Attachment 0002 - C-7 IMCOM Worksheet 29.pdf
PDF 479 KB Posted
- Solicitation number
- W9124J26RRESP
About this file
This is a Residency History Worksheet form used for federal security clearance investigations requiring T1 or higher clearance levels with Special Competitive Hiring Authorities (SCHR), OFI86C (SCHR), or INTERPOL clearances.
The form requires individuals to provide complete personal identification information including full legal name, maiden/former names, place of birth, sex, and email address. Respondents must document their federal service work history and status, answering whether they currently work or have ever worked in federal service, which includes APF/NAF civilian, contractor, in-home care provider, military, and volunteer positions with existing investigations. If currently employed or previously employed in federal service, individuals must provide the last date worked. The residency history section requires listing all places of residence for the past 5 to 10 years based on investigation requirements, starting with the current address and working backward chronologically. Each residence entry must include complete physical street address, city, state, zip code, country, and date range in MM/YY format. Post office boxes are prohibited except for overseas APO/FPO addresses. Temporary duty locations lasting fewer than 90 days may be omitted in favor of listing the permanent address. The form notes that a two-year break in federal service requires initiation of a new Tiered investigation. Additional space for residency entries may be provided on continuation sheets if needed.
View the file
Other files
Show all 19
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Maiden / Former Name
PLEASE LIST PLACES WHERE YOU HAVE LIVED STARTING WITH YOUR CURRENT ADDRESS AND GOING BACK 5 or 10 YEARS BASED ON INVESTIGATION REQUIREMENT. DO NOT USE A POST OFFICE BOX, UNLESS STATIONED OVERSEAS, THEN AN APO/FPO MUST BE USED INSTEAD OF THE FOREIGN COUNTRY PHYSICAL ADDRESS. YOU MAY OMIT TDY LOCATIONS UNDER 90 DAYS (list permanent address instead).
MAKE SURE TO INCLUDE PHYSICAL RESIDENCE ADDRESS WITH A COMPLETE STREET ADDRESS WITH CITY, STATE, ZIP CODE, AND
COUNTRY.
MM/YY to MM/YY
MM/YY to MM/YY
Email addressSex
Address
Address
Address
Address
Address
(2) (mm/yy)
(3) (mm/yy)
(5) (mm/yy)
(6) (mm/yy)
(4) (mm/yy)
City
City
City
City
City
State
State
State
State
Zip
Zip
Zip
Zip
Zip
Country
Country
Country
Country
Country
State
Maiden / Former Name
First
Signature:_________________________________ Date completed:_________________
Middle
MM/YY to MM/YY
Maiden / Former Name
Place of birth (City, County, State, Country)
MM/YY to MM/YYMaiden / Former Name
FEDERAL SERVICE WORK HISTORY/STATUS
2) Are you currently working in federal service? (select yes if in LWOP status)
Page 2 of 2Residency History Worksheet 29 v1 May23
1) Have you ever worked in federal service? Federal service is inclusive of all the following APF/NAF Civilian, Contractor, In Home Care Provider, Military, volunteer with existing Investigation etc.
3) YES- proceed to question 2 NO- STOP. Complete residency history below
When was the last date worked? (provide month and year)
Residency History Worksheet For individuals requiring a T1 or higher (with SCHR), OFI86C (SCHR) or INTERPOL
CHECK FULL LEGAL NAME
Address _________________________________________________________
____________________________ State ________ Zip ___________ Country ________________
_________ to _________ __________________________________________________________
_________ to _________ __________________________________________________________
_________ to _________ __________________________________________________________
_________ to _________ __________________________________________________________
_________ to _________ __________________________________________________________
Last
City
YES- STOP. Complete residency history below NO- proceed to question 3
- Complete residency history below
(1) (mm/yy) _________ to _________
Male Female
NOTE: A two year break in federal service requires a new Tiered investigation.
*If additional space is needed, attach a continuation sheet to this worksheet.
| CHECK FULL LEGAL NAME |
| FEDERAL SERVICE WORK HISTORY/STATUS |
| 1: |
| 2: |
| 3: |
| 4: |
| 5: |
| 6: |
| 7: |
| 8: |
| 9: |
| 10: |
| 11: |
| 12: |
| 14: |
| Proceed: Off |
| STOP: Off |
| 16: |
| 17: |
| 18: |
| 19: |
| 20: |
| 21: |
| 22: |
| 23: |
| 24: |
| 25: |
| 26: |
| 27: |
| 28: |
| 29: |
| 30: |
| 31: |
| 32: |
| 33: |
| 34: |
| 35: |
| 36: |
| 37: |
| 38: |
| 39: |
| 40: |
| 41: |
| 42: |
| 43: |
| 44: |
| 45: |
| 46: |
| 47: |
| 48: |
| 49: |
| 50: |
| 51: |
| 52: |
| 53: |
| 54: |
| 55: |
| 56: |
| 57: |
| 58: |
| Text24: |
| Proceed111: Off |
| STOP222: Off |
| Male: Off |
| Female: Off |
File details come from the government source that posted it. Updated .