2.02c_Attachment_NSGBINST_5530.4G_SECURITY_QUESTIONNAIRE.pdf

NSGBINST 5530.4G NS Guantanamo Bay Security Form

Country:

State/Region:

City:

IDENTIFICATION

Country:

Visa#: Date Issued:

Expires:

Date Issued:

Expires:

Other Passport?

Passport#:

Country:

BIRTH DATE & LOCATION

Date of Birth:

Date Issued:

Expires:

Yes No

Passport #:

US Visa? Yes No

NAME section complete

BIRTH section complete

Form Instructions: Fill out the form as completely as possible. Fields bordered in red are mandatory. Hover over a field to get formatting instructions and other tips. Once completed, sign, save (append subject's name to form name), and return to the command for processing.

NAME

Full Name:

Full Maiden Name:

Other Names Used:

Yes No

Date:

Are you a US Citizen, a dual US Citizen, or have a US Permanent Resident Card?

POC Email:

IDENTIFICATION (continued)

Date Issued:

Expires:

Date Issued:

Expires:

Yes No

Yes No

Date Issued:

Expires:

Work: Personal:

Base Badge?

Other Personal Phone Numbers?

Phone:

Phone:

CONTACT INFORMATION

CONTACT section complete

Personal Cell Phone?

Yes NoEmail?

Work-Provided Cell Phone? Yes No Phone:

Yes No

Yes No

ID#:

National ID?

GTMO Driver ID?

IDENTIFICATION section complete

JTF Badge? Yes No

ID#:

Badge#:

Yes No

NSGBINST 5530.4G

Account/ User Name:Site/App:

SOCIAL MEDIA/MESSAGING

Date From:

To:

Street:

Unit:

City:

State/Region & Postal:

Country:

SOCIAL MEDIA section complete

Are you on Social Media or use Messaging Apps?

NoYes

RESIDENCE/HOME OF RECORD - CURRENT

Date From: Street:

Unit:

City:

State/Region & Postal:

Country:

RESIDENCE/HOME OF RECORD - PREVIOUS (past 5 years)

RESIDENCE/HOME OF RECORD - PREVIOUS (past 5 years)... continued)

Date From:

To:

Date From:

To:

Date From:

To:

Date From:

To:

Street:

Unit:

City:

State/Region & Postal:

Country:

Street:

Unit:

City:

State/Region & Postal:

Country:

Street:

Unit:

City:

State/Region & Postal:

Country:

Street:

Unit:

City:

State/Region & Postal:

Country:

RESIDENCE/HOME OF RECORD section complete

MILITARY EXPERIENCE

To:

Date ToDate From Base (where stationed)

Military Sevice?

Branch of Service:

Job Title:

Highest Rank Obtained:

Specialized Training:

Yes No to:

Yes No

Work Hours:

MILITARY section complete

CURRENT EMPLOYMENT (GTMO)

How did you hear about this position?

M-FWork Week:

M T W Th SuSaF

Employer:

Job Title:

Duties:

Other Job Title:

Other Job Duties:

Employed since:

JTF Access Required?

Provide Justification:

Employer:

Job Title:

PREVIOUS EMPLOYMENT (minimum 5 years)

Date From: To:

Location:

Employer:

Date From:

Date From:

Location:

Location:

Location:

Job Title:

Job Title:

Job Title:

Employer:

To:

Employer:

Date From: To:

Employer:

Date From: To:

Location:

Job Title:

EMPLOYMENT section complete

To:

Duties:

Duties:

Duties:

Duties:

Duties:

Do you have any relatives that work at

GTMO?

GTMO

First Arrived:

Relatives Working at GTMO Yes No

Full Name:

Employer:

Residence & Unit#:

Residence Phone:

Employer:

Employer:

Full Name:

Full Name:

GTMO section complete

Relationship:

Relationship:

Relationship:

More entries

EDUCATION

To:

Date From:

To:

Date From:

To:

Date From:

To:

LANGUAGES

Language How Learned

TRAVEL

Country:

Reason:

Country:

Reason:

Country:

Reason:

School/Location:

Degree/Certificate:

School/Location:

Degree/Certificate:

School/Location:

Degree/Certificate:

School/Location:

Degree/Certificate:

Fluency

Date From:

To:

Date From:

To:

Date From:

To:

EDUCATION section complete

LANGUAGE section complete

NoHave you traveled to a foreign country? Yes

TRAVEL (continued)

To:

Date From:

To:

Country:

Reason:

Country:

Reason:

TRAVEL section complete

FAMILY

City:

Phone:

Email:

Other ways of contacting:

Mother

Full Name:

Full Maiden Name:

Country:

State/Region:

City:

Phone:

Other ways of contacting:

Email:

Father

Full Name:

Deceased? Yes No Location (if not deceased):

Country:

State/Region:

Deceased? Yes No Location (if not deceased):

No Spouse Married? Yes

Full Name:

Full Maiden Name:

FAMILY (continued)

Date of Birth

Children

Gender

No Do you have children? Yes

Full Name

FAMILY section complete

No Yes US Citizen? Location

Country:

State/Region::

City::

Phone::

Email:

Other ways of contacting:

COMPLETION

After completing the form, review the below statement, affirm, and save.

I HAVE ANSWERED ALL QUESTIONS TO THE BEST OF MY KNOWLEDGE AND BELIEF

AND HAVE NOT INTENTIONALLY OR MALICIOUSLY PROVIDED INCORRECT OR

MISLEADING INFORMATION. I DO ALSO UNDERSTAND THAT KNOWINGLY PROVIDING

FALSE INFORMATION CAN RESULT IN LOSS OF ACCESS TO THE GUANTANAMO BAY

NAVAL STATION AND/OR ALL US MILITARY INSTALLATIONS.

I Affirm

Sign here to acknowledge the above