Attachment 5 OF-174 Security Form.pdf

U.S. Embassy Rome FSN Security (Re)certification Form (Rev 12/2005) INSTRUCTIONS: The questions on this application must be answered fully and completely. Do not use the abbreviation "N/A" (Not Applicable); all questions are applicable and should be given an appropriate response. Making a false statement on this form may be cause for dismissal. If more space is needed for an answer, use the space provided on page 3.

1. NAME

FIRST MIDDLE LAST

2. NAME AT BIRTH, IF DIFFERENT FROM ABOVE

3. HAVE YOU EVER BEEN KNOWN BY ANY OTHER NAMES? □ YES □ NO

If yes, give name and explain circumstances:

4. PRESENT ADDRESS AND TELEPHONE NUMBER 5. DATE OF BIRTH (MM/DD/YYYY)

6. PLACE OF BIRTH (City, Country)

7.

□ MALE

SEX

□ FEMALE

8. HEIGHT 9. WEIGHT 10. EYE COLOR 11. HAIR COLOR 13. TA

□ SINGLE □ DIVORCED

MARITAL S TUS

□ MARRIED □ SEPARATED

□ WIDOWED □ REMARRIED

12. DESCRIBE ANY SPECIAL CHARACTERISTICS OR IDENTIFYING MARKS (SCARS, TATTOOS, ETC.)

14. RESIDENCES SINCE LAST INVESTIGATION (FOR NEW EMPLOYEES, PLEASE LIST LAST FIVE YEARS)

DATES STREET AND NUMBER CITY COUNTRY

FROM TO

15. WHAT IS YOUR CURRENT CITIZENSHIP (LIST ALL)?

16. CURRENT SPOUSE

16a. FULL NAME OF SPOUSE (If wife, maiden name) b. DATE OF BIRTH c. PLACE OF BIRTH (City, Country)

d. PRESENT ADDRESS IN FULL e. PRESENT OCCUPATION

f. CITIZENSHIP AT BIRTH g. PRESENT CITIZENSHIP

17. CHILDREN

NAME DATE OF BIRTH PRESENT ADDRESS IN FULL OCCUPATION

PARENTS

18a. FATHER'S NAME b. DATE OF BIRTH c. PLACE OF BIRTH (City, Country)

d. PRESENT ADDRESS IN FULL e. PRESENT OCCUPATION

f. CITIZENSHIP AT BIRTH g. PRESENT CITIZENSHIP

19a. MOTHER'S NAME b. DATE OF BIRTH c. PLACE OF BIRTH (City, Country)

d. PRESENT ADDRESS IN FULL e. PRESENT OCCUPATION

f. CITIZENSHIP AT BIRTH g. PRESENT CITIZENSHIP

20. RELATIVES (brothers, sisters, and in-laws)

NAME RELATIONSHIP NATIONALITY OCCUPATION PRESENT ADDRESS IN FULL

21. Are any relatives or family members listed above employed by an agency or representative of a national or local government? If so, list name, relationship, agency, and agency address.

□ YES □ NO

22. Do you have any business interests (Owner, Part-Owner, etc.)? If so, list business name, type, your relationship, and address.

□ YES □ NO

23. FOREIGN TRAVEL (SINCE YOUR LAST INVESTIGATION) (NEW EMPLOYEES PLEASE LIST LAST FIVE YEARS)

DATES COUNTRY PURPOSE

FROM TO

24. Are you a member of any societies, clubs, or other organizations (except religious organizations)? If so, list organization name(s), purpose, and address.

□ YES □ NO

25. (Current employees only) Since your last investigation, has your military status changed, or have you become a member of any police or security organization? If so, list organization name(s) and address.

□ YES □ NO

REFERENCES

26. List three competent and responsible adult persons, not related to you by blood or marriage, who are qualified to supply definite information regarding your character. Ideally, the period they have known you should be long enough to cover the past five years.

NAME OCCUPATION PRESENT ADDRESS IN FULL TELEPHONE

EMPLOYMENT

27. Beginning with your current job, list all positions you have held in the past five years.

POSITION TITLE START DATE END DATE SUPERVISOR'S NAME

28. Write “YES” or “NO” in the column to the right.

If you answer "YES" to any of these questions, provide additional information in the space provided below.

a. Do you have any physical limitations?

b. Are you currently under a physician's care? If so, why?

c. Have you ever been arrested or detained by any police or military authority?

d. Do you have a drug or alcohol addiction?

e. Do you have tuberculosis or other communicable diseases?

f. Have you been involved in any act of sabotage, espionage, treason, terrorism, sedition, or other act against any person, group, or government?

g. Have you associated or sympathized with persons who are attempting to commit, or who are committing, any of the above acts?

h. Have you associated or sympathized with persons or organizations that advocate the overthrow of the United States Government, or any state or subdivision, by force or violence or by other unconstitutional means?

i. Have you or any member of your family ever been associated with any group that participated (or will participate) in hostile action against the U.S. or its allies?

j. Have you, or any of your family, friends, or associates ever been employed by or offered employment by an intelligence or security service?

k. Have you ever been a member of a military service? If so, specify which country, dates of service, and provide your Military Service Number or equivalent identification number in the space for detailed answers below.

SPACE FOR DETAILED ANSWERS

Use this space for detailed answers. Number your answers to correspond with questions. Add any information not already covered which might affect your employment. Use additional blank pages, if necessary.

CERTIFICATION

I certify that the information contained herein is correct to the best of my knowledge and belief. I understand that deliberately making false statements on this form may be grounds for dismissal, or may result in my not being hired.

Signature Date