Attachment 3 - Security Questionnaire.pdf

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APPLICATION FOR CONTRACTOR CERTIFICATION

All questions on the application form must be answered fully and completely. Any false statements on this form will result in rejection of your application. Further information may be requested by the Regional Security Office in order to complete the security certification process.

ALL APPLICANTS MUST PROVIDE A COPY OF THEIR PASSPORT

1. Last name: _____

2. First and middle names (where applicable): _____

3. Name at birth, if different from above: _______________________

4. Have you ever been known by any other names? Please circle: Yes No

If yes, please give name: _____

5. Sex, please circle: Male Female

6. Date of birth:

Day: Month: (write in full) Year:

7. Place of birth (town, country): _______

8. Present nationality:

9. Nationality at birth:

10. Are you legally entitled to work in the UK? Please circle: Yes No

(Please PROVIDE a copy of relevant documents)

11. National Insurance number: ___________

12. Non-UK Citizens – National ID (Issuing Country, ID Type & Number)

13. Present Address in full (House #, Name, Street, City/Town, County & Postcode): _________

Contact telephone number: _____

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14. Name and details of current employer:

Name: _____

Address: _____

Postcode: _____

Telephone Number: _____

Your Job Title: _____

How long have you been employed by this company: _____

15. Please list all of the countries where you have ever resided since birth, apart from the

United Kingdom (please include full addresses – use additional pages if required):

Address: _____

Telephone: _____

From: ____(month/year) Until: ____ _____ ____(month/year)

16. PARENTS DETAILS:

FATHER:

Last name: _____

First and middle names: _____

Date of birth: _____

Place of birth: _____

MOTHER:

Last name: ___________

First and middle names: _____

Maiden name: ______________________________________________________________

Date of birth: _____

Place of birth: _____

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17. Have you EVER been arrested, detained, cautioned or convicted by any police or military authority either in the UK or abroad (to INCLUDE spent convictions and Road Traffic violations)?

Please circle: Yes No

18. Have you ever been involved in an act of sabotage, espionage, treason, terrorism or any other act whose aim is to overthrow any government or alter the form of government by unconstitutional means?

Please circle: Yes No

19. Have you ever associated or sympathized with any persons who have committed or are attempting to commit sabotage, espionage, treason, terrorism or any other act whose aim is to overthrow any government or alter the form of government by unconstitutional means?

Please circle: Yes No

20. Are you or any of your family members or associates – members of any organization dedicated to the violent overthrow of any government or is intent on causing damage or harm to any citizen and or property which engages in illegal activities?

Please circle: Yes No

21. Have you or any of your family engaged in any acts designed to overthrow any government by force or harm any citizens and/or property?

Please circle: Yes No

If you have answered YES to any of the above, please provide details below (FAILURE TO

COMPLETE IN FULL COULD RESULT IN DISQUALIFICATION FROM THE POSITION FOR

WHICH YOU HAVE APPLIED):

DECLARATION:

I declare that the information I have given is true and complete to the best of my knowledge and belief.

I understand that any false statement or deliberate omission in the information I have given in this application will disqualify me for security certification.

SIGNATURE: DATE:

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DEPARTMENT OF STATE

Washington, D. C. 20520

AUTHORITY FOR RELEASE OF INFORMATION

TO WHOM IT MAY CONCERN:

I hereby authorize any Special Agent or Investigator of the United States Department of State, or any Investigator or duly accredited representative of the United States Office of Personnel Management bearing this release, or a copy thereof, within one year of its date, to obtain any information from schools, residential management agents, employers, criminal justice agencies, credit agencies or individuals, relating to my activities. This information may include, but is not limited to, academic, residential, achievement, performance, attendance, personal history, disciplinary, arrest and conviction records, and credit information. I hereby direct you to release such information upon request of the bearer.

I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature, which may at any time result to me on account of compliance, or any attempts to comply, with this authorization. Should there be any question as to the validity of this release, you may contact me as indicated below.

Full Name: __________________________________________

Other Names used: __________________________________________

Current Address: __________________________________________

Telephone: __________________________________________

Signature: __________________________________________

Date: __________________________________________