Eligibility Final determination on your eligibility for a national security position is the responsibility of the Federal agency that requested your investigation and the agency that conducted your investigation. You will 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 race, color, religion, sex, national origin, disability, or sexual orientation when granting access to classified information. 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, do not grant a security clearance, 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 or security clearance 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 national security 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. The office that gave you this form will provide you a copy of its routine uses. Privacy Act Routine Uses 1. To the Department of Justice when: (a) the agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the employee; or (d) the United States Government, is a party to litigation or has interest in such litigation, and by careful review, the agency determines that the records are both relevant and necessary to the litigation and the use of such 3. Except as noted in Sections 23 and 27, when a record on its face, or in conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute, particular program statute, regulation, rule, or order issued pursuant thereto, the relevant records may be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order. 4. To any source or potential source from which information is requested in the course of an investigation concerning the hiring or retention of an employee or other personnel action, or the issuing or retention of a security clearance, contract, grant, license, or other benefit, to the extent necessary to identify the individual, inform the source of the nature and purpose of the investigation, and to identify the type of information requested. 5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains information relevant to the retention of an employee, or the retention of a security clearance, contract, license, grant, or other benefit. The other agency or licensing organization may then make a request supported by written consent of the individual for the entire record if it so chooses. No disclosure will be made unless the information has been determined to be sufficiently reliable to support a referral to another office within the agency or to another Federal agency for criminal, civil, administrative, personnel, or regulatory action. 6. To contractors, grantees, experts, consultants, or volunteers when necessary to perform a function or service related to this record for which they have been engaged. Such recipients shall be required to comply with the Privacy Act of 1974, as amended. 7. To the news media or the general public, factual information the disclosure of which would be in the public interest and which would not constitute an unwarranted invasion of personal privacy. 8. To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison channels to selected foreign governments, in order to enable an intelligence agency to carry out its responsibilities under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or any successor order, applicable national security directives, or classified implementing procedures approved by the Attorney General and promulgated pursuant to such statutes, orders or directives. 9. To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained. 10. To the National Archives and Records Administration for records management inspections conducted under 44 U.S.C. 2904 and 2906. 11. To the Office of Management and Budget when necessary to the review of private relief legislation. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS LOCATION CODES Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia AL AK AZ AR CA CO CT DE DC FL GA Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland HI ID IL IN IA KS KY LA ME MD Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey MA MI MN MS MO MT NE NV NH NJ New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina NM NY NC ND OH OK OR PA RI SC South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming SD TN TX UT VT VA WA WV WI WY American Samoa Baker Island Guam Howland Island Jarvis Island AS FQ GU HQ DQ Johnson Atoll Kingman Reef Marshall Islands Micronesia, Federated States JQ KQ MH FM Midway Islands Navassa Island Northern Mariana Islands Palau MQ BQ MP PW Palmyra Atoll Puerto Rico Virgin Islands, United States LQ PR VI Wake Island APO/FPO America APO/FPO Europe APO/FPO Pacific WQ AA AE AP PUBLIC BURDEN INFORMATION Public burden reporting for this collection of information is estimated to average 150 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, Federal Investigative Services, Attn: OMB Number 3206-0005, 1900 E. Street N.W., Washington, DC 20415. Do not send your completed form to this address; send it to the office that provided you the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. AGENCY USE BLOCK "AUB" Case Number: Codes: (FIPC CODES) Investigating agency user only FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION PROVIDED IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE, THOSE DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION. A Type of investigation B Extra coverage/Advance results F Date of action (Month/Day/Year) G Geographic location K Location of official personnel folder C Sensitivity level Compu/ADP D Access/Eligibility E Nature of action code H Position code I Position title J SON (Submitting Office Number) None L SOI (Security Office Identifier) NPRC M Location of security folder N IPAC O Treasury Account Symbol At SON Other Other address/Web address of e-OPF e-OPF None At SOI Other address NPI Other P Obligating document number R Accounting data and/or Agency case number Zip Code Zip Code Q Business Event Type Code S Investigative requirement Initial Reinvestigation T Requesting official - Name Title Signature Email address Telephone number (Include Ext.) U Secondary requesting official - Name Date (Month/Day/Year) Title Telephone number (Include Ext.) Email address V Applicant affiliation FED CIV MIL CON Other W Deployment/PCS - (Do not provide deployment data if Classified or Sensitive information) Location (if imminent) From (Month/Day/Year) Est. Point of contact at location Telephone number (Include Ext.) To (Month/Day/Year) Commercial and Government Entity (CAGE) Code Agency Special Instructions for the Investigative Service Provider. Reason(s) for temporary duty assignment or PCS Est. Permanent Relocation Address/Unit/Duty location (Include City or Post Name) Contract Number Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW 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), denial or revocation of a security clearance, and/or removal and debarment from Federal Service. YES NO 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. Suffix First name Last name Middle name Section 2 - Date of Birth Section 3 - Place of Birth Provide your date of birth. Provide your place of birth. City (Month/Day/Year) State County Country (Required) Section 4 - Social Security Number Provide your U.S. Social Security Number. Not applicable Section 5 - Other Names Used Have you used any other names? YES NO (If NO, proceed to Section 6) Complete the following if you have responded 'Yes' to having used other names. 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)]. If you have only initials in your name(s), provide them and indicate "Initial only." If you do not have a middle name (s), indicate "No Middle Name" (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix. #1 Last name First name To (Month/Year) From (Month/Year) Est. Present Maiden name? YES Est. #2 Last name To (Month/Year) Est. Present Maiden name? YES To (Month/Year) Est. Present Maiden name? YES To (Month/Year) Est. Present Provide the reason(s) why the name changed NO First name From (Month/Year) Suffix Middle name Est. #4 Last name Provide the reason(s) why the name changed NO First name From (Month/Year) Suffix Middle name Est. #3 Last name Provide the reason(s) why the name changed NO First name From (Month/Year) Suffix Middle name Suffix Middle name Maiden name? Est. YES Provide the reason(s) why the name changed NO Section 6 - Your Identifying Information Provide your identifying information. Weight (in pounds) Height (feet) Hair color (inches) Enter your Social Security Number before going to the next page Page 1 Eye color Sex Female Male Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 7 - Your Contact Information Provide your contact information. Home e-mail address Work e-mail address International or DSN phone number Home telephone number Extension International or DSN phone number Day Work telephone number Extension Night International or DSN phone number Mobile/Cell telephone number Extension Day Night Day Night 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 Issue date (Month/Day/Year) Expiration date (Month/Day/Year) The following link will provide U.S. State Department passport help. http://travel.state.gov/passport Est. Est. Provide the name in which passport was first issued. First name Last name Suffix Middle name 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. I am a naturalized U.S. citizen. (Complete 9.2) I am not a U.S. citizen. (Complete 9.3) (Complete 9.1) 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 type of documentation of U.S. citizen born abroad. FS240 or FS545 DS 1350 Other (Provide explanation) Provide document number for U.S. citizen born abroad. Provide the date the document was issued. (Month/Day/Year) Est. Provide the place of issuance. (Provide City and Country if outside the United States; otherwise, provide City and State.) State Country City Provide the name in which document was issued. First name Last name Provide your citizenship certificate number. Provide the name of the court that issued the citizenship certificate. Provide the address of the court that issued the citizenship certificate. Street Provide the name in which the certificate was issued. First name Last name Provide the date the certificate was issued. (Month/Day/Year) Est. State City Middle name Were you born on a U.S. military installation? YES Enter your Social Security Number before going to the next page Page 2 Suffix Middle name NO (If NO, proceed to Section 10) Zip Code Suffix Provide the name of the base. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 9 - Citizenship - (Continued) 9.2 Complete the following if you answered that you are a naturalized U.S. citizen. Provide the location of entry into the U.S. City Provide the date of entry into the U.S. (Month/Day/Year) State Est. Provide country(ies) of prior citizenship. #1 Country #2 Country Do/did you have a U.S. alien registration number? YES NO Provide your U.S. alien registration number. Provide your citizenship certificate number. Provide the name of the court that issued the citizenship certificate. Provide the date the citizenship certificate was issued. (Month/Day/Year) Est. Provide the address of the court that issued the citizenship certificate. Street State City Provide the name in which the citizenship certificate was issued. First name Last name Middle name Zip Code Suffix Provide the date the naturalization certificate was issued. (Month/Day/Year) Provide your naturalization certificate number. Est. Provide the name of the court that issued the naturalization certificate. Provide the address of the court that issued the naturalization certificate. State Street City Provide the name in which the naturalization certificate was issued. First name Last name Provide the basis of naturalization. Based on my own individual naturalization application Middle name Zip Code Suffix Other (Provide explanation) By operation of law through my U.S. citizen parent 9.3 Complete the following if you answered that you are not a U.S. Citizen. Provide your residence status. Provide your date of entry in the U.S. (Month/Day/Year) Est. Provide country(ies) of prior citizenship. #1 Country #2 Country Provide your place of entry in the U.S. City State Provide your alien registration number. Provide type of document issued. (I-94, etc.) I-94 U.S. Visa Other (Provide explanation) Provide document number. Provide the date document was issued (Month/Day/Year) Provide the expiration date of visa. (Month/Day/Year) Est. Provide the name in which the document was issued. First name Last name Enter your Social Security Number before going to the next page Page 3 Est. Middle name Suffix Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 10 - Dual/Multiple Citizenship & Foreign Passport Information YES 10.1 Do you now or have you EVER held dual/multiple citizenships? NO (If NO, proceed to 10.2) 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) To Date (Month/Year) Present Est. Est. Have you taken any action to renounce your foreign citizenship? YES NO Provide explanation: Do you currently hold citizenship with this country? YES NO Provide explanation: Entry #2 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) To Date (Month/Year) Present Est. Est. Have you taken any action to renounce your foreign citizenship? YES NO Provide explanation: Do you currently hold citizenship with this country? YES NO Provide explanation: 10.2 Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.? YES NO (If NO, proceed to Section 11) 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 date the passport (or identity card) was issued. (Month/Day/Year) Provide the country in which the passport (or identity card) was issued. Est. Provide the place the passport (or identity card) was issued. City Country Provide the name in which passport (or identity card) was issued. First name Last name Middle name Provide the passport (or identity card) number. Suffix Provide the passport (or identity card) expiration date. (Month/Day/Year) Est. Have you EVER used this passport (or identity card) for foreign travel? YES NO 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 Page 4 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (Continued) 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 #2 Provide the date the passport (or identity card) was issued. (Month/Day/Year) Provide country in which the passport (or identity card) was issued. Est. Provide the place the passport (or identity card) was issued. City Country Provide the name in which passport (or identity card) was issued. First name Last name Middle name Provide the passport (or identity card) number. Suffix Provide the passport (or identity card) expiration date. (Month/Day/Year) Est. Have you EVER used this passport (or identity card) for foreign travel? YES NO 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 Page 5 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS 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. Enter residence information. Entry #1 Is/was this residence: Provide dates of residence. From Date (Month/Year) To Date (Month/Year) Est. Present Owned by you Rented or leased by you Est. Military housing Other (Provide explanation) Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Street State Zip Code Country If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Did you have an APO/FPO address while at this location? Address YES State Country Zip Code APO or FPO APO/FPO State Code Zip Code NO Provide the name of a neighbor or other person who knows you at this address. First name Last name Middle name Provide date of last contact. Suffix (Month/Year) Est. Provide your relationship to this person (Check all that apply). Neighbor Friend Landlord Business associate Other (Provide explanation) Provide the following contact information for this person. I don't know International or DSN phone number Evening telephone number Extension I don't know I don't know International or DSN phone number Daytime telephone number Extension International or DSN phone number Cell/mobile telephone number Extension Provide e-mail address for this person. I don't know 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.) City Country Street State Zip Code If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Does the person who knew you have an APO/FPO address? Address YES NO Enter your Social Security Number before going to the next page Page 6 State APO or FPO Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 11 - Where You Have Lived - (Continued) Enter residence information. Entry #2 Is/was this residence: Provide dates of residence. From Date (Month/Year) To Date (Month/Year) Est. Present Owned by you Rented or leased by you Est. Military housing Other (Provide explanation) Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Street State Zip Code Country If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Did you have an APO/FPO address while at this location? Address YES State Country Zip Code APO or FPO APO/FPO State Code Zip Code NO Provide the name of a neighbor or other person who knows you at this address. First name Last name Middle name Provide date of last contact. Suffix (Month/Year) Est. Provide your relationship to this person (Check all that apply). Neighbor Friend Landlord Business associate Other (Provide explanation) Provide the following contact information for this person. I don't know International or DSN phone number Evening telephone number Extension I don't know I don't know International or DSN phone number Daytime telephone number Extension International or DSN phone number Cell/mobile telephone number Extension Provide e-mail address for this person. I don't know 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.) City Country Street State Zip Code If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Does the person who knew you have an APO/FPO address? Address YES NO Enter your Social Security Number before going to the next page Page 7 State APO or FPO Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 11 - Where You Have Lived - (Continued) Enter residence information. Entry #3 Is/was this residence: Provide dates of residence. From Date (Month/Year) To Date (Month/Year) Est. Present Owned by you Rented or leased by you Est. Military housing Other (Provide explanation) Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Street State Zip Code Country If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Did you have an APO/FPO address while at this location? Address YES State Country Zip Code APO or FPO APO/FPO State Code Zip Code NO Provide the name of a neighbor or other person who knows you at this address. First name Last name Middle name Provide date of last contact. Suffix (Month/Year) Est. Provide your relationship to this person (Check all that apply). Neighbor Friend Landlord Business associate Other (Provide explanation) Provide the following contact information for this person. I don't know International or DSN phone number Evening telephone number Extension I don't know I don't know International or DSN phone number Daytime telephone number Extension International or DSN phone number Cell/mobile telephone number Extension Provide e-mail address for this person. I don't know 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.) City Country Street State Zip Code If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Does the person who knew you have an APO/FPO address? Address YES NO Enter your Social Security Number before going to the next page Page 8 State APO or FPO Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 11 - Where You Have Lived - (Continued) Enter residence information. Entry #4 Provide dates of residence. From Date (Month/Year) Is/was this residence: To Date (Month/Year) Est. Present Owned by you Rented or leased by you Est. Military housing Other (Provide explanation) Provide the street address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Street State Zip Code Country If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Did you have an APO/FPO address while at this location? Address YES State Country Zip Code APO or FPO APO/FPO State Code Zip Code NO Provide the name of a neighbor or other person who knows you at this address. First name Last name Middle name Provide date of last contact. Suffix (Month/Year) Est. Provide your relationship to this person (Check all that apply). Neighbor Friend Landlord Business associate Other (Provide explanation) Provide the following contact information for this person. I don't know International or DSN phone number Evening telephone number Extension I don't know I don't know International or DSN phone number Daytime telephone number Extension International or DSN phone number Cell/mobile telephone number Extension Provide e-mail address for this person. I don't know 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.) City Country Street State Zip Code If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Does the person who knew you have an APO/FPO address? Address YES NO Enter your Social Security Number before going to the next page Page 9 State APO or FPO Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 12 - Where You Went to School Do not list education before your 18th birthday, unless to provide a minimum of two years of education history. (a) Have you attended any schools in the last 10 years? YES (b) Have you received a degree or diploma more than 10 years ago? NO YES Entry #1 Provide the dates of attendance. From Date (Month/Year) To Date (Month/Year) Est. NO (If NO to 12(a) and 12(b), proceed to Section 13A) Select the most appropriate code to describe your school. Present High School Vocational/Technical/Trade School Est. College/University/Military College Correspondence/Distance/Extension/Online School Provide the name of the school. 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.) City Street 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. First name Last name I don't know 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.) Country City State Street Zip Code Provide telephone number for this person. Telephone number Extension Provide email address for this person. I don't know International or DSN phone number Day Night I don't know Did you receive a degree/diploma? YES NO 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) Entry #2 Provide the dates of attendance. From Date (Month/Year) To Date (Month/Year) Est. Date awarded Other degree/diploma (Month/Year) Est. Select the most appropriate code to describe your school. Present High School Vocational/Technical/Trade School Est. College/University/Military College Correspondence/Distance/Extension/Online School Provide the name of the school. 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.) Street City 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. First name Last name I don't know Enter your Social Security Number before going to the next page Page 10 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 12 - Where You Went to School - (Continued) Entry #2 (Continued) 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.) Country City State Street Zip Code Provide telephone number for this person. Telephone number Extension Provide email address for this person. I don't know International or DSN phone number Day Night I don't know Did you receive a degree/diploma? YES NO 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) Entry #3 Provide the dates of attendance. From Date (Month/Year) To Date (Month/Year) Est. Other degree/diploma Date awarded (Month/Year) Est. Select the most appropriate code to describe your school. Present High School Vocational/Technical/Trade School Est. College/University/Military College Correspondence/Distance/Extension/Online School Provide the name of the school. 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.) City Street 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. First name Last name I don't know 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.) Country City State Street Zip Code Provide telephone number for this person. Telephone number Extension Provide email address for this person. I don't know International or DSN phone number Day Night I don't know Did you receive a degree/diploma? YES NO 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) Enter your Social Security Number before going to the next page Page 11 Other degree/diploma Date awarded (Month/Year) Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 12 - Where You Went to School - (Continued) Entry #4 Provide the dates of attendance. From Date (Month/Year) To Date (Month/Year) Est. Select the most appropriate code to describe your school. Present High School Vocational/Technical/Trade School Est. College/University/Military College Correspondence/Distance/Extension/Online School Provide the name of the school. 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.) City Street 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. First name Last name I don't know 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.) Country City State Street Zip Code Provide telephone number for this person. Telephone number Extension Provide email address for this person. I don't know International or DSN phone number Day Night I don't know Did you receive a degree/diploma? YES NO 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) Enter your Social Security Number before going to the next page Page 12 Other degree/diploma Date awarded (Month/Year) Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 10 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. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history. Entry #1 Select your employment activity: Active military duty station (Complete 13A.1, State Government (Non-Federal employment) National Guard/Reserve (Complete 13A.1, 13A.5 Self-employment (Complete 13A.3, 13A.5 and USPHS Commissioned Corps (Complete 13A.1, Unemployment (Complete 13A.4) Other Federal employment (Complete 13A.2, 13A.5 and 13A.6) (Complete 13A.2, 13A.5 and 13A.6) 13A.5 and 13A.6) 13A.6) and 13A.6) 13A.5 and 13A.6) Non-government employment (excluding selfemployment) (Complete 13A.2, 13A.5 and 13A.6) Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6) Federal Contractor (Complete 13A.2, 13A.5 and 13A.6) Entry #1 13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps. Select the employment status for this position: Provide dates of employment. To Date From Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide your assigned duty station during this period. Provide your most recent rank/position title. Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Do you or did you have an APO/FPO address while at this location? Address YES State APO or FPO Country Zip Code APO/FPO State Code Zip Code NO Provide the name of your supervisor. Provide the email address of your supervisor. Provide the rank/position title of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number Day Night Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code If 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) (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Street Address/Unit/Duty Location City or Post Name Country State Zip Code Enter your Social Security Number before going to the next page Page 13 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #1 13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other. Provide dates of employment. From Date Select the employment status for this position: To Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide most recent position title. Provide the name of your employer. Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number Extension International or DSN phone number Day Night 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 From date (Month/Year) Position Title To date (Month/Year) Est. Est. Est. Est. Est. Est. Est. Est. Supervisor (a) Is/was your physical work address different than your employer's address? YES NO (If NO, proceed to (b)) Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number Extension International or DSN phone number Day Night (b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2). (b.1) 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.) Street Address/Unit/Duty Location City or Post Name State Country Zip Code (b.2) Do you or did you have an APO/FPO address while at this location? APO or FPO Address YES APO/FPO State Code Zip Code NO Provide the position title of your supervisor. Provide the name of your supervisor. Provide the email address of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number Day Night Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name State (b) Did/does your supervisor have an APO/FPO address while at this location? APO or FPO Address YES NO Enter your Social Security Number before going to the next page Page 14 Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #1 13A.3 Complete the following if employment type is self-employment Provide dates of employment. From Date Select the employment status for this position: To Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide most recent position title. Provide the name of your employer. Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number. Extension International or DSN phone number Day Night (a) Is your physical work address different than your employment address? YES NO (If NO, proceed to (b)) Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the telephone number for this address. Telephone number Extension International or DSN phone number Day Night (b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2). (b.1) 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.) Street Address/Unit/Duty Location City or Post Name State Zip Code (b.2) Do you or did you have an APO/FPO address while at this location? APO or FPO Address YES Country APO/FPO State Code Zip Code NO Provide the name of someone that can verify your self-employment. First name Last name Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the telephone number for this person. Telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Does your self-employment verifier have an APO/FPO address? Address YES NO Enter your Social Security Number before going to the next page Page 15 State APO or FPO Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #1 13A.4 Complete the following if employment type is unemployment. Provide dates of unemployment. To Date (Month/Year) From Date (Month/Year) Est. Present Est. Provide the name of someone that can verify your unemployment activities and means of support. First name Last name Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Country Street City State Zip Code Provide the telephone number for this person. Verifier telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) City or Post Name Street Address/Unit/Duty Location (b) Does your unemployment verifier have an APO/FPO address? Address YES State APO or FPO Zip Code Country APO/FPO State Code Zip Code NO Entry #1 13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other. Provide the reason for leaving the employment activity. For this employment have any of the following happened to you in the last seven (7) years? 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. YES NO (If NO, proceed to 13A.6) Select your type of incident: Fired Employment departure date Provide the reason for being fired. Provide the date you were fired. (Month/Year) Est. 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 Entry #1 Reason: Provide the reason for quitting. Provide the date you quit after being told you would be fired. (Month/Year) Est. Provide the charges or allegations of misconduct. Provide the date you left following charges or allegations of misconduct. (Month/Year) Provide the reason(s) for unsatisfactory performance. Provide the date you left by mutual agreement following a notice of unsatisfactory performance. (Month/Year) Est. Est. 13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other. For this employment, in the last seven (7) 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 #1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #2 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) Enter your Social Security Number before going to the next page Page 16 Est. Est. Est. Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities Entry #2 Select your employment activity: Active military duty station (Complete 13A.1, State Government (Non-Federal employment) National Guard/Reserve (Complete 13A.1, 13A.5 Self-employment (Complete 13A.3, 13A.5 and USPHS Commissioned Corps (Complete 13A.1, Unemployment (Complete 13A.4) Other Federal employment (Complete 13A.2, 13A.5 and 13A.6) (Complete 13A.2, 13A.5 and 13A.6) 13A.5 and 13A.6) 13A.6) and 13A.6) 13A.5 and 13A.6) Non-government employment (excluding selfemployment) (Complete 13A.2, 13A.5 and 13A.6) Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6) Federal Contractor (Complete 13A.2, 13A.5 and 13A.6) Entry #2 13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps. Select the employment status for this position: Provide dates of employment. To Date From Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide your assigned duty station during this period. Provide your most recent rank/position title. Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Do you or did you have an APO/FPO address while at this location? Address YES State APO or FPO Country Zip Code APO/FPO State Code Zip Code NO Provide the name of your supervisor. Provide the email address of your supervisor. Provide the rank/position title of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number Day Night Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code If 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) (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Street Address/Unit/Duty Location City or Post Name Country State Zip Code Enter your Social Security Number before going to the next page Page 17 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #2 13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other. Provide dates of employment. From Date Select the employment status for this position: To Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide most recent position title. Provide the name of your employer. Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number Extension International or DSN phone number Day Night 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 From date (Month/Year) Position Title To date (Month/Year) Est. Est. Est. Est. Est. Est. Est. Est. Supervisor (a) Is/was your physical work address different than your employer's address? YES NO (If NO, proceed to (b)) Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number Extension International or DSN phone number Day Night (b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2). (b.1) 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.) Street Address/Unit/Duty Location City or Post Name State Country Zip Code (b.2) Do you or did you have an APO/FPO address while at this location? APO or FPO Address YES APO/FPO State Code Zip Code NO Provide the position title of your supervisor. Provide the name of your supervisor. Provide the email address of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number Day Night Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name State (b) Did/does your supervisor have an APO/FPO address while at this location? APO or FPO Address YES NO Enter your Social Security Number before going to the next page Page 18 Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #2 13A.3 Complete the following if employment type is self-employment Provide dates of employment. From Date Select the employment status for this position: To Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide most recent position title. Provide the name of your employer. Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number. Extension International or DSN phone number Day Night (a) Is your physical work address different than your employment address? YES NO (If NO, proceed to (b)) Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the telephone number for this address. Telephone number Extension International or DSN phone number Day Night (b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2). (b.1) 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.) Street Address/Unit/Duty Location City or Post Name State Zip Code (b.2) Do you or did you have an APO/FPO address while at this location? APO or FPO Address YES Country APO/FPO State Code Zip Code NO Provide the name of someone that can verify your self-employment. First name Last name Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the telephone number for this person. Telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Does your self-employment verifier have an APO/FPO address? Address YES NO Enter your Social Security Number before going to the next page Page 19 State APO or FPO Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #2 13A.4 Complete the following if employment type is unemployment. Provide dates of unemployment. To Date (Month/Year) From Date (Month/Year) Est. Present Est. Provide the name of someone that can verify your unemployment activities and means of support. First name Last name Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Country Street City State Zip Code Provide the telephone number for this person. Verifier telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) City or Post Name Street Address/Unit/Duty Location (b) Does your unemployment verifier have an APO/FPO address? Address YES State APO or FPO Zip Code Country APO/FPO State Code Zip Code NO Entry #2 13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other. Provide the reason for leaving the employment activity. For this employment have any of the following happened to you in the last seven (7) years? 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. YES NO (If NO, proceed to 13A.6) Select your type of incident: Fired Employment departure date Provide the reason for being fired. Provide the date you were fired. (Month/Year) Est. 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 Entry #2 Reason: Provide the reason for quitting. Provide the date you quit after being told you would be fired. (Month/Year) Est. Provide the charges or allegations of misconduct. Provide the date you left following charges or allegations of misconduct. (Month/Year) Provide the reason(s) for unsatisfactory performance. Provide the date you left by mutual agreement following a notice of unsatisfactory performance. (Month/Year) Est. Est. 13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other. For this employment, in the last seven (7) 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 #1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #2 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) Enter your Social Security Number before going to the next page Page 20 Est. Est. Est. Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities Entry #3 Select your employment activity: Active military duty station (Complete 13A.1, State Government (Non-Federal employment) National Guard/Reserve (Complete 13A.1, 13A.5 Self-employment (Complete 13A.3, 13A.5 and USPHS Commissioned Corps (Complete 13A.1, Unemployment (Complete 13A.4) Other Federal employment (Complete 13A.2, 13A.5 and 13A.6) (Complete 13A.2, 13A.5 and 13A.6) 13A.5 and 13A.6) 13A.6) and 13A.6) 13A.5 and 13A.6) Non-government employment (excluding selfemployment) (Complete 13A.2, 13A.5 and 13A.6) Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6) Federal Contractor (Complete 13A.2, 13A.5 and 13A.6) Entry #3 13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps. Select the employment status for this position: Provide dates of employment. To Date From Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide your assigned duty station during this period. Provide your most recent rank/position title. Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Do you or did you have an APO/FPO address while at this location? Address YES State APO or FPO Country Zip Code APO/FPO State Code Zip Code NO Provide the name of your supervisor. Provide the email address of your supervisor. Provide the rank/position title of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number Day Night Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code If 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) (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Street Address/Unit/Duty Location City or Post Name Country State Zip Code Enter your Social Security Number before going to the next page Page 21 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #3 13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other. Provide dates of employment. From Date Select the employment status for this position: To Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide most recent position title. Provide the name of your employer. Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number Extension International or DSN phone number Day Night 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 From date (Month/Year) Position Title To date (Month/Year) Est. Est. Est. Est. Est. Est. Est. Est. Supervisor (a) Is/was your physical work address different than your employer's address? YES NO (If NO, proceed to (b)) Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number Extension International or DSN phone number Day Night (b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2). (b.1) 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.) Street Address/Unit/Duty Location City or Post Name State Country Zip Code (b.2) Do you or did you have an APO/FPO address while at this location? APO or FPO Address YES APO/FPO State Code Zip Code NO Provide the position title of your supervisor. Provide the name of your supervisor. Provide the email address of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number Day Night Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name State (b) Did/does your supervisor have an APO/FPO address while at this location? APO or FPO Address YES NO Enter your Social Security Number before going to the next page Page 22 Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #3 13A.3 Complete the following if employment type is self-employment Provide dates of employment. From Date Select the employment status for this position: To Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide most recent position title. Provide the name of your employer. Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number. Extension International or DSN phone number Day Night (a) Is your physical work address different than your employment address? YES NO (If NO, proceed to (b)) Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the telephone number for this address. Telephone number Extension International or DSN phone number Day Night (b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2). (b.1) 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.) Street Address/Unit/Duty Location City or Post Name State Zip Code (b.2) Do you or did you have an APO/FPO address while at this location? APO or FPO Address YES Country APO/FPO State Code Zip Code NO Provide the name of someone that can verify your self-employment. First name Last name Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the telephone number for this person. Telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Does your self-employment verifier have an APO/FPO address? Address YES NO Enter your Social Security Number before going to the next page Page 23 State APO or FPO Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #3 13A.4 Complete the following if employment type is unemployment. Provide dates of unemployment. To Date (Month/Year) From Date (Month/Year) Est. Present Est. Provide the name of someone that can verify your unemployment activities and means of support. First name Last name Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Country Street City State Zip Code Provide the telephone number for this person. Verifier telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) City or Post Name Street Address/Unit/Duty Location (b) Does your unemployment verifier have an APO/FPO address? Address YES State APO or FPO Zip Code Country APO/FPO State Code Zip Code NO Entry #3 13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other. Provide the reason for leaving the employment activity. For this employment have any of the following happened to you in the last seven (7) years? 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. YES NO (If NO, proceed to 13A.6) Select your type of incident: Fired Employment departure date Provide the reason for being fired. Provide the date you were fired. (Month/Year) Est. 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 Entry #3 Reason: Provide the reason for quitting. Provide the date you quit after being told you would be fired. (Month/Year) Est. Provide the charges or allegations of misconduct. Provide the date you left following charges or allegations of misconduct. (Month/Year) Provide the reason(s) for unsatisfactory performance. Provide the date you left by mutual agreement following a notice of unsatisfactory performance. (Month/Year) Est. Est. 13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other. For this employment, in the last seven (7) 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 #1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #2 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) Enter your Social Security Number before going to the next page Page 24 Est. Est. Est. Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities Entry #4 Select your employment activity: Active military duty station (Complete 13A.1, State Government (Non-Federal employment) National Guard/Reserve (Complete 13A.1, 13A.5 Self-employment (Complete 13A.3, 13A.5 and USPHS Commissioned Corps (Complete 13A.1, Unemployment (Complete 13A.4) Other Federal employment (Complete 13A.2, 13A.5 and 13A.6) (Complete 13A.2, 13A.5 and 13A.6) 13A.5 and 13A.6) 13A.6) and 13A.6) 13A.5 and 13A.6) Non-government employment (excluding selfemployment) (Complete 13A.2, 13A.5 and 13A.6) Other (Provide explanation and complete 13A.2, 13A.5 and 13A.6) Federal Contractor (Complete 13A.2, 13A.5 and 13A.6) Entry #4 13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps. Select the employment status for this position: Provide dates of employment. To Date From Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide your assigned duty station during this period. Provide your most recent rank/position title. Provide address of duty station. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Do you or did you have an APO/FPO address while at this location? Address YES State APO or FPO Country Zip Code APO/FPO State Code Zip Code NO Provide the name of your supervisor. Provide the email address of your supervisor. Provide the rank/position title of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number Day Night Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code If 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) (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Street Address/Unit/Duty Location City or Post Name Country State Zip Code Enter your Social Security Number before going to the next page Page 25 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #4 13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other. Provide dates of employment. From Date Select the employment status for this position: To Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide most recent position title. Provide the name of your employer. Provide the address of employer. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number Extension International or DSN phone number Day Night 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 From date (Month/Year) Position Title To date (Month/Year) Est. Est. Est. Est. Est. Est. Est. Est. Supervisor (a) Is/was your physical work address different than your employer's address? YES NO (If NO, proceed to (b)) Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number Extension International or DSN phone number Day Night (b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2). (b.1) 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.) Street Address/Unit/Duty Location City or Post Name State Country Zip Code (b.2) Do you or did you have an APO/FPO address while at this location? APO or FPO Address YES APO/FPO State Code Zip Code NO Provide the position title of your supervisor. Provide the name of your supervisor. Provide the email address of your supervisor. I don't know Provide supervisor's telephone number. Extension International or DSN phone number Day Night Provide physical work location of your supervisor. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name State (b) Did/does your supervisor have an APO/FPO address while at this location? APO or FPO Address YES NO Enter your Social Security Number before going to the next page Page 26 Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #4 13A.3 Complete the following if employment type is self-employment Provide dates of employment. From Date Select the employment status for this position: To Date (Month/Year) (Month/Year) Est. Present Full-time Est. Part-time Provide most recent position title. Provide the name of your employer. Provide address of this employment. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide telephone number. Extension International or DSN phone number Day Night (a) Is your physical work address different than your employment address? YES NO (If NO, proceed to (b)) Provide the work address where you are/were physically located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the telephone number for this address. Telephone number Extension International or DSN phone number Day Night (b) If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2). (b.1) 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.) Street Address/Unit/Duty Location City or Post Name State Zip Code (b.2) Do you or did you have an APO/FPO address while at this location? APO or FPO Address YES Country APO/FPO State Code Zip Code NO Provide the name of someone that can verify your self-employment. First name Last name Provide the address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the telephone number for this person. Telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) Street Address/Unit/Duty Location City or Post Name (b) Does your self-employment verifier have an APO/FPO address? Address YES NO Enter your Social Security Number before going to the next page Page 27 State APO or FPO Zip Code Country APO/FPO State Code Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13A - Employment Activities - (Continued) Entry #4 13A.4 Complete the following if employment type is unemployment. Provide dates of unemployment. To Date (Month/Year) From Date (Month/Year) Est. Present Est. Provide the name of someone that can verify your unemployment activities and means of support. First name Last name Provide address of this verifier. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Country Street City State Zip Code Provide the telephone number for this person. Verifier telephone number Extension International or DSN phone number Day Night If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) 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.) City or Post Name Street Address/Unit/Duty Location (b) Does your unemployment verifier have an APO/FPO address? Address YES State APO or FPO Zip Code Country APO/FPO State Code Zip Code NO Entry #4 13A.5 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other. Provide the reason for leaving the employment activity. For this employment have any of the following happened to you in the last seven (7) years? 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. YES NO (If NO, proceed to 13A.6) Select your type of incident: Fired Employment departure date Provide the reason for being fired. Provide the date you were fired. (Month/Year) Est. 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 Entry #4 Reason: Provide the reason for quitting. Provide the date you quit after being told you would be fired. (Month/Year) Est. Provide the charges or allegations of misconduct. Provide the date you left following charges or allegations of misconduct. (Month/Year) Provide the reason(s) for unsatisfactory performance. Provide the date you left by mutual agreement following a notice of unsatisfactory performance. (Month/Year) Est. Est. 13A.6 Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self-Employment, or Other. For this employment, in the last seven (7) 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 #1 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #2 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #3 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) #4 Provide the reason(s) for being warned, reprimanded, suspended or disciplined. Date: (Month/Year) Enter your Social Security Number before going to the next page Page 28 Est. Est. Est. Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 13B - Employment Activities - Former Federal Service Do you have former federal civilian employment, excluding military service, NOT indicated previously, to report? YES NO (If NO, proceed to Section 13C) Complete the following if you selected "Yes" to having former federal civilian employment, excluding military service, NOT indicated previously. Entry #1 Provide dates of federal civilian employment. To Date (Month/Year) From Date (Month/Year) Est. Provide the name of the federal agency for Present which you are/were employed. Provide your position title. Est. Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Entry #2 Provide dates of federal civilian employment. From Date (Month/Year) To Date (Month/Year) Est. Provide the name of the federal agency for Present which you are/were employed. Provide your position title. Est. Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Entry #3 Provide dates of federal civilian employment. To Date (Month/Year) From Date (Month/Year) Est. Provide the name of the federal agency for Present which you are/were employed. Provide your position title. Est. Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Entry #4 Provide dates of federal civilian employment. From Date (Month/Year) To Date (Month/Year) Est. Provide the name of the federal agency for Present which you are/were employed. Provide your position title. Est. Provide the location of the agency. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Section 13C - Employment Record Have any of the following happened to you in the last 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? YES (If YES, you will be required to add an additional employment in Section 13A) NO (If NO, proceed to Section 14) Enter your Social Security Number before going to the next page Page 29 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 14 - Selective Service Record Were you born a male after December 31, 1959? YES NO (If NO, proceed to Section 15) Have you registered with the Selective Service System (SSS)? Yes Provide registration number: No Provide explanation: I don't know 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 Have you EVER served in the U.S. Military? YES NO (If NO, proceed to Section 15.2) 15.1 Complete the following if you responded 'Yes' to having served in the U.S. Military. Entry #1 Provide the branch of service you served in. Army Air National Guard Army National Guard Marine Corps Navy Coast Guard State of service, if National Guard Officer or enlisted Not Applicable Officer Provide your status Active Duty Enlisted Active Reserve Air Force Provide your service number. Provide your dates of service. To Date From Date (Month/Year) (Month/Year) Est. Inactive Reserve Present Est. Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard? YES NO Provide the type of discharge you received: Honorable Dishonorable Under Other than Honorable Conditions General Provide the date of discharge listed Bad Conduct (Month/Year) Other (provide type) Est. Provide the reason(s) for the discharge, if discharge is other than Honorable Entry #2 Provide the branch of service you served in. Army Air National Guard Army National Guard Marine Corps Navy Coast Guard State of service, if National Guard Officer or enlisted Provide your status Active Duty Air Force Active Reserve Provide your service number. Not Applicable Officer Enlisted Provide your dates of service. To Date From Date (Month/Year) (Month/Year) Inactive Reserve Est. Present Est. Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard? YES NO Provide the type of discharge you received: Honorable Dishonorable Under Other than Honorable Conditions General Bad Conduct Other (provide type) Provide the reason(s) for the discharge, if discharge is other than Honorable Enter your Social Security Number before going to the next page Page 30 Provide the date of discharge listed (Month/Year) Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 15 - Military History - (Continued) 15.2 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? YES NO (If NO, proceed to Section 15.3) 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. Entry #1 Provide the date of the court martial or other disciplinary procedure. (Month/Year) Est. 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. Entry #2 Provide the date of the court martial or other disciplinary procedure. (Month/Year) Est. 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. Enter your Social Security Number before going to the next page Page 31 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 15 - Military History - (Continued) 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? 15.3 YES NO (If NO, proceed to Section 16) 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. Entry #1 During your foreign service, which organization were you serving under? Military (Specify Army, Navy, Air Force, Marines, etc.) Intelligence Service Diplomatic Service Provide the name of the country. Provide the name of the foreign organization. Security Forces Militia Provide your period of service. Other Defense Forces From Date (Month/Year) Provide the highest position/rank held. To Date (Month/Year) Est. Other Government Agency Present Est. Provide division/department/office in which you served. Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service. Do you maintain contact with current or former associates, colleagues, or acquaintances from your service in this organization? YES NO (If NO, proceed to Section 16) Contact #1 Provide the contact's full name. Last name First name Provide the contact's address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City State Zip Code Street Provide the contact's official title. Provide the frequency of contact. Suffix Middle name Country Provide the length of your association with the contact. To Date (Month/Year) From Date (Month/Year) Present Est. Est. Contact #2 Provide the contact's full name. Last name First name Provide the contact's address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code Provide the contact's official title. Provide the frequency of contact. Suffix Middle name Country Provide the length of your association with the contact. From Date (Month/Year) To Date (Month/Year) Present Est. Enter your Social Security Number before going to the next page Page 32 Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 15 - Military History - (Continued) 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. Entry #2 During your foreign service, which organization were you serving under? Military (Specify Army, Navy, Air Force, Marines, etc.) Intelligence Service Diplomatic Service Provide the name of the country. Provide the name of the foreign organization. Security Forces Militia Provide your period of service. Other Defense Forces From Date (Month/Year) Est. Other Government Agency Provide the highest position/rank held. To Date (Month/Year) Present Est. Provide division/department/office in which you served. Provide a description of the circumstances of your association with this organization. Provide a description of the reason for leaving this service. Do you maintain contact with current or former associates, colleagues, or acquaintances from your service in this organization? YES NO (If NO, Proceed to Section 16) Contact #1 Provide the contact's full name. Last name First name Provide the contact's address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City State Zip Code Street Provide the contact's official title. Provide the frequency of contact. Suffix Middle name Country Provide the length of your association with the contact. To Date (Month/Year) From Date (Month/Year) Present Est. Est. Contact #2 Provide the contact's full name. Last name First name Provide the contact's address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code Provide the contact's official title. Provide the frequency of contact. Suffix Middle name Country Provide the length of your association with the contact. From Date (Month/Year) To Date (Month/Year) Present Est. Enter your Social Security Number before going to the next page Page 33 Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS 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 Provide dates known. From Date (Month/Year) To Date (Month/Year) Est. Present Provide relationship to you. (Check all that apply) Neighbor Work associate Other (Provide explanation) Est. Provide full name. Last name Friend Schoolmate First name Provide e-mail address for this person. Provide telephone number for this person. I don't know Extension Provide rank/title I don't know International or DSN Provide mobile/cell telephone number for this person. phone number Day Suffix Middle name Not applicable I don't know Extension Night International or DSN phone number Day Night Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country Street City State Zip Code Entry #2 Provide dates known. From Date (Month/Year) To Date (Month/Year) Est. Present Provide relationship to you. (Check all that apply) Neighbor Work associate Other (Provide explanation) Est. Provide full name. Last name Friend Schoolmate First name Provide e-mail address for this person. Provide telephone number for this person. I don't know Extension Provide rank/title I don't know International or DSN Provide mobile/cell telephone number for this person. phone number Day Suffix Middle name Not applicable I don't know Extension Night International or DSN phone number Day Night 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 Country City State Zip Code Entry #3 Provide dates known. From Date (Month/Year) To Date (Month/Year) Est. Present Est. Provide full name. Last name Friend Schoolmate First name Provide e-mail address for this person. Provide telephone number for this person. Provide relationship to you. (Check all that apply) Neighbor Work associate Other (Provide explanation) I don't know Extension I don't know Provide rank/title International or DSN Provide mobile/cell telephone number for this person. phone number Day Not applicable I don't know Extension Night Provide home or work address for this person. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country Street City State Zip Code Enter your Social Security Number before going to the next page Page 34 Suffix Middle name International or DSN phone number Day Night Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 17 - Marital Status Provide your current marital status. Never Married (Complete 17.3) Separated (Complete 17.1 and 17.3) Divorced (Complete 17.2 and 17.3) Married (including Common Law) (Complete 17.1 and 17.3) Annulled (Complete 17.2 and 17.3) Widowed (Complete 17.2 and 17.3) 17.1 Complete the following if you selected 'Married' or 'Separated.' Complete the following about your current spouse only. Provide spouse's full name. Last name Provide spouse's date of birth. First name Middle name Suffix (Month/Day/Year) Est. Provide spouse's place of birth. City County State Country (required) For your foreign born spouse, provide one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Passport (current or most recent) None (Provide explanation) DS 1350 Alien registration U.S. Citizenship certificate U.S. Naturalization certificate Provide document number. Other (Provide explanation) Explanation Provide your spouse's U.S. Social Security Number. Not applicable Provide other names used by your spouse (such as maiden name, names by other marriages, nicknames, etc. and provide dates used for each name). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name YES To (Month/Year) From (Month/Year) NO Est. #3 Last name YES Est. #4 Last name YES NO Est. Provide your spouse's country(ies) of citizenship. Country #1 Suffix Middle name Suffix Present Present Est. Provide date married. (Month/Day/Year) Country #2 Enter your Social Security Number before going to the next page Page 35 Middle name Est. To (Month/Year) From (Month/Year) Suffix Present First name Maiden name? Middle name Est. To (Month/Year) From (Month/Year) NO Suffix Present First name Maiden name? Middle name Est. First name Maiden name? Not applicable Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 17 - Marital Status - (Continued) 17.1 Complete the following if you selected 'Married' or 'Separated.' (Continued) Provide place married. (Provide City and Country if outside the United States; otherwise, provide City or County and State.) County Country City State Provide your spouse's current address, if different than your current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street Provide telephone number. Extension State Day Use my current telephone number Night International or DSN phone number Zip Code Country Provide email address. If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b). (a) Provide your spouse's APO/FPO address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.) City or Post Name Street Address/Unit/Duty Location (b) Does your spouse have an APO/FPO address? Address YES State APO or FPO Zip Code Country APO/FPO State Code Zip Code NO If legally separated, provide the location of the record. Provide date of separation. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code (Month/Day/Year) Are you separated from your spouse? YES NO Est. Enter your Social Security Number before going to the next page Page 36 Not Applicable Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 17 - Marital Status - (Continued) 17.2 Complete the following if you selected 'Divorced', 'Annulled', 'Widowed', or 'Other Former Spouses'. Entry #1 Provide the full name of your former spouse. Last name First name Middle name Provide the date of birth of your former spouse. (Month/Day/Year) Suffix Est. Provide the place of birth for your former spouse. City State Zip Code Country (Required) Provide the country(ies) of citizenship for your former spouse. Country #1 Country #2 Provide the date you married your former spouse. (Month/Day/Year) Est. Provide the place married. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.) Country City State Provide the status of this marriage. Divorced Widowed Provide the date divorced, annulled or widowed. (Month/Day/Year) Annulled Est. For your divorced or annulled marriage, provide where the record is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City State Zip Code Country Is this former spouse deceased? YES NO (If NO, complete (a)) I don't know (a) For divorced or annulled marriage provide last known address of the former spouse. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City Enter your Social Security Number before going to the next page Page 37 State Zip Code Country I don't know Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 17 - Marital Status - (Continued) 17.2 Complete the following if you selected 'Divorced', 'Annulled', 'Widowed', or 'Other Former Spouses'. Entry #2 Provide the full name of your former spouse. Last name First name Provide the date of birth of your former spouse. (Month/Day/Year) Suffix Middle name Est. Provide the place of birth for your former spouse. City State Zip Code Country (Required) Provide the country(ies) of citizenship for your former spouse. Country #1 Country #2 Provide the date you married your former spouse. (Month/Day/Year) Est. Provide the place married. (Provide City and Country if outside the United States; otherwise, provide City, State and Country.) Country City State Provide the status of this marriage. Divorced Widowed Provide the date divorced, annulled or widowed. (Month/Day/Year) Annulled Est. For your divorced or annulled marriage, provide where the record is located. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City State Zip Code Country Is this former spouse deceased? YES NO (If NO, complete (a)) I don't know (a) For divorced or annulled marriage provide last known address of the former spouse. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City Enter your Social Security Number before going to the next page Page 38 State Zip Code Country I don't know Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 17 - Marital Status - (Continued) 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 with for reasons of convenience (e.g. a roommate). If applicable, complete the following about your cohabitant. If your cohabitant was born outside the U.S., provide citizenship information. 17.3 Do you presently reside with a cohabitant? YES NO (If NO, proceed to Section 18) Complete the following if you presently reside with a cohabitant. Entry #1 Provide the cohabitant full name. Last name First name Middle name Provide the cohabitant place of birth. City Provide the cohabitant date of birth. Date (Month/Day/Year) Est. Suffix Country (Required) State For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Passport (current or most recent) None (Provide explanation) DS 1350 Alien registration U.S. Citizenship certificate U.S. Naturalization certificate Provide document number. Other (Provide explanation) Explanation Provide your cohabitant's U.S. Social Security Number. Not applicable Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each name was used). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name YES To (Month/Year) From (Month/Year) NO Est. #3 Last name YES Est. #4 Last name YES NO Est. Provide your cohabitant's country(ies) of citizenship. Country #1 Suffix Middle name Suffix Present Present Est. Provide date cohabitation began. Country #2 Enter your Social Security Number before going to the next page Page 39 Middle name Est. To (Month/Year) From (Month/Year) Suffix Present First name Maiden name? Middle name Est. To (Month/Year) From (Month/Year) NO Suffix Present First name Maiden name? Middle name Est. First name Maiden name? Not applicable (Month/Day/Year) Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 17 - Marital Status - (Continued) Complete the following if you presently reside with a cohabitant. Entry #2 Provide the cohabitant full name. Last name First name Middle name Provide the cohabitant place of birth. City Provide the cohabitant date of birth. Date (Month/Day/Year) Est. Suffix Country (Required) State For your foreign born cohabitant, indicate one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Passport (current or most recent) None (Provide explanation) DS 1350 Alien registration U.S. Citizenship certificate U.S. Naturalization certificate Provide document number. Other (Provide explanation) Explanation Provide your cohabitant's U.S. Social Security Number. Not applicable Provide other names used by your cohabitant (such as maiden name, names by other marriages, etc., and provide dates each name was used). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name YES To (Month/Year) From (Month/Year) NO Est. #3 Last name YES Est. #4 Last name YES NO Est. Provide your cohabitant's country(ies) of citizenship. Country #1 Suffix Middle name Suffix Present Present Est. Provide date cohabitation began. Country #2 Enter your Social Security Number before going to the next page Page 40 Middle name Est. To (Month/Year) From (Month/Year) Suffix Present First name Maiden name? Middle name Est. To (Month/Year) From (Month/Year) NO Suffix Present First name Maiden name? Middle name Est. First name Maiden name? Not applicable (Month/Day/Year) Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives 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. Mother Foster parent Sister Half-sister Father Child (including adopted/foster) Stepbrother Father-in-law Stepmother Stepchild Stepsister Mother-in-law Stepfather Brother Half-brother Guardian Entry #1 Provide relative type. Provide your relative's full name. Last name Provide your relative's date of birth. Date (Month/Day/Year) Est. Middle name First name Provide your relative's place of birth. City Provide your relative's country(ies) of citizenship. Country #1 Suffix Country (Required) State Country #2 Entry #1 18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister. If mother, provide your mother's maiden name. Last name Same as listed First name I don't know Middle name Suffix Has this relative used any other names? YES NO 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). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name NO Est. NO Est. #4 Last name NO Est. Enter your Social Security Number before going to the next page Page 41 Present Suffix Provide the reason(s) why the name changed. Est. To (Month/Year) From (Month/Year) Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. To (Month/Year) From (Month/Year) Provide the reason(s) why the name changed. Middle name First name Maiden name? Suffix Est. To (Month/Year) From (Month/Year) #3 Last name YES Present First name Maiden name? YES Middle name Not applicable Middle name Present Est. Suffix Provide the reason(s) why the name changed. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Is your relative deceased? YES (If YES, proceed to 18.3) NO Entry #1 18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased. Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Does this relative have an APO/FPO address? Provide your relative's APO/FPO address. YES Address NO APO or FPO APO/FPO State Code Zip Code I don't know Entry #1 18.3 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-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, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, foreign born and has a U.S. or APO/FPO address. Provide one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Naturalization certificate DS 1350 U.S. Passport U.S. Citizenship certificate None (Provide explanation) Provide document number. Other (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. Street City Enter your Social Security Number before going to the next page Page 42 State Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Entry #1 18.4 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a U.S. address and is not deceased. Provide type of documentation he or she possesses to support U.S. residence. U.S. Alien registration Provide document number U.S. Visa Other (Provide explanation) Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Written correspondence Other (Provide explanation) Electronic (Such as e-mail, texting, chat rooms, etc) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I don't know Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City I don't know and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Entry #1 18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I 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 Zip Code I don't know Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Enter your Social Security Number before going to the next page Page 43 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 18 - Relatives - (Continued) Entry #2 Provide relative type. Provide your relative's full name. Last name Provide your relative's date of birth. Date (Month/Day/Year) Est. Middle name First name Provide your relative's place of birth. City Provide your relative's country(ies) of citizenship. Country #1 Suffix Country (Required) State Country #2 Entry #2 18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister. If mother, provide your mother's maiden name. Last name Same as listed First name I don't know Middle name Suffix Has this relative used any other names? YES NO 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). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name To (Month/Year) From (Month/Year) NO Est. #3 Last name Est. #4 Last name NO Est. Enter your Social Security Number before going to the next page Page 44 Present Suffix Provide the reason(s) why the name changed. Est. To (Month/Year) From (Month/Year) Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. To (Month/Year) From (Month/Year) NO Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. First name Maiden name? YES Middle name Not applicable Middle name Present Est. Suffix Provide the reason(s) why the name changed. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Is your relative deceased? YES (If YES, proceed to 18.3) NO Entry #2 18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased. Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Does this relative have an APO/FPO address? Provide your relative's APO/FPO address. YES Address NO APO or FPO APO/FPO State Code Zip Code I don't know Entry #2 18.3 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-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, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, foreign born and has a U.S. or APO/FPO address. Provide one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Naturalization certificate DS 1350 U.S. Passport U.S. Citizenship certificate None (Provide explanation) Provide document number. Other (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. Street City Enter your Social Security Number before going to the next page Page 45 State Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Entry #2 18.4 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a U.S. address and is not deceased. Provide type of documentation he or she possesses to support U.S. residence. U.S. Alien registration Provide document number U.S. Visa Other (Provide explanation) Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Written correspondence Other (Provide explanation) Electronic (Such as e-mail, texting, chat rooms, etc) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I don't know Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City I don't know and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Entry #2 18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I 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 Zip Code I don't know Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Enter your Social Security Number before going to the next page Page 46 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 18 - Relatives - (Continued) Entry #3 Provide relative type. Provide your relative's full name. Last name Provide your relative's date of birth. Date (Month/Day/Year) Est. Middle name First name Provide your relative's place of birth. City Provide your relative's country(ies) of citizenship. Country #1 Suffix Country (Required) State Country #2 Entry #3 18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister. If mother, provide your mother's maiden name. Last name Same as listed First name I don't know Middle name Suffix Has this relative used any other names? YES NO 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). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name To (Month/Year) From (Month/Year) NO Est. #3 Last name Est. #4 Last name NO Est. Enter your Social Security Number before going to the next page Page 47 Present Suffix Provide the reason(s) why the name changed. Est. To (Month/Year) From (Month/Year) Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. To (Month/Year) From (Month/Year) NO Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. First name Maiden name? YES Middle name Not applicable Middle name Present Est. Suffix Provide the reason(s) why the name changed. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Is your relative deceased? YES (If YES, proceed to 18.3) NO Entry #3 18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased. Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Does this relative have an APO/FPO address? Provide your relative's APO/FPO address. YES Address NO APO or FPO APO/FPO State Code Zip Code I don't know Entry #3 18.3 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-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, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, foreign born and has a U.S. or APO/FPO address. Provide one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Naturalization certificate DS 1350 U.S. Passport U.S. Citizenship certificate None (Provide explanation) Provide document number. Other (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. Street City Enter your Social Security Number before going to the next page Page 48 State Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Entry #3 18.4 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a U.S. address and is not deceased. Provide type of documentation he or she possesses to support U.S. residence. U.S. Alien registration Provide document number U.S. Visa Other (Provide explanation) Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Written correspondence Other (Provide explanation) Electronic (Such as e-mail, texting, chat rooms, etc) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I don't know Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City I don't know and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Entry #3 18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I 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 Zip Code I don't know Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Enter your Social Security Number before going to the next page Page 49 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 18 - Relatives - (Continued) Entry #4 Provide relative type. Provide your relative's full name. Last name Provide your relative's date of birth. Date (Month/Day/Year) Est. Middle name First name Provide your relative's place of birth. City Provide your relative's country(ies) of citizenship. Country #1 Suffix Country (Required) State Country #2 Entry #4 18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister. If mother, provide your mother's maiden name. Last name Same as listed First name I don't know Middle name Suffix Has this relative used any other names? YES NO 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). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name To (Month/Year) From (Month/Year) NO Est. #3 Last name Est. #4 Last name NO Est. Enter your Social Security Number before going to the next page Page 50 Present Suffix Provide the reason(s) why the name changed. Est. To (Month/Year) From (Month/Year) Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. To (Month/Year) From (Month/Year) NO Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. First name Maiden name? YES Middle name Not applicable Middle name Present Est. Suffix Provide the reason(s) why the name changed. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Is your relative deceased? YES (If YES, proceed to 18.3) NO Entry #4 18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased. Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Does this relative have an APO/FPO address? Provide your relative's APO/FPO address. YES Address NO APO or FPO APO/FPO State Code Zip Code I don't know Entry #4 18.3 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-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, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, foreign born and has a U.S. or APO/FPO address. Provide one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Naturalization certificate DS 1350 U.S. Passport U.S. Citizenship certificate None (Provide explanation) Provide document number. Other (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. Street City Enter your Social Security Number before going to the next page Page 51 State Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Entry #4 18.4 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a U.S. address and is not deceased. Provide type of documentation he or she possesses to support U.S. residence. U.S. Alien registration Provide document number U.S. Visa Other (Provide explanation) Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Written correspondence Other (Provide explanation) Electronic (Such as e-mail, texting, chat rooms, etc) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I don't know Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City I don't know and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Entry #4 18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I 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 Zip Code I don't know Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Enter your Social Security Number before going to the next page Page 52 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 18 - Relatives - (Continued) Entry #5 Provide relative type. Provide your relative's full name. Last name Provide your relative's date of birth. Date (Month/Day/Year) Est. Middle name First name Provide your relative's place of birth. City Provide your relative's country(ies) of citizenship. Country #1 Suffix Country (Required) State Country #2 Entry #5 18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister. If mother, provide your mother's maiden name. Last name Same as listed First name I don't know Middle name Suffix Has this relative used any other names? YES NO 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). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name To (Month/Year) From (Month/Year) NO Est. #3 Last name Est. #4 Last name NO Est. Enter your Social Security Number before going to the next page Page 53 Present Suffix Provide the reason(s) why the name changed. Est. To (Month/Year) From (Month/Year) Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. To (Month/Year) From (Month/Year) NO Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. First name Maiden name? YES Middle name Not applicable Middle name Present Est. Suffix Provide the reason(s) why the name changed. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Is your relative deceased? YES (If YES, proceed to 18.3) NO Entry #5 18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased. Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Does this relative have an APO/FPO address? Provide your relative's APO/FPO address. YES Address NO APO or FPO APO/FPO State Code Zip Code I don't know Entry #5 18.3 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-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, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, foreign born and has a U.S. or APO/FPO address. Provide one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Naturalization certificate DS 1350 U.S. Passport U.S. Citizenship certificate None (Provide explanation) Provide document number. Other (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. Street City Enter your Social Security Number before going to the next page Page 54 State Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Entry #5 18.4 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a U.S. address and is not deceased. Provide type of documentation he or she possesses to support U.S. residence. U.S. Alien registration Provide document number U.S. Visa Other (Provide explanation) Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Written correspondence Other (Provide explanation) Electronic (Such as e-mail, texting, chat rooms, etc) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I don't know Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City I don't know and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Entry #5 18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I 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 Zip Code I don't know Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Enter your Social Security Number before going to the next page Page 55 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 18 - Relatives - (Continued) Entry #6 Provide relative type. Provide your relative's full name. Last name Provide your relative's date of birth. Date (Month/Day/Year) Est. Middle name First name Provide your relative's place of birth. City Provide your relative's country(ies) of citizenship. Country #1 Suffix Country (Required) State Country #2 Entry #6 18.1 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister. If mother, provide your mother's maiden name. Last name Same as listed First name I don't know Middle name Suffix Has this relative used any other names? YES NO 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). #1 Last name First name Maiden name? YES To (Month/Year) From (Month/Year) NO Est. #2 Last name To (Month/Year) From (Month/Year) NO Est. #3 Last name Est. #4 Last name NO Est. Enter your Social Security Number before going to the next page Page 56 Present Suffix Provide the reason(s) why the name changed. Est. To (Month/Year) From (Month/Year) Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. To (Month/Year) From (Month/Year) NO Provide the reason(s) why the name changed. Middle name First name Maiden name? YES Present Suffix Est. First name Maiden name? YES Middle name Not applicable Middle name Present Est. Suffix Provide the reason(s) why the name changed. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Is your relative deceased? YES (If YES, proceed to 18.3) NO Entry #6 18.2 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not deceased. Provide your relative's current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Does this relative have an APO/FPO address? Provide your relative's APO/FPO address. YES Address NO APO or FPO APO/FPO State Code Zip Code I don't know Entry #6 18.3 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-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, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is a U.S. Citizen, foreign born and has a U.S. or APO/FPO address. Provide one type of documentation that he or she possesses and the document number. FS 240 or 545 U.S. Naturalization certificate DS 1350 U.S. Passport U.S. Citizenship certificate None (Provide explanation) Provide document number. Other (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. Street City Enter your Social Security Number before going to the next page Page 57 State Zip Code Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 18 - Relatives - (Continued) Entry #6 18.4 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a U.S. address and is not deceased. Provide type of documentation he or she possesses to support U.S. residence. U.S. Alien registration Provide document number U.S. Visa Other (Provide explanation) Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Written correspondence Other (Provide explanation) Electronic (Such as e-mail, texting, chat rooms, etc) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I don't know Provide the address of current employer, or provide the address of their most recent employer if not currently employed. (Provide City I don't know and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Entry #6 18.5 Complete the following if the relative listed is your Mother, Father, Stepmother, Stepfather, Foster parent, Child (including adopted/foster), Stepchild, Brother, Sister, Stepbrother, Stepsister, Half-brother, Half-sister, Father-in-law, Mother-in-law, Guardian and is not a U.S. Citizen, has a foreign address and is not deceased. Provide approximate date of first contact. (Month/Year) Provide approximate date of last contact. (Month/Year) Est. Present Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide name of current employer, or provide the name of their most recent employer if not currently employed (if known). Employer name I 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 Zip Code I don't know Country Is this relative affiliated with a foreign government, military, security, defense industry, foreign movement, or intelligence service? YES NO Describe the relative's relationship with the foreign government, military, security, defense industry, foreign movement, or intelligence service. I don't know Enter your Social Security Number before going to the next page Page 58 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 19 - Foreign Contacts A foreign national is defined as any person who is not a citizen or national of the U.S. 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. YES NO (If NO, proceed to Section 20A) Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national. Entry #1 Provide the full name of the foreign national, if known. Last name First name I don't know Explanation if name is unknown Suffix Middle name Provide approximate date of last contact. (Month/Year) Provide approximate date of first contact. (Month/Year) Est. Est. Provide methods of contact (Check all that apply). In person Telephone Written correspondence Other (Provide explanation) Electronic (Such as e-mail, texting, chat rooms, etc) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide the nature of relationship (Check all that apply). Professional or Business Personal (Such as family ties, friendship, affection, common interests, etc) Obligation (Provide explanation) Other (Provide explanation) Provide other names and/or nicknames, as appropriate. Last name First name Middle name Provide country(ies) of citizenship. Country #1 Country #2 Provide date of birth. Provide place of birth. (Month/Day/Year) I don't know I don't know City Suffix Country (If country unknown, requires explanation) Est. Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Street State Zip Code I don't know Country Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address. Address YES NO APO or FPO APO/FPO State Code Zip Code I don't know 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 I don't know 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.) Country Street State City Zip Code I don't know Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service? Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service. YES NO I don't know Enter your Social Security Number before going to the next page Page 59 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 19 - Foreign Contacts - (Continued) Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national. Entry #2 Provide the full name of the foreign national, if known. Last name First name Suffix Middle name I don't know Explanation if name is unknown Provide approximate date of last contact. (Month/Year) Provide approximate date of first contact. (Month/Year) Est. Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide the nature of relationship (Check all that apply). Professional or Business Personal (Such as family ties, friendship, affection, common interests, etc) Obligation (Provide explanation) Other (Provide explanation) Provide other names and/or nicknames, as appropriate. Last name First name Middle name Provide country(ies) of citizenship. Country #1 Country #2 Provide date of birth. Provide place of birth. (Month/Day/Year) I don't know I don't know City Suffix Country (If country unknown, requires explanation) Est. Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Street State Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address. APO or FPO Address YES NO Zip Code I don't know Country APO/FPO State Code Zip Code I don't know 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 I don't know 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.) Country Street State City Zip Code I don't know Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service? Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service. YES NO I don't know Enter your Social Security Number before going to the next page Page 60 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 19 - Foreign Contacts - (Continued) Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national. Entry #3 Provide the full name of the foreign national, if known. Last name First name I don't know Explanation if name is unknown Suffix Middle name Provide approximate date of last contact. (Month/Year) Provide approximate date of first contact. (Month/Year) Est. Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide the nature of relationship (Check all that apply). Professional or Business Personal (Such as family ties, friendship, affection, common interests, etc) Obligation (Provide explanation) Other (Provide explanation) Provide other names and/or nicknames, as appropriate. Last name First name Middle name Provide country(ies) of citizenship. Country #1 Country #2 Provide date of birth. Provide place of birth. (Month/Day/Year) I don't know I don't know City Suffix Country (If country unknown, requires explanation) Est. Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Street State Zip Code I don't know Country Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address. Address YES NO APO or FPO APO/FPO State Code Zip Code I don't know 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 I don't know 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.) Country Street State City Zip Code I don't know Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service? Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service. YES NO I don't know Enter your Social Security Number before going to the next page Page 61 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 19 - Foreign Contacts - (Continued) Complete the following if you responded 'Yes' to have, or have had, close and/or continuing contact with a foreign national. Entry #4 Provide the full name of the foreign national, if known. Last name First name Suffix Middle name I don't know Explanation if name is unknown Provide approximate date of last contact. (Month/Year) Provide approximate date of first contact. (Month/Year) Est. Est. Provide methods of contact (Check all that apply). In person Telephone Electronic (Such as e-mail, texting, chat rooms, etc) Written correspondence Other (Provide explanation) Provide approximate frequency of contact. Daily Monthly Annually Weekly Quarterly Other (Provide explanation) Provide the nature of relationship (Check all that apply). Professional or Business Personal (Such as family ties, friendship, affection, common interests, etc) Obligation (Provide explanation) Other (Provide explanation) Provide other names and/or nicknames, as appropriate. Last name First name Middle name Provide country(ies) of citizenship. Country #1 Country #2 Provide date of birth. Provide place of birth. (Month/Day/Year) I don't know I don't know City Suffix Country (If country unknown, requires explanation) Est. Provide current address. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Street State Zip Code I don't know Country Does this person have an APO/FPO address? Provide the foreign national's APO/FPO address. Address YES NO APO or FPO APO/FPO State Code Zip Code I don't know 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 I don't know 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.) Country Street State City Zip Code I don't know Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence service? Describe the contact's relationship with the foreign government, military, security, defense industry, or intelligence service. YES NO I don't know Enter your Social Security Number before going to the next page Page 62 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities 20A.1 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.) YES NO (If NO, proceed to 20A.2) 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.) Entry #1 Specify (Check all that apply): Yourself Spouse Cohabitant Dependent children Provide the date acquired. (Month/Day/Year) Provide the type of financial interest. Est. Provide how the financial interest was acquired (such as purchase, gift, etc.). Provide the cost (in U.S. dollars) at time of acquisition. 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. Provide the date control or ownership was relinquished. (Month/Day/Year) Date Est. Provide explanation of how interest control or ownership was sold, lost or otherwise disposed of. Not Applicable Are there any co-owners of this foreign financial interest? YES NO #1 Provide full name of co-owner. Last name First name Middle name Suffix 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 Provide your co-owner's country(ies) of citizenship. Country #2 Country #1 #2 Provide full name of co-owner. Last name Zip Code Country Provide the nature of your relationship with the co-owner. First name Middle name Suffix 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 Provide your co-owner's country(ies) of citizenship. Country #1 Country #2 Enter your Social Security Number before going to the next page Page 63 State Zip Code Country Provide the nature of your relationship with the co-owner. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities (Continued) 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.) Entry #2 Specify (Check all that apply): Yourself Spouse Cohabitant Dependent children Provide the date acquired. (Month/Day/Year) Provide the type of financial interest. Est. Provide how the financial interest was acquired (such as purchase, gift, etc.). Provide the cost (in U.S. dollars) at time of acquisition. 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. Provide the date control or ownership was relinquished. (Month/Day/Year) Date Est. Provide explanation of how interest control or ownership was sold, lost or otherwise disposed of. Not Applicable Are there any co-owners of this foreign financial interest? YES NO #1 Provide full name of co-owner. Last name First name Middle name Suffix 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 Provide your co-owner's country(ies) of citizenship. Country #2 Country #1 #2 Provide full name of co-owner. Last name Zip Code Country Provide the nature of your relationship with the co-owner. First name Middle name Suffix 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 Provide your co-owner's country(ies) of citizenship. Country #1 Country #2 Enter your Social Security Number before going to the next page Page 64 State Zip Code Country Provide the nature of your relationship with the co-owner. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities - (Continued) 20A.2 Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests that someone controlled on your behalf? YES NO (If NO, Proceed to 20A.3) 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. Entry #1 Specify: (Check all that apply): Yourself Provide the type of financial interest. Spouse Cohabitant Dependent children Provide the name of the individual who controls this financial interest on your behalf. Last name First name Provide details regarding how the financial interest was acquired (such as purchase, gift, etc.). Provide the date this financial interest was acquired. (Month/Day/Year) Provide this individual's relationship to you. Provide the cost (in U.S. dollars) at time of acquisition. Est. Provide the date interest was sold, lost, or other wise disposed of. (Month/Day/Year) Provide the current value (in U.S. dollars) or value at the time interest was sold, lost or otherwise disposed of. Est. Est. Provide explanation if interest was sold, lost or otherwise disposed of. Est. Not Applicable Are there any co-owners of this foreign financial interest controlled on your behalf? YES NO #1 Provide the full name of co-owner. Last name First name Middle name Suffix 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 Provide the co-owner's country(ies) of citizenship. Country #1 Country #2 #2 Provide the full name of co-owner. Last name Zip Code Country Provide your relationship with the co-owner. Middle name First name Suffix 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 Provide the co-owner's country(ies) of citizenship. Country #2 Country #1 Enter your Social Security Number before going to the next page Page 65 State Zip Code Country Provide your relationship with the co-owner. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities - (Continued) 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. Entry #2 Specify: (Check all that apply): Yourself Provide the type of financial interest. Spouse Cohabitant Dependent children Provide the name of the individual who controls this financial interest on your behalf. Last name First name Provide details regarding how the financial interest was acquired (such as purchase, gift, etc.). Provide this individual's relationship to you. Provide the cost (in U.S. dollars) Provide the date this financial interest was acquired. (Month/Year) at time of acquisition. Est. Provide the date interest was sold, lost, or other wise disposed of. (Month/Day/Year) Provide the current value (in U.S. dollars) or value at the time interest was sold, lost or otherwise disposed of. Est. Est. Provide explanation if interest was sold, lost or otherwise disposed of. Est. Not Applicable Are there any co-owners of this foreign financial interest controlled on your behalf? YES NO #1 Provide the full name of co-owner. Last name First name Middle name Suffix 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 Provide the co-owner's country(ies) of citizenship. Country #1 Country #2 #2 Provide the full name of co-owner. Last name Zip Code Country Provide your relationship with the co-owner. Middle name First name Suffix 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 Provide the co-owner's country(ies) of citizenship. Country #1 Country #2 Enter your Social Security Number before going to the next page Page 66 State Zip Code Country Provide your relationship with the co-owner. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities - (Continued) 20A.3 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? YES NO (If NO, Proceed to 20A.4) 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. Entry #1 Specify (Check all that apply): Yourself Provide the type of real estate property (such as home, business, etc.). Spouse Cohabitant Provide the location/address of property. Street Provide the date to be acquired. Dependent children City Country Provide how the foreign real estate is to be acquired (such as purchase, gift, etc.). (Month/Day/Year) Provide the cost (in U.S. dollars) expected at time of acquisition. Est. Est. Are there any co-owners of this foreign real estate? YES NO #1 Provide the full name of co-owner. Last name First name Middle name Suffix 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 Provide the co-owner's country(ies) of citizenship. Country #1 Country #2 #2 Provide the full name of co-owner. Last name Zip Code Country Provide the nature of your relationship with the co-owner. First name Middle name Suffix 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 Provide the co-owner's country(ies) of citizenship. Country #1 Country #2 Enter your Social Security Number before going to the next page Page 67 State Zip Code Country Provide the nature of your relationship with the co-owner. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities - (Continued) 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. Entry #2 Specify (Check all that apply): Yourself Provide the type of real estate property (such as home, business, etc.). Spouse Cohabitant Provide the location/address of property. Street Provide the date to be acquired. Dependent children City Country Provide how the foreign real estate is to be acquired (such as purchase, gift, etc.). (Month/Day/Year) Provide the cost (in U.S. dollars) expected at time of acquisition. Est. Est. Are there any co-owners of this foreign real estate? YES NO #1 Provide the full name of co-owner. Last name First name Middle name Suffix 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 Provide the co-owner's country(ies) of citizenship. Country #1 Country #2 #2 Provide the full name of co-owner. Last name Zip Code Country Provide the nature of your relationship with the co-owner. First name Middle name Suffix 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 Provide the co-owner's country(ies) of citizenship. Country #1 Country #2 Enter your Social Security Number before going to the next page Page 68 State Zip Code Country Provide the nature of your relationship with the co-owner. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities - (Continued) 20A.4 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? YES NO (If NO, Proceed to 20A.5) 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. Entry #1 Specify (Check all that apply) Yourself Spouse Cohabitant Dependent children Provide the type of benefit. Educational Medical Retirement Social Welfare Other such benefit (Provide explanation) Provide the frequency of the benefit. Onetime benefit (Complete (a)) Future benefit (Complete (b)) Continuing benefit (Complete (c)) Other (Complete (c)) (Provide explanation) (a) If you have indicated that you, your spouse, cohabitant, or dependent children received a onetime benefit from a foreign country: Provide the date the benefit was received. (Month/Day/Year) Provide the name of the country providing the benefit. Provide the total value (in U.S. dollars) of the benefit received. Provide the reason this benefit was received. Est. Est. As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country? If yes, provide explanation. YES NO (b) If you have indicated that you, your spouse, cohabitant, or dependent children expect to receive a benefit from a foreign country: Provide the date the benefit will begin. (Month/Day/Year) Provide the frequency the benefit will be received. Est. Annually Monthly Quarterly Weekly Other (Provide explanation) Provide the name of the country providing this benefit. Provide the value (in U.S. dollars) of the benefit to be received. Provide the reason this benefit will be received. Est. As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country? If yes, provide explanation. YES NO (c) If have indicated that you, your spouse, cohabitant, or dependent children receive a continuing or other benefit from a foreign country: Provide the date the benefit began. (Month/Day/Year) Provide the date the benefit is expected to end. (Month/Day/Year) Est. Est. Provide the frequency that this benefit is received. Annually Monthly Quarterly Weekly Provide the name of the country providing this benefit. Other (Provide explanation) Provide the total value (in U.S. dollars) of benefit. Provide the reason this benefit is being received. Est. As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country? If yes, provide explanation. YES NO Enter your Social Security Number before going to the next page Page 69 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities - (Continued) Complete the following if you responded 'YES' to as a U.S. citizen, 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. Entry #2 Specify (Check all that apply) Yourself Spouse Cohabitant Dependent children Provide the type of benefit. Educational Medical Retirement Social Welfare Other such benefit (Provide explanation) Provide the frequency of the benefit. Onetime benefit (Complete (a)) Future benefit (Complete (b)) Continuing benefit (Complete (c)) Other (Complete (c)) (Provide explanation) (a) If you have indicated that you, your spouse, cohabitant, or dependent children received a onetime benefit from a foreign country: Provide the date the benefit was received. (Month/Day/Year) Provide the name of the country providing the benefit. Provide the total value (in U.S. dollars) of the benefit received. Provide the reason this benefit was received. Est. Est. As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country? If yes, provide explanation. YES NO (b) If you have indicated that you, your spouse, cohabitant, or dependent children expect to receive a benefit from a foreign country: Provide the date the benefit will begin. (Month/Day/Year) Provide the frequency the benefit will be received. Est. Annually Monthly Quarterly Weekly Other (Provide explanation) Provide the name of the country providing this benefit. Provide the value (in U.S. dollars) of the benefit to be received. Provide the reason this benefit will be received. Est. As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country? If yes, provide explanation. YES NO (c) If have indicated that you, your spouse, cohabitant, or dependent children receive a continuing or other benefit from a foreign country: Provide the date the benefit began. (Month/Day/Year) Provide the date the benefit is expected to end. (Month/Day/Year) Est. Est. Provide the frequency that this benefit is received. Annually Monthly Quarterly Weekly Provide the name of the country providing this benefit. Other (Provide explanation) Provide the total value (in U.S. dollars) of benefit. Provide the reason this benefit is being received. Est. As a result of this benefit are you, your spouse, your cohabitant, or dependant children obligated in any way to this foreign country? If yes, provide explanation. YES NO Enter your Social Security Number before going to the next page Page 70 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20A - Foreign Activities - (Continued) 20A.5 Have you EVER provided financial support for any foreign national? YES NO (If NO, proceed to 20B) Complete the following if you responded 'Yes' to providing financial support for any foreign national. Entry #1 Provide the name of the foreign national you support or have supported financially. First name Last name Middle name Suffix 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.) City Country Street State Zip Code Provide the nature of your relationship with the foreign national listed above. Provide the amount (in U.S. dollars) of all financial support provided. Est. Provide the frequency of your support. Provide this foreign national's country(ies) of citizenship. Country #1 Country #2 Entry #2 Provide the name of the foreign national you support or have supported financially. First name Last name Middle name Suffix 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.) City Country Street State Zip Code Provide the nature of your relationship with the foreign national listed above. Provide the amount (in U.S. dollars) of all financial support provided. Est. Provide the frequency of your support. Provide this foreign national's country(ies) of citizenship. Country #1 Country #2 Enter your Social Security Number before going to the next page Page 71 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts 20B.1 Have you in the past seven (7) years provided advice or support to any individual associated with a foreign business or other foreign organization that you have not previously listed as a former employer? (Answer "No" if all your advice or support was authorized pursuant to official U.S. Government business.) YES NO (If NO, proceed to 20B.2) Complete the following if you responded 'Yes' to having in the past seven (7) years provided advice or support to any individual associated with a foreign business or other foreign organization that you have not previously listed as a former employer. Entry #1 Provide a description of advice/support provided. Provide the name of the individual to whom advice or support was provided. First name Last name Middle name Provide the name of the foreign organization or foreign business with whom the individual is associated. Provide the date(s) during which this advice or support was provided. To Date (Month/Year) From Date (Month/Year) Present Est. Suffix Provide the country of origin for the organization or business. Describe what compensation, if any, was provided for your service. Est. Entry #2 Provide a description of advice/support provided. Provide the name of the individual to whom advice or support was provided. First name Last name Middle name Provide the name of the foreign organization or foreign business with whom the individual is associated. Provide the date(s) during which this advice or support was provided. To Date (Month/Year) From Date (Month/Year) Present Est. Suffix Provide the country of origin for the organization or business. Describe what compensation, if any, was provided for your service. Est. For this question, 'Immediate Family' means your spouse, parents, step-parents, siblings, half and step-siblings, children, step-children, and cohabitant. 20B.2 Have you, your spouse, cohabitant, or any member of your immediate family in the past seven (7) years been asked to provide advice or serve as a consultant, even informally, by any foreign government official or agency? (Answer 'No' if all the advice or support was authorized pursuant to official U.S. Government business.) YES NO (If NO, proceed to 20B.3) Complete the following if you responded 'Yes' to you, your spouse, cohabitant, or any member of your immediate family having in the past seven (7) years been asked to provide advice or serve as a consultant, even informally, by any foreign government official or agency. Entry #1 Provide the name of the government official. Last name First name Provide the name of the agency. Middle name Suffix Provide the country with which the government official or agency is affiliated. Provide the circumstances of request. Provide the date of the request. (Month/Year) Est. Entry #2 Provide the name of the government official. Last name First name Provide the name of the agency. Suffix Provide the country with which the government official or agency is affiliated. Provide the circumstances of request. Provide the date of the request. (Month/Year) Est. Enter your Social Security Number before going to the next page Page 72 Middle name Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued) 20B.3 Has any foreign national in the past seven (7) years offered you a job, asked you to work as a consultant, or consider employment with them? YES NO (If NO, proceed to 20B.4) Complete the following if you responded 'Yes' to any foreign national having in the past seven (7) years offered you a job, asked you to work as a consultant, or consider employment with them. Entry #1 Provide the name of the foreign national who made the offer. First name Last name Provide a description of the position offered. Middle name Suffix Did you accept the offer? Provide the date when this offer was extended. (Month/Year) YES Explanation Est. NO Explanation Provide location of where this occurred. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Country City State Zip Code Entry #2 Provide the name of the foreign national who made the offer. First name Last name Provide a description of the position offered. Middle name Did you accept the offer? Provide the date when this offer was extended. (Month/Year) YES Explanation Est. NO Explanation Provide location of where this occurred. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Country City State Zip Code Enter your Social Security Number before going to the next page Page 73 Suffix Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued) 20B.4 Have you in the past seven (7) years 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.)? YES NO (If NO, proceed to 20B.5) Complete the following if you responded 'Yes' to having in the past seven (7) years been involved in any other type of business venture with a foreign national not described above. Entry #1 Provide the full name of this foreign national. Last name First name Middle name Suffix Provide the full current address of this foreign national. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the citizenship(s) of this foreign national. Country #1 Country #2 Provide a description of the business venture. Provide your relationship to this foreign national. Provide the length of time you have been involved in the business venture. Provide the nature of association with From Date (Month/Year) To Date (Month/Year) Present this business venture. Est. Provide the service you provided. Provide the position you held. Est. Provide the financial support involved. Provide a description of what compensation was provided for your service. Entry #2 Provide the full name of this foreign national. Last name First name Middle name Suffix Provide the full current address of this foreign national. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) City Country Street State Zip Code Provide the citizenship(s) of this foreign national. Country #1 Country #2 Provide a description of the business venture. Provide your relationship to this foreign national. Provide the length of time you have been involved in the business venture. Provide the nature of association with From Date (Month/Year) To Date (Month/Year) Present this business venture. Est. Provide the service you provided. Est. Provide the financial support involved. Enter your Social Security Number before going to the next page Page 74 Provide the position you held. Provide a description of what compensation was provided for your service. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued) 20B.5 Have you in the past seven (7) years attended or participated in any conferences, trade shows, seminars, or meetings outside the U.S.? (Do not include those you attended or participated in on official business for the U.S. government.) YES NO (If NO, proceed to 20B.6) Complete the following if you responded 'Yes' to in the past seven (7) years having attended or participated in any conferences, trade shows, seminars, or meetings outside the U.S. Entry #1 Provide the name and description of event. Provide the dates for the event. To Date (Month/Year) From Date (Month/Year) Est. Provide the name of sponsoring organization. Provide the city where the event was held. Present Provide the purpose of the event. Est. Provide the country where the event was held. Was there any subsequent contact with any foreign nationals as a result of the event? Provide explanation Contact #1 YES for each contact. Contact #2 NO Contact #3 Contact #4 Entry #2 Provide the name and description of event. Provide the dates for the event. To Date (Month/Year) From Date (Month/Year) Est. Provide the name of sponsoring organization. Provide the city where the event was held. Was there any subsequent contact with any foreign nationals as a result of the event? Provide explanation Contact #1 YES for each contact. Contact #2 NO Contact #3 Contact #4 Enter your Social Security Number before going to the next page Page 75 Present Provide the purpose of the event. Est. Provide the country where the event was held. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued) For this question, 'Immediate Family' means your spouse, parents, step-parents, siblings, half and step-siblings, children, step-children, and cohabitant. Have you or any member of your immediate family in the past seven (7) years had any contact with a foreign government, its establishment (such as embassy, consulate, agency, military service, intelligence or security service, etc.) or its representatives, whether inside or outside the U.S.? (Answer 'No' if the contact was for routine visa applications and border crossings related to either official U.S. Government travel or foreign travel on a U.S. passport.) 20B.6 YES NO (If NO, Proceed to 20B.7) Complete the following if you responded 'Yes' to you or any member of your immediate family having in the past seven (7) years had any contact with a foreign government, its establishment (such as embassy, consulate, agency, military service, intelligence or security service, etc.) or its representatives, whether inside or outside the U.S. Entry #1 Provide the name of the individual involved in the contact. First name Last name Middle name Suffix Provide the location of the contact. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Country City State Zip Code Provide the date of contact. Provide the foreign government(s) involved. Country #1 (Month/Year) Country #2 Est. Provide the type of establishment (such as embassy, consulate, agency, military service, intelligence or security service, etc.) involved. Provide the names of the foreign representatives involved in contact. Provide the purpose/circumstances of contact. Was there any subsequent contact initiated by you, your immediate family member, or a representative of the foreign organization? YES Provide the purpose of the subsequent contact NO Provide date of most recent contact (Month/Day/Year) Provide plans for future contact Entry #2 Provide the name of the individual involved in the contact. First name Last name Middle name Suffix Provide the location of the contact. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.) Country City State Zip Code Provide the date of contact. Provide the foreign government(s) involved. Country #1 (Month/Year) Country #2 Est. Provide the type of establishment (such as embassy, consulate, agency, military service, intelligence or security service, etc.) involved. Provide the names of the foreign representatives involved in contact. Provide the purpose/circumstances of contact. Was there any subsequent contact initiated by you, your immediate family member, or a representative of the foreign organization? YES NO Provide the purpose of the subsequent contact Provide date of most recent contact (Month/Day/Year) Enter your Social Security Number before going to the next page Page 76 Provide plans for future contact Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued) 20B.7 Have you in the past seven (7) years sponsored any foreign national to come to the U.S. as a student, for work, or for permanent residence? YES NO (If NO, proceed to 20B.8) Complete the following if you responded 'Yes' to in the past seven (7) years having sponsored any foreign national to come to the U.S. as a student, for work, or for permanent residence. Entry #1 Provide the name of the sponsored foreign national. First name Suffix Last name Middle name Provide the date of birth for the sponsored foreign national. Date (Month/Year) I don't know Est. Provide the place of birth for the sponsored foreign national. City State Zip Code Country (Required) Provide the current street address of the sponsored foreign national. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the name of the organization through which sponsorship was arranged, if applicable. Provide the country(ies) of citizenship for the sponsored foreign national. Country #1 Country #2 Provide the address of the organization through which sponsorship was arranged, if applicable. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code State Zip Code Not Applicable Not Applicable Country Provide the dates of stay in the U.S. for the sponsored foreign national. From Date (Month/Year) To Date (Month/Year) Present Est. Est. Provide the address of the sponsored foreign national while residing in the U.S. City Street Provide the purpose of stay in the U.S. for the sponsored foreign national. Enter your Social Security Number before going to the next page Page 77 Provide the purpose of your sponsorship for the sponsored foreign national. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued) Complete the following if you responded 'Yes' to in the past seven (7) years having sponsored any foreign national to come to the U.S. as a student, for work, or for permanent residence. Entry #2 Provide the name of the sponsored foreign national. First name Suffix Last name Middle name Provide the date of birth for the sponsored foreign national. Date (Month/Year) I don't know Est. Provide the place of birth for the sponsored foreign national. City State Zip Code Country (Required) Provide the current street address of the sponsored foreign national. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the name of the organization through which sponsorship was arranged, if applicable. Provide the country(ies) of citizenship for the sponsored foreign national. Country #1 Country #2 Provide the address of the organization through which sponsorship was arranged, if applicable. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Zip Code State Zip Code Not Applicable Not Applicable Country Provide the dates of stay in the U.S. for the sponsored foreign national. From Date (Month/Year) To Date (Month/Year) Present Est. Est. Provide the address of the sponsored foreign national while residing in the U.S. City Street Provide the purpose of stay in the U.S. for the sponsored foreign national. Enter your Social Security Number before going to the next page Page 78 Provide the purpose of your sponsorship for the sponsored foreign national. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20B - Foreign Business, Professional Activities, and Foreign Government Contacts - (Continued) 20B.8 Have you EVER held political office in a foreign country? YES NO (If NO, proceed to 20B.9) Complete the following if you responded 'Yes' to having EVER held political office in a foreign country. Entry #1 Provide the position held. Provide the dates you held political office. From Date (Month/Year) To Date (Month/Year) Est. Est. Provide your current eligibility to hold political office in a foreign country. Provide the reason(s) for these activities. Entry #2 Provide the position held. Provide the dates you held political office. From Date (Month/Year) To Date (Month/Year) Est. Provide the reason(s) for these activities. 20B.9 Provide the name of the country involved. Present Provide the name of the country involved. Present Est. Provide your current eligibility to hold political office in a foreign country. Have you EVER voted in the election of a foreign country? YES NO (If NO, Proceed to 20C) Complete the following if you responded 'Yes' to having EVER voted in the election of a foreign country. Entry #1 Provide the date you voted in the foreign election. (Month/Year) Provide the name of the country involved. Est. Provide the reason(s) for these activities. Provide your current eligibility to vote in a foreign country. Entry #2 Provide the date you voted in the foreign election. (Month/Year) Provide the name of the country involved. Est. Provide the reason(s) for these activities. Enter your Social Security Number before going to the next page Page 79 Provide your current eligibility to vote in a foreign country. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20C - Foreign Travel Have you traveled outside the U.S. in the last seven (7) years? YES 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)? YES (If YES, proceed to Section 21) NO (If NO, 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. Entry #1 Provide the country visited. Provide the dates of your travel to this country. To Date (Month/Year) From Date (Month/Year) Est. Provide the total number of days involved in the visit. Present 1-5 11-20 More than 30 Est. 6-10 21-30 Many short trips Provide the purpose of the travel to this country (Check all that apply). Business/Professional conference Education Trade shows, conferences, and seminars Volunteer activities Tourism Visit family or friends Other 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? YES If yes, provide explanation. NO While traveling to or in this country, were you involved in any encounter with the police? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO 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? If yes, provide explanation. YES NO Enter your Social Security Number before going to the next page Page 80 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20C - Foreign Travel - (Continued) 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. Entry #2 Provide the dates of your travel to this country. Provide the total number of days involved in the visit. Provide the country visited. To Date (Month/Year) From Date (Month/Year) Present 1-5 11-20 More than 30 Est. Est. 6-10 21-30 Many short trips Provide the purpose of the travel to this country (Check all that apply). Business/Professional conference Education Trade shows, conferences, and seminars Volunteer activities Tourism Visit family or friends Other 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? YES If yes, provide explanation. NO While traveling to or in this country, were you involved in any encounter with the police? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO Enter your Social Security Number before going to the next page Page 81 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20C - Foreign Travel - (Continued) 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. Entry #3 Provide the country visited. Provide the dates of your travel to this country. To Date (Month/Year) From Date (Month/Year) Est. Provide the total number of days involved in the visit. Present 1-5 11-20 More than 30 Est. 6-10 21-30 Many short trips Provide the purpose of the travel to this country (Check all that apply). Business/Professional conference Education Trade shows, conferences, and seminars Volunteer activities Tourism Visit family or friends Other 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? YES If yes, provide explanation. NO While traveling to or in this country, were you involved in any encounter with the police? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO Enter your Social Security Number before going to the next page Page 82 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 20C - Foreign Travel - (Continued) 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. Entry #4 Provide the country visited. Provide the dates of your travel to this country. To Date (Month/Year) From Date (Month/Year) Est. Provide the total number of days involved in the visit. Present 1-5 11-20 More than 30 Est. 6-10 21-30 Many short trips Provide the purpose of the travel to this country (Check all that apply). Business/Professional conference Education Trade shows, conferences, and seminars Volunteer activities Tourism Visit family or friends Other 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? YES If yes, provide explanation. NO While traveling to or in this country, were you involved in any encounter with the police? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO 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? YES If yes, provide explanation. NO Enter your Social Security Number before going to the next page Page 83 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 21 - Psychological and Emotional Health 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. 21.1 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 Please respond to this question with the following additional instruction: Victims of sexual assault who have consulted with the health care professional regarding an emotional or mental health condition during this period strictly in relation to the sexual assault are instructed to answer No. 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. Entry #1 Provide the dates of counseling or treatment. From Date To Date (Month/Year) (Month/Year) Est. Provide the name of the health care professional. Provide the telephone number of the health care professional. Day International or DSN phone number Telephone number Present Night Extension Est. Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the name of agency/organization/facility where counseling/treatment was provided. Same as above Provide the address of agency/organization/facility provider. (Provide City and Country if outside the United States; otherwise, provide City, Same as above State and Zip Code) City Street State Zip Code Country Were you EVER admitted as an inpatient to the agency/organization where counseling/treatment was provided? YES NO 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? Voluntary Involuntary Explanation Entry #2 Provide the dates of counseling or treatment. From Date To Date (Month/Year) (Month/Year) Est. Provide the name of the health care professional. Provide the telephone number of the health care professional. International or DSN phone number Telephone number Present Day Night Extension Est. Provide the address of the health care professional. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the name of agency/organization/facility where counseling/treatment was provided. 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) City Street State Zip Code Same as above Country Were you EVER admitted as an inpatient to the agency/organization where counseling/treatment was provided? YES NO 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? Voluntary Involuntary Explanation Enter your Social Security Number before going to the next page Page 84 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 21 - Psychological and Emotional Health - (Continued) Has a court or administrative agency EVER declared you mentally incompetent? 21.2 YES NO (If NO, proceed to Section 22) Complete the following if you responded 'Yes' to having a court or administrative agency EVER declare you mentally incompetent. Entry #1 Provide the date this occurred. (Month/Year) Provide the name of the court or administrative agency that declared you mentally incompetent. Est. 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) City Country Street State Zip Code Was this matter appealed to a higher court? YES NO Appeal #1 Provide the name of the court. Provide the final disposition. Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code Street Appeal #2 Provide the name of the court. Provide the final disposition. Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code Street Entry #2 Provide the date this occurred. (Month/Year) Provide the name of the court or administrative agency that declared you mentally incompetent. Est. 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) City Country Street State Zip Code Was this matter appealed to a higher court? YES NO (If NO, proceed to Section 22) Appeal #1 Provide the name of the court. Provide the final disposition. Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code Street Appeal #2 Provide the name of the court. Provide the final disposition. Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code Street Enter your Social Security Number before going to the next page Page 85 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 22 - 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. 22.1 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 (If NO, proceed to 22.2) Entry #1 - In the past seven (7) 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 past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official? - In the past seven (7) years have you been charged, convicted, or sentenced of 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 past seven (7) years have you been or are you currently on probation or parole? - Are you currently on trial or awaiting a trial on criminal charges? Entry #1 Provide a description of the specific nature of the offense. Provide the date of offense. (Month/Year) Est. (a) Did this offense involve any of the following? YES NO (Check all that apply.) Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common? Involve firearms or explosives? Involve alcohol or drugs? Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code) Country City County State Zip Code (b) 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 (If NO, proceed to (c)) Provide the name of the law enforcement agency that arrested/cited/summoned you. Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code) Country State City County Zip Code (c) 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 Provide the name of the court. (If YES, complete (c.1)) Provide explanation (c.1) Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code) Country City County State Zip Code 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 Charge Outcome Date (Month/Year) Est. Est. Est. Est. Enter your Social Security Number before going to the next page Page 86 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 22 - Police Record - (Continued) Entry #1 Complete the following if you responded 'Yes' to one of the following: - In the past seven (7) 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 past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official? - In the past seven (7) years have you been charged, convicted, or sentenced of 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 past seven (7) years have you been or are you currently on probation or parole? - Are you currently on trial or awaiting a trial on criminal charges? (d) Were you sentenced as a result of this offense? YES (If YES, complete (d.1)) NO (If NO, complete (d.2)) (d.1) Provide a description of the sentence. Were you sentenced to imprisonment for a term exceeding 1 year? YES NO Were you incarcerated as a result of that sentence for not less than 1 year? YES NO If the conviction resulted in imprisonment, provide the dates that you actually were incarcerated. Not Applicable If conviction resulted in probation or parole, provide the dates of probation or parole. Not Applicable From Date (Month/Year) To Date (Month/Year) Est. Est. From Date (Month/Year) Present To Date (Month/Year) Present Est. Est. (d.2) Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? Provide explanation. Enter your Social Security Number before going to the next page Page 87 YES NO Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 22 - Police Record - (Continued) Entry #2 Complete the following if you responded 'Yes' to one of the following: - In the past seven (7) 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 past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official? - In the past seven (7) years have you been charged, convicted, or sentenced of 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 past seven (7) years have you been or are you currently on probation or parole? - Are you currently on trial or awaiting a trial on criminal charges? Entry #2 Provide a description of the specific nature of the offense. Provide the date of offense. (Month/Year) Est. (a) Did this offense involve any of the following? YES NO (Check all that apply.) Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common? Involve firearms or explosives? Involve alcohol or drugs? Provide the location where the offense occurred. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code) Country City County State Zip Code (b) 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 (If NO, proceed to (c)) Provide the name of the law enforcement agency that arrested/cited/summoned you. Provide the location of the law enforcement agency. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code) Country State City County Zip Code (c) 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 Provide the name of the court. (If YES, complete (c.1)) Provide explanation (c.1) Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code) Country City County State Zip Code 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 Charge Outcome Date (Month/Year) Est. Est. Est. Est. Enter your Social Security Number before going to the next page Page 88 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 22 - Police Record - (Continued) Entry #2 Complete the following if you responded 'Yes' to one of the following: - In the past seven (7) 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 past seven (7) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official? - In the past seven (7) years have you been charged, convicted, or sentenced of 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 past seven (7) years have you been or are you currently on probation or parole? - Are you currently on trial or awaiting a trial on criminal charges? (d) Were you sentenced as a result of this offense? YES (If YES, complete (d.1)) NO (If NO, complete (d.2)) (d.1) Provide a description of the sentence. Were you sentenced to imprisonment for a term exceeding 1 year? YES NO Were you incarcerated as a result of that sentence for not less than 1 year? YES NO If the conviction resulted in imprisonment, provide the dates that you actually were incarcerated. Not Applicable If conviction resulted in probation or parole, provide the dates of probation or parole. Not Applicable From Date (Month/Year) To Date (Month/Year) Est. Est. From Date (Month/Year) Present To Date (Month/Year) Present Est. Est. (d.2) Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? Provide explanation. Enter your Social Security Number before going to the next page Page 89 YES NO Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 22 - Police Record - (Continued) Other than those offenses already listed, have you EVER had the following happen to you? 22.2 YES NO (If NO, proceed to 22.3) - Have you EVER been convicted in any court of the United States of a crime, sentenced to imprisonment for a term exceeding 1 year for that crime, and incarcerated as a result of that sentence for not less than 1 year? (Include all qualifying convictions in Federal, state, local, or military court, even if previously listed on this form) - Have you EVER been charged with any felony offense? (Include those under the Uniform Code of Military Justice and non-military/ civilian felony offenses) - Have you EVER been convicted of an offense involving domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common? - Have you EVER been charged with an offense involving firearms or explosives? - Have you EVER been charged with an offense involving alcohol or drugs? Entry #1 Provide a description of the specific nature of the offense. Provide the date of offense. (Month/Year) Est. (a) Did this offense involve any of the following? YES NO (Check all that apply). Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common? Involve firearms or explosives? Involve alcohol or drugs? Provide the name of the court. Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code) Country State City County Zip Code Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser offense separately. Felony/misdemeanor Charge Outcome Date (Month/Year) Est. Est. Est. Est. (b) Were you sentenced as a result of these charges? YES (If YES, complete (b.1)) NO (If NO, complete (b.2)) (b.1) Provide a description of the sentence. Were you sentenced to imprisonment for a term exceeding 1 year? YES NO Were you incarcerated as a result of that sentence for not less than 1 year? YES NO If the conviction resulted in imprisonment, provide the dates that you actually were incarcerated. Not Applicable From Date (Month/Year) If conviction resulted in probation or parole, provide the dates of probation or parole. Not Applicable From Date (Month/Year) To Date (Month/Year) Est. Present Est. To Date (Month/Year) Est. Present Est. (b.2) Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? Provide explanation. Enter your Social Security Number before going to the next page Page 90 YES NO Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 22 - Police Record - (Continued) Entry #2 Provide a description of the specific nature of the offense. Provide the date of offense. (Month/Year) Est. (a) Did this offense involve any of the following? YES NO (Check all that apply). Domestic violence or a crime of violence (such as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with whom you share a child in common? Involve firearms or explosives? Involve alcohol or drugs? Provide the name of the court. Provide the location of the court. (Provide City and Country if outside the United States; otherwise, provide City, County, State and Zip Code) Country State City County Zip Code Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found guilty, found not-guilty, or charge dropped or "nolle pros," etc). If you were found guilty of or pleaded guilty to a lesser offense, list both the original charge and the lesser offense separately. Felony/misdemeanor Charge Outcome Date (Month/Year) Est. Est. Est. Est. (b) Were you sentenced as a result of these charges? YES (If YES, complete (b.1)) NO (If NO, complete (b.2)) (b.1) Provide a description of the sentence. Were you sentenced to imprisonment for a term exceeding 1 year? YES NO Were you incarcerated as a result of that sentence for not less than 1 year? YES NO If the conviction resulted in imprisonment, provide the dates that you actually were incarcerated. Not Applicable From Date (Month/Year) If conviction resulted in probation or parole, provide the dates of probation or parole. Not Applicable From Date (Month/Year) To Date (Month/Year) Est. Present Est. To Date (Month/Year) Est. Present Est. (b.2) Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal charges for this offense? Provide explanation. Enter your Social Security Number before going to the next page Page 91 YES NO Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 22 - Police Record - (Continued) 22.3 Is there currently a domestic violence protective order or restraining order issued against you? YES NO (If NO, proceed to Section 23) Complete the following if you responded 'Yes' to currently having a domestic violence protective order or restraining order issued against you? Entry #1 Provide explanation. Provide the name of the court or agency that issued the order. Provide the date the order was issued. (Month/Year) Est. Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code Entry #2 Provide explanation. Provide the name of the court or agency that issued the order. Provide the date the order was issued. (Month/Year) Est. Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code Entry #3 Provide explanation. Provide the name of the court or agency that issued the order. Provide the date the order was issued. (Month/Year) Est. Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code Entry #4 Provide explanation. Provide the name of the court or agency that issued the order. Provide the date the order was issued. (Month/Year) Est. Provide the location of the court or agency that issued the order: (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country City State Zip Code Enter your Social Security Number before going to the next page Page 92 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 23 - 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. As to this particular section, this 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. In the last seven (7) years, 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. 23.1 YES NO (If NO, proceed to 23.2) Complete the following if you answered 'Yes' to in the last seven (7) years having illegally used a drug or controlled substance. Entry #1 Provide the type of drug or controlled substance. Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.) THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation) Provide an estimate of the month and year of first use. (Month/Year) Provide an estimate of the month and year of most recent use. (Month/Year) Est. Provide nature of use, frequency, and number of times used. Est. Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety? YES NO Was your use while possessing a security clearance? YES NO Do you intend to use this drug or controlled substance in the future? YES NO Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future. Entry #2 Provide the type of drug or controlled substance. Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.) THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation) Provide an estimate of the month and year of first use. (Month/Year) Provide an estimate of the month and year of most recent use. (Month/Year) Est. Provide nature of use, frequency, and number of times used. Est. Was your use while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety? YES NO Was your use while possessing a security clearance? YES NO Do you intend to use this drug or controlled substance in the future? YES NO Provide explanation of why you intend or do not intend to use this drug or controlled substance in the future. Enter your Social Security Number before going to the next page Page 93 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 23 - Illegal Use of Drugs and Drug Activity - (Continued) 23.2 In the last seven (7) years, 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 (If NO, proceed to 23.3) Complete the following if you answered 'Yes' to in the last seven (7) years having been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of a drug or controlled substance. Entry #1 Provide the type of drug or controlled substance. Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.) THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation) Provide an estimate of the month and year of first involvement. (Month/Year) Provide an estimate of the month and year of most recent involvement. (Month/Year) Est. Provide the nature and frequency of activity. Est. Provide the reason(s) why you engaged in the activity Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety? YES NO Was your involvement while possessing a security clearance? YES NO Do you intend to engage in this activity in the future? YES Provide explanation. NO Entry #2 Provide the type of drug or controlled substance. Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.) THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation) Provide an estimate of the month and year of first involvement. (Month/Year) Provide an estimate of the month and year of most recent involvement. (Month/Year) Est. Provide the nature and frequency of activity. Est. Provide the reason(s) why you engaged in the activity Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety? YES NO Was your involvement while possessing a security clearance? YES NO Do you intend to engage in this activity in the future? YES Provide explanation. NO Enter your Social Security Number before going to the next page Page 94 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 23 - Illegal Use of Drugs and Drug Activity - (Continued) 23.3 Have you EVER illegally used or otherwise been involved with a drug or controlled substance while possessing a security clearance other than previously listed? YES NO (If NO, proceed to 23.4) Complete the following if you responded 'Yes' to having EVER illegally used or otherwise been involved with a drug or controlled substance while possessing a security clearance, other than previously listed. Entry #1 Provide a description of your involvement. Provide the dates of involvement/use. From Date (Month/Year) To Date (Month/Year) Est. Present Provide an estimate of the number of times you used and/or were involved with this drug or controlled substance while possessing a security clearance. Est. Entry #2 Provide a description of your involvement. Provide the dates of involvement/use. From Date (Month/Year) To Date (Month/Year) Est. 23.4 Present Provide an estimate of the number of times you used and/or were involved with this drug or controlled substance while possessing a security clearance. Est. Have you EVER illegally used or otherwise been involved with a drug or controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety other than previously listed? YES NO (If NO, proceed to 23.5) Complete the following if you responded 'Yes' to having EVER illegally used, or otherwise been involved with a drug or controlled substance while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety other than previously listed. Entry #1 Provide a description of the drugs or controlled substances used and your involvement. Provide the dates of involvement/use. From Date (Month/Year) To Date (Month/Year) Est. Present Provide an estimate of the number of times you used and/or were involved with this drug or controlled substance while employed in this capacity. Est. Entry #2 Provide a description of the drugs or controlled substances used and your involvement. Provide the dates of involvement/use. From Date (Month/Year) Est. To Date (Month/Year) Present Provide an estimate of the number of times you used and/or were involved with this drug or controlled substance while employed in this capacity. Est. Enter your Social Security Number before going to the next page Page 95 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 23 - Illegal Use of Drugs and Drug Activity - (Continued) 23.5 In the last seven (7) years 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 (If NO, proceed to 23.6) Complete the following if you responded 'Yes' to in the last seven (7) years having intentionally engaged in the misuse of prescription drugs, regardless of whether the drugs were prescribed for you or someone else. Entry #1 Provide the name of the prescription drug that you misused. Provide the dates of involvement/use From Date (Month/Year) To Date (Month/Year) Est. Provide the reason(s) for and circumstances of the misuse of the prescription drug. Present Est. Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety? YES NO Was your involvement while possessing a security clearance? YES NO Entry #2 Provide the name of the prescription drug that you misused. Provide the dates of involvement/use From Date (Month/Year) Est. To Date (Month/Year) Provide the reason(s) for and circumstances of the misuse of the prescription drug. Present Est. Was your involvement while you were employed as a law enforcement officer, prosecutor, or courtroom official, or while in a position directly and immediately affecting the public safety? YES NO Was your involvement while possessing a security clearance? YES NO Enter your Social Security Number before going to the next page Page 96 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 23 - Illegal Use of Drugs and Drug Activity - (Continued) 23.6 Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or controlled substances? YES NO (If NO, proceed to 23.7) Complete the following if you responded 'Yes' to having EVER been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or controlled substances. Entry #1 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? (Check all that apply): An employer, military commander, or employee assistance program A court official / judge A medical professional I have not been ordered, advised, or asked to seek counseling or treatment by any of the above A mental health professional Provide explanation YES (If YES, complete (b)) Did you take action to receive counseling or treatment? NO (If NO, complete (a)) (a) You have indicated that you did not receive treatment. Provide explanation. (b) You have indicated that you did receive treatment. Provide the type of drug or controlled substance for which you were treated. Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.) THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation) Provide the name of the treatment provider. Last name First name Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a telephone number for the treatment provider. Did you successfully complete the treatment? Extension YES International or DSN phone number Day Night NO (Provide explanation) Enter your Social Security Number before going to the next page Page 97 Provide the dates of treatment. From Date (Month/Year) To Date (Month/Year) Est. Present Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 23 - Illegal Use of Drugs and Drug Activity - (Continued) Complete the following if you responded 'Yes' to having EVER been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or controlled substances. Entry #2 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? (Check all that apply): An employer, military commander, or employee assistance program A court official / judge A medical professional I have not been ordered, advised, or asked to seek counseling or treatment by any of the above A mental health professional Provide explanation YES (If YES, complete (b)) Did you take action to receive counseling or treatment? NO (If NO, complete (a)) (a) You have indicated that you did not receive treatment. Provide explanation. (b) You have indicated that you did receive treatment. Provide the type of drug or controlled substance for which you were treated. Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.) THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation) Provide the name of the treatment provider. Last name First name Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a telephone number for the treatment provider. Did you successfully complete the treatment? Extension YES International or DSN phone number Day Night NO (Provide explanation) Enter your Social Security Number before going to the next page Page 98 Provide the dates of treatment. From Date (Month/Year) To Date (Month/Year) Est. Present Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 23 - Illegal Use of Drugs and Drug Activity - (Continued) 23.7 Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance? YES NO (If NO, proceed to Section 24) Complete the following if you responded 'Yes' to having EVER voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance? Entry #1 Provide the type of drug or controlled substance for which you were treated. Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.) THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation) Provide the name of the treatment provider. Last name First name Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a telephone number for the treatment provider. Did you successfully complete the treatment? Extension YES International or DSN phone number Day Night NO Provide the dates of treatment. From Date (Month/Year) To Date (Month/Year) Est. Present Est. (Provide explanation) Entry #2 Provide the type of drug or controlled substance for which you were treated. Cocaine or crack cocaine (Such as rock, freebase, etc.) Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.) THC (Such as marijuana, weed, pot, hashish, etc.) Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) Ketamine (Such as special K, jet, etc.) Steroids (Such as the clear, juice, etc.) Narcotics (Such as opium, morphine, codeine, heroin, etc.) Inhalants (Such as toluene, amyl nitrate, etc.) Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.) Other (Provide explanation) Provide the name of the treatment provider. Last name First name Provide the address for this treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a telephone number for the treatment provider. Did you successfully complete the treatment? Extension YES International or DSN phone number Day Night NO (Provide explanation) Enter your Social Security Number before going to the next page Page 99 Provide the dates of treatment. From Date (Month/Year) To Date (Month/Year) Est. Present Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 24 - Use of Alcohol 24.1 In the last seven (7) years 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? YES NO (If NO, proceed to 24.2) Complete the following if you responded 'Yes' to your alcohol use having 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. Entry #1 Provide the dates of involvement or use. From Date (Month/Year) To Date (Month/Year) Est. Provide the month/year when this negative impact occurred. Present Est. Provide circumstances. Provide negative impact. From Date (Month/Year) Est. Entry #2 Provide the dates of involvement or use. From Date (Month/Year) To Date (Month/Year) Est. Provide the month/year when this negative impact occurred. Present Est. Provide circumstances. Provide negative impact. From Date (Month/Year) Est. Entry #3 Provide the dates of involvement or use. From Date (Month/Year) To Date (Month/Year) Est. Provide the month/year when this negative impact occurred. Present Est. Provide circumstances. Provide negative impact. From Date (Month/Year) Est. Entry #4 Provide the dates of involvement or use. From Date (Month/Year) To Date (Month/Year) Est. Provide the month/year when this negative impact occurred. Present Est. Provide circumstances. From Date (Month/Year) Est. Enter your Social Security Number before going to the next page Page 100 Provide negative impact. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 24 - Use of Alcohol - (Continued) 24.2 Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol? YES NO (If NO, proceed to 24.3) Complete the following if you responded 'Yes' to having been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol. Entry #1 Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your use of alcohol? (Check all that apply) An employer, military commander, or employee assistance program A court official / judge A medical professional I have not been ordered, advised, or asked to seek counseling or treatment by any of the above A mental health professional Other (Provide explanation) YES (If YES, complete (b)) Did you take action to receive counseling or treatment? (a) NO (If NO, complete (a)) You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment. Provide explanation. (b) You responded 'Yes' to having taken action to seek counseling or treatment. Provide the dates of counseling or treatment. From Date (Month/Year) To Date (Month/Year) Est. Provide the name of the individual counselor or treatment provider. Present Est. Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide telephone number. Extension International or DSN phone number Day Did you successfully complete the treatment? YES NO Night (Provide explanation) Entry #2 Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your use of alcohol? (Check all that apply): An employer, military commander, or employee assistance program A court official / judge A medical professional I have not been ordered, advised, or asked to seek counseling or treatment by any of the above A mental health professional Other (Provide explanation) YES (If YES, complete (b)) Did you take action to receive counseling or treatment? (a) NO (If NO, complete (a)) You responded 'No' to having taken action to seek counseling or treatment. Explain the reasons for not taking action to seek counseling or treatment. Provide explanation. (b) You responded 'Yes' to having taken action to seek counseling or treatment. Provide the dates of counseling or treatment. From Date (Month/Year) To Date (Month/Year) Est. Provide the name of the individual counselor or treatment provider. Present Est. Provide the full address for the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide telephone number. Extension International or DSN phone number Day Did you successfully complete the treatment? YES NO Enter your Social Security Number before going to the next page Page 101 Night (Provide explanation) Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 24 - Use of Alcohol - (Continued) 24.3 Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol? YES NO (If NO, proceed to 24.4) Complete the following if you responded 'Yes' to voluntarily seeking counseling or treatment. Entry #1 Provide the dates of counseling or treatment. From Date (Month/Year) To Date (Month/Year) Provide the name of the individual counselor or treatment provider. Present Est. Est. Provide the full address of the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide telephone number. Extension International or DSN phone number Day Did you successfully complete the treatment? YES Entry #2 Provide the dates of counseling or treatment. From Date (Month/Year) To Date (Month/Year) NO Night (Provide explanation) Provide the name of the individual counselor or treatment provider. Present Est. Est. Provide the full address of the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide telephone number. Extension International or DSN phone number Day Did you successfully complete the treatment? YES NO (Provide explanation) Enter your Social Security Number before going to the next page Page 102 Night Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 24 - Use of Alcohol - (Continued) 24.4 Have you EVER received counseling or treatment as a result of your use of alcohol in addition to what you have already listed on this form? YES NO (If NO, proceed to Section 25) Complete the following if you responded 'Yes' to having EVER received counseling or treatment as a result of your use of alcohol. Entry #1 Provide the name of the individual counselor or treatment provider. Name Provide the full address of the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the name of agency/organization where counseling/treatment was provided. Name Provide the address of agency/organization where counseling/treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City Provide the dates of counseling or treatment. From Date (Month/Year) To Date (Month/Year) Est. State Zip Code Same as above Country Present Est. Did you successfully complete your counseling or treatment? YES (Provide explanation) NO (Provide explanation) Explanation Entry #2 Provide the name of the individual counselor or treatment provider. Name Provide the full address of the counseling/treatment provider. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Country Street State City Zip Code Provide the name of agency/organization where counseling/treatment was provided. Name Provide the address of agency/organization where counseling/treatment was provided. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street Provide the dates of counseling or treatment. From Date (Month/Year) To Date (Month/Year) Est. State Country Present Est. Did you successfully complete your counseling or treatment? Explanation Enter your Social Security Number before going to the next page Page 103 Zip Code Same as above YES (Provide explanation) NO (Provide explanation) Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 25 - Investigations and Clearance Record 25.1 Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a security clearance eligibility/access? YES NO (If NO, proceed to 25.2) Complete the following if 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. Entry #1 Provide the investigating agency: U.S. Department of Defense U.S. Department of Homeland Security U.S. Department of State Foreign government (Provide name of government) U.S. Office of Personnel Management I don't know Federal Bureau of Investigation Other (Provide explanation) U.S. Department of Treasury Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency. Date the investigation was completed (Month/Year) I don't know Provide the date clearance eligibility/access was granted. (Month/Year) Est. I don't know Est. Provide the level of clearance eligibility/access granted: None Q Confidential L Secret I don't know Top Secret Issued by foreign country Sensitive Compartmented Information (SCI) Other (Provide explanation) Entry #2 Provide the investigating agency: U.S. Department of Defense U.S. Department of Homeland Security U.S. Department of State Foreign government (Provide name of government) U.S. Office of Personnel Management I don't know Federal Bureau of Investigation Other (Provide explanation) U.S. Department of Treasury Provide the name of agency that issued the clearance eligibility/access if different from the investigating agency. Date the investigation was completed (Month/Year) I don't know Provide the date clearance eligibility/access was granted. (Month/Year) Est. Provide the level of clearance eligibility/access granted: None Q Confidential L Secret I don't know Top Secret Issued by foreign country Sensitive Compartmented Information (SCI) Other (Provide explanation) Enter your Social Security Number before going to the next page Page 104 I don't know Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 25 - Investigations and Clearance Record - (Continued) 25.2 Have you EVER 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 (If NO, proceed to 25.3) Complete the following if you responded 'Yes' to having EVER had a security clearance eligibility/access authorization denied, suspended, or revoked. Entry #1 Provide the date security clearance eligibility/access authorization was denied, suspended or revoked. (Month/Year) Provide the name of the agency that took the action. Provide an explanation of the circumstances of the denial, suspension or revocation action. Provide the name of the agency that took the action. Provide an explanation of the circumstances of the denial, suspension or revocation action. Est. Entry #2 Provide the date security clearance eligibility/access authorization was denied, suspended or revoked. (Month/Year) Est. 25.3 Have you EVER been debarred from government employment? YES NO (If NO, proceed to Section 26) Complete the following if you responded 'Yes' to having EVER been debarred from government employment. Entry #1 Provide the name of the government agency taking debarment action. Provide an explanation of the circumstances of the debarment. Provide the date the debarment occurred. (Month/Year) Est. Entry #2 Provide the name of the government agency taking debarment action. Provide an explanation of the circumstances of the debarment. Provide the date the debarment occurred. (Month/Year) Est. Enter your Social Security Number before going to the next page Page 105 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 26 - Financial Record In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code? 26.1 YES NO (If NO, proceed to 26.2) Complete the following if you responded 'Yes' to in the last seven (7) years having filed a petition under any chapter of the bankruptcy code. Entry #1 Select the applicable bankruptcy petition type. Chapter 7 Chapter 11 Provide the bankruptcy court docket/account number. Chapter 13 Provide the date of bankruptcy discharge. (Month/Year) Provide the date bankruptcy was filed. (Month/Year) Not Applicable Est. Est. Est. Provide the name debt is recorded under. Last name Provide the total amount (in U.S. dollars) involved in the bankruptcy. First name Suffix Middle name Provide the name of the court involved. Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code (a) If Chapter 13 previously selected: Provide the name of the trustee for this bankruptcy. Provide the address of the trustee for this bankruptcy. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Street State Country Zip Code Were you discharged of all debts claimed in the bankruptcy? YES (Provide explanation) NO (Provide explanation) Provide Explanation. Entry #2 Select the applicable bankruptcy petition type. Chapter 7 Chapter 11 Provide the bankruptcy court docket/account number. Chapter 13 Provide the date of bankruptcy discharge. (Month/Year) Provide the date bankruptcy was filed. (Month/Year) Not Applicable Est. Est. Est. Provide the name debt is recorded under. Last name Provide the total amount (in U.S. dollars) involved in the bankruptcy. First name Suffix Middle name Provide the name of the court involved. Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code (a) If Chapter 13 previously selected: Provide the name of the trustee for this bankruptcy. Provide the address of the trustee for this bankruptcy. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) Street City Were you discharged of all debts claimed in the bankruptcy? Provide Explanation. Enter your Social Security Number before going to the next page Page 106 State Zip Code Country YES (Provide explanation) NO (Provide explanation) Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 26 - Financial Record - (Continued) Have you EVER experienced financial problems due to gambling? 26.2 YES NO (If NO, proceed to 26.3) Complete the following if you responded 'Yes' to having EVER experienced financial problems due to gambling. Entry #1 Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred. From Date (Month/Year) To Date (Month/Year) Present Est. Est. Provide a description of your financial problems due to gambling. If you have taken any action(s) to rectify your financial problems due to gambling,provide a description of your actions. If you have not taken any action(s), provide explanation. Entry #2 Provide the date range of your financial problems due to gambling. Provide an estimate of the amount (in U.S. dollars) of gambling losses incurred. From Date (Month/Year) To Date (Month/Year) Present Est. Est. Provide a description of your financial problems due to gambling. 26.3 If you have taken any action(s) to rectify your financial problems due to gambling,provide a description of your actions. If you have not taken any action(s), provide explanation. In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance? YES NO (If NO, proceed to 26.4) Complete the following if you responded 'Yes' to having failed to file or pay Federal, state, or other taxes when required by law or ordinance. Entry #1 Did you fail to file, pay as required, or both? File Pay Provide the year you failed to file or pay your Federal, state, or other taxes. Est. Both Provide the reason(s) for your failure to file or pay required taxes. Provide the Federal, state, or other agency to which you failed to file or pay taxes. Provide date satisfied. (Month/Year) Provide the amount (in U.S. dollars) of the taxes. Est. Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.). Not Applicable Est. 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. Entry #2 Did you fail to file, pay as required, or both? File Pay Provide the year you failed to file or pay your Federal, state, or other taxes. Est. Both Provide the reason(s) for your failure to file or pay required taxes. Provide the Federal, state, or other agency to which you failed to file or pay taxes. Provide date satisfied. (Month/Year) Provide the amount (in U.S. dollars) of the taxes. Est. Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.). Not Applicable Est. 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. Enter your Social Security Number before going to the next page Page 107 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 26 - Financial Record - (Continued) 26.4 In the past seven (7) years have you been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card provided by your employer? YES NO (If NO, proceed to 26.5) Complete the following if you responded 'Yes' to having been counseled, warned, or disciplined for violating the terms of agreement for a travel or credit card provided by your employer. Entry #1 Provide the name of the agency or company. Provide the address of the agency or company. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country State Street Zip Code Provide the date of your counseling, warning, or disciplinary action. (Month/Year) Provide the reason(s) for the counseling, warning, or disciplinary action Est. Provide the amount (in U.S. dollars) of violation. Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any action(s) provide explanation. Est. Entry #2 Provide the name of the agency or company. Provide the address of the agency or company. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country State Street Zip Code Provide the date of your counseling, warning, or disciplinary action. (Month/Year) Provide the reason(s) for the counseling, warning, or disciplinary action Est. Provide the amount (in U.S. dollars) of violation. Provide a description of any action(s) you have taken to rectify this situation. If you have not taken any action(s) provide explanation. Est. 26.5 Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve your financial difficulties? YES NO (If NO, proceed to 26.6) Complete the following if you responded 'Yes' to being currently utilizing, or seeking assistance from, a credit counseling service or other similar resource to resolve your financial difficulties. Entry #1 Provide explanation. Provide the name of the credit counseling organization or resource. Provide the telephone number of the credit counseling organization. Telephone number Extension International or DSN phone number Day Provide the location of the credit counseling organization. City State Night As a result of this counseling, provide a description of any action(s) you have taken to resolve your financial difficulties. If you have not taken any action(s), provide explanation. Entry #2 Provide the name of the credit counseling organization or resource. Provide explanation. Provide the telephone number of the credit counseling organization. Telephone number Extension International or DSN phone number Day Provide the location of the credit counseling organization. City State Night As a result of this counseling, provide a description of any action(s) you have taken to resolve your financial difficulties. If you have not taken any action(s), provide explanation. Enter your Social Security Number before going to the next page Page 108 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 26 - Financial Record - (Continued) 26.6 Other than previously listed, have any of the following happened to you? (You will be asked to provide details about each financial obligation that pertains to the items identified below) - In the past seven (7) years, you have been delinquent on alimony or child support payments. - In the past seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor). - In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor). - 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 NO (If NO, Proceed to 26.7) Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues. Entry #1 Provide the name of agency/organization/individual to which debt is/was owed. Did/does this financial issue include any of the following? (Check all that apply) YES NO (If NO, Proceed to 26.7) In the past seven (7) years, you have been delinquent on alimony or child support payments. In the past seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor). In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor). 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). Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any). Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue. Provide the current status of the financial issue. Est. Provide the date the financial issue began. (Month/Year) Provide date the financial issue was resolved. (Month/Year) Est. Provide the name of the court involved. Not Resolved Est. Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code 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. Enter your Social Security Number before going to the next page Page 109 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 26 - Financial Record - (Continued) Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues. Entry #2 Provide the name of agency/organization/individual to which debt is/was owed. Did/does this financial issue include any of the following? (Check all that apply) YES NO (If NO, Proceed to 26.7) In the past seven (7) years, you have been delinquent on alimony or child support payments. In the past seven (7) years, you had a judgment entered against you. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor). In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or other debts. (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor). 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). Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any). Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue. Provide the current status of the financial issue. Est. Provide the date the financial issue began. (Month/Year) Provide date the financial issue was resolved. (Month/Year) Est. Provide the name of the court involved. Not Resolved Est. Provide the address of the court involved. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code 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. Enter your Social Security Number before going to the next page Page 110 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 26 - Financial Record - (Continued) 26.7 Other than previously listed, have any of the following happened? - In the past seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) - In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) - In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) - In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) - In the past seven (7) years, you were evicted for non-payment? - In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason? - In the past seven (7) years, you have been over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) - You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor) YES NO (If NO, proceed to Section 27) Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues. Entry #1 Provide the name of agency/organization/individual to which debt is/was owed. Did/does this financial issue include any of the following? (Check all that apply) YES NO (If NO, proceed to Section 27) In the past seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) In the past seven (7) years, you were evicted for non-payment? In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason? In the past seven (7) years, you have been over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor) Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any). Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue. Provide the current status of the financial issue. Est. Provide the date the financial issue began. (Month/Year) Provide date the financial issue was resolved. (Month/Year) Est. Not Resolved Est. 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. Enter your Social Security Number before going to the next page Page 111 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 26 - Financial Record - (Continued) Complete the following if you answered 'Yes' to having experienced one or more of the previously stated financial issues. Entry #2 Provide the name of agency/organization/individual to which debt is/was owed. Did/does this financial issue include any of the following? (Check all that apply) YES NO (If NO, proceed to Section 27) In the past seven (7) years, you had any possessions or property voluntarily or involuntarily repossessed or foreclosed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) In the past seven (7) years, you were evicted for non-payment? In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any reason? In the past seven (7) years, you have been over 120 days delinquent on any debt not previously entered? (Include financial obligations for which you were the sole debtor, as well as those for which you were a cosigner or guarantor) You are currently over 120 days delinquent on any debt? (Include financial obligations for which you are the sole debtor, as well as those for which you are a cosigner or guarantor) Provide the associated loan/account number(s) involved. Identify/describe the type of property involved (if any). Provide the amount (in U.S. dollars) of the financial issue. Provide the reason(s) for the financial issue. Provide the current status of the financial issue. Est. Provide the date the financial issue began. (Month/Year) Provide date the financial issue was resolved. (Month/Year) Est. Not Resolved Est. 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. Enter your Social Security Number before going to the next page Page 112 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 27 - Use of Information Technology Systems 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. As to this particular section, this applies whether or not you are currently employed by the Federal government. The following questions ask about your use of information technology systems. Information technology systems include all related computer hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage or protection of information. 27.1 In the last seven (7) years have you illegally or without proper authorization accessed or attempted to access any information technology system? YES NO (If NO, proceed to 27.2) Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without proper authorization entered or attempted to enter into any information technology system. Entry #1 Provide the date of the incident. (Month/Year) Provide a description of the nature of the incident or offense. Est. Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a description of the action (administrative, criminal or other) taken as a result of this incident. Entry #2 Provide the date of the incident. (Month/Year) Provide a description of the nature of the incident or offense. Est. Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a description of the action (administrative, criminal or other) taken as a result of this incident. 27.2 In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or denied others access to information residing on an information technology system or attempted any of the above? YES NO (If NO, proceed to 27.3) Complete the following if you responded 'Yes' to having in the last seven (7) years illegally or without authorization, modified, destroyed, manipulated, or denied others access to information residing on an information technology system or attempted any of the above. Entry #1 Provide the date of the incident. (Month/Year) Provide a description of the nature of the incident or offense. Est. Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a description of the action (administrative, criminal or other) taken as a result of this incident. Entry #2 Provide the date of the incident. (Month/Year) Provide a description of the nature of the incident or offense. Est. Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a description of the action (administrative, criminal or other) taken as a result of this incident. Enter your Social Security Number before going to the next page Page 113 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 27 - Use of Information Technology Systems - (Continued) 27.3 In the last seven (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 or attempted any of the above? YES NO (If NO, proceed to Section 28) Complete the following if you responded 'Yes' to having in the last seven (7) years 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 or attempted any of the above. Entry #1 Provide the date of the incident. (Month/Year) Provide a description of the nature of the incident or offense. Est. Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a description of the action (administrative, criminal or other) taken as a result of this incident. Entry #2 Provide the date of the incident. (Month/Year) Provide a description of the nature of the incident or offense. Est. Provide the location where the incident took place. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a description of the action (administrative, criminal or other) taken as a result of this incident. Enter your Social Security Number before going to the next page Page 114 Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 28 - Involvement in Non-Criminal Court Actions In the last ten (10) years, have you been a party to any public record civil court action not listed elsewhere on this form? YES NO (If NO, proceed to Section 29) Complete the following if you responded 'Yes' to having been a party to any public record civil court action(s) not listed elsewhere on this form in the last ten (10) years. Entry #1 Provide the date of the civil action. (Month/Year) Provide the court name. Est. Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide a description of the results of the action. Provide details of the nature of the action. Entry #2 Provide the date of the civil action. (Month/Year) Provide the name(s) of the principal parties involved in the court action. Provide the court name. Est. Provide the address of the court. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide details of the nature of the action. Provide a description of the results of the action. Enter your Social Security Number before going to the next page Page 115 Provide the name(s) of the principal parties involved in the court action. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 29 - 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, security, 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. 29.1 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 (If NO, proceed to 29.2) Complete the following if 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. Entry #1 Provide the full name of the organization. Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the dates of your involvement with the organization. From Date (Month/Year) To Date (Month/Year) Present Est. Provide all contributions made to the organization, if any. Provide all positions held in the organization, if any. No positions held Est. No contributions made Provide a description of the nature of and reasons for your involvement with the organization. Entry #2 Provide the full name of the organization. Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the dates of your involvement with the organization. From Date (Month/Year) To Date (Month/Year) Present Est. Provide all contributions made to the organization, if any. Provide all positions held in the organization, if any. Est. No contributions made Provide a description of the nature of and reasons for your involvement with the organization. Enter your Social Security Number before going to the next page Page 116 No positions held Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 29 - Association Record - (Continued) 29.2 Have you EVER knowingly engaged in any acts of terrorism? YES NO (If NO, proceed to 29.3) Complete the following if you responded 'Yes' to EVER having knowingly engaged in any acts of terrorism. Entry #1 Describe the nature and reasons for the activity. Provide the dates for any such activities. From Date (Month/Year) To Date (Month/Year) Est. Entry #2 Describe the nature and reasons for the activity. Est. Provide the dates for any such activities. From Date (Month/Year) To Date (Month/Year) Est. 29.3 Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force? Present Present Est. YES NO (Proceed to 29.4) Complete the following if you responded 'Yes' to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force. Entry #1 Provide the reason(s) for advocating acts of terrorism. Provide the dates of advocating acts of terrorism. From Date (Month/Year) To Date (Month/Year) Est. Present Est. Entry #2 Provide the reason(s) for advocating acts of terrorism. Provide the dates of advocating acts of terrorism. From Date (Month/Year) To Date (Month/Year) Est. Enter your Social Security Number before going to the next page Page 117 Present Est. Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 29 - Association Record - (Continued) 29.4 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 (If NO, proceed to 29.5) Complete the following if 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. Entry #1 Provide the full name of the organization. Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the dates of your involvement with the organization. From Date (Month/Year) To Date (Month/Year) Present Est. Provide all contributions made to the organization, if any. Provide all positions held in the organization, if any. No positions held Est. No contributions made Provide a description of the nature of and reasons for your involvement with the organization. Entry #2 Provide the full name of the organization. Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the dates of your involvement with the organization. From Date (Month/Year) To Date (Month/Year) Present Est. Provide all contributions made to the organization, if any. Provide all positions held in the organization, if any. Est. No contributions made Provide a description of the nature of and reasons for your involvement with the organization. Enter your Social Security Number before going to the next page Page 118 No positions held Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 29 - Association Record - (Continued) 29.5 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 (If NO, proceed to 29.6) Complete the following if 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. Entry #1 Provide the full name of the organization. Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the dates of your involvement with the organization. Provide all positions held in the organization, if any. From Date (Month/Year) To Date (Month/Year) Present Est. Provide all contributions (in U.S. dollars) made to the organization, if any. No positions held Est. No contributions made Provide a description of the nature of and reasons for your involvement with the organization. Entry #2 Provide the full name of the organization. Provide the address/location of the organization. (Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code) City Country Street State Zip Code Provide the dates of your involvement with the organization. Provide all positions held in the organization, if any. From Date (Month/Year) To Date (Month/Year) Present Est. Provide all contributions (in U.S. dollars) made to the organization, if any. Est. No contributions made Provide a description of the nature of and reasons for your involvement with the organization. Enter your Social Security Number before going to the next page Page 119 No positions held Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS Section 29 - Association Record - (Continued) 29.6 Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force? YES NO (If NO, proceed to 29.7) Complete the following if you responded 'Yes' to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force. Entry #1 Describe the nature and reasons for the activity. Provide the dates of such activities. From Date (Month/Year) To Date (Month/Year) Est. Present Est. Entry #2 Describe the nature and reasons for the activity. Provide the dates of such activities. From Date (Month/Year) To Date (Month/Year) Est. 29.7 Have you EVER associated with anyone involved in activities to further terrorism? YES Complete the following if you responded 'Yes' to having EVER associated with anyone involved in activities to further terrorism. Entry #1 Provide explanation. Entry #2 Provide explanation. Enter your Social Security Number before going to the next page Page 120 Present Est. NO 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 Continuation Space 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. 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 following 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 read 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 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 (Sign in ink) Enter your Social Security Number before going to the next page Page 121 Date signed (mm/dd/yyyy) Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS UNITED STATES OF AMERICA AUTHORIZATION FOR RELEASE OF INFORMATION Carefully read this authorization to release information about you, then sign and date it in ink. I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation, reinvestigation or continuous evaluation (as defined in Executive Order 12968 as amended by Executive Order 13467) to obtain any information relating to my activities 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, my academic, residential, achievement, performance, attendance, disciplinary, employment history, criminal history record information, and financial and credit information. I authorize the Federal agency conducting my investigation to disclose the record of my background investigation to the requesting agency for the purpose of making a determination of suitability or eligibility for a national security position. 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 releases 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 State, and any other authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment to, or retention in, a national security position, in accordance with 5 U.S.C. 9101. 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 86, 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 personnel security-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 shall remain in effect so long as I remain employed in a sensitive position requiring eligibility for access to classified information. Signature (Sign in ink) Full name (Type or print legibly) Other names used Current street address Apt. # City (Country) Enter your Social Security Number before going to the next page State Date signed (mm/dd/yyyy) Date of birth Social Security Number Zip Code Home telephone number Standard Form 86 Revised December 2010 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206 0005 QUESTIONNAIRE FOR NATIONAL SECURITY POSITIONS UNITED STATES OF AMERICA AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) If you answered "Yes" to Question 21, carefully read this authorization to release information about you, then sign and date it in ink. Instructions for Completing this Release This is a release for the investigator to ask your health practitioner(s) the questions below concerning your mental health consultations. Your signature will allow the practitioner(s) to answer only these questions. Authorization I am seeking assignment to or retention in a national security position. As part of the clearance process, I hereby authorize the investigator, special agent, or duly accredited representative of the authorized Federal agency conducting my background investigation, to obtain the following information relating to my mental health consultations. In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to the U.S. Office of Personnel Management. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. Further, I understand that this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. I understand the information disclosed pursuant to this release is for use by the Federal Government only for purposes provided in the Standard Form 86 and that it may be disclosed by the Government only as authorized by law, but will no longer be subject to the HIPAA privacy rule. Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed or upon 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) Social Security Number Other names used Current street address Apt. # City (Country) State Zip Code Home telephone number For Use By Practitioner(s) Only Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to properly safeguard classified national security information? YES NO If so, describe the nature of the condition and the extent and duration of the impairment or treatment. What is the prognosis? Dates of treatment? Signature (Sign in ink) Practitioner name Enter your Social Security Number before going to the next page Date signed (mm/dd/yyyy) 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 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. ยง 1681 et seq. Purpose Information provided by you on this form will be furnished to the consumer reporting agency in order to obtain information in connection with a background investigation to determine your (1) fitness for Federal employment, (2) clearance to perform contractual service for the Federal government, and/or (3) eligibility for a sensitive position or access to classified information. 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 the investigative agency conducting my background to obtain such reports from any consumer reporting agency for employment purposes described above. Note: If you have a security freeze on your consumer or credit report file, then we may not be able to complete your investigation, which can adversely affect your eligibility for a national security position. To avoid such delays, you should request that the consumer reporting agencies lift the freeze in these instances. Your Social Security Number (SSN) is needed to identify your unique records. 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. Print Name Social Security Number Signature (Sign in ink) Date signed (mm/dd/yyyy) Enter your Social Security Number before going to the next page