Attachment 5_Contractor Security Certification.pdf

American Consulate General Frankfurt Contractor Security Certification INSTRUCTIONS: Use computer to complete form. Do not use any abbreviations. All questions are applicable and appropriate response is required. Making false statement on this form may be cause for dismissal. If more space is needed for an answer, attach additional sheet. All form fields are pre-formatted. Use TAB-key to scroll through form. Otherwise you may miss form or dropdown fields.

1. PERSONAL INFORMATION

LAST NAME FIRST NAME MIDDLE

PRESENT ADDRESS

Street:

Zip:

Town:

Phone:

E-Mail:

DATE OF BIRTH

PLACE OF BIRTH

City/COUNTRY

GENDER: HEIGHT: cm EYE COLOR:

MARITAL STATUS: WEIGHT: kg HAIR COLOR:

HAVE YOU EVER BEEN KNOW BY ANY OTHER NAME? (E.g. Maiden Name, Tribal Name, Patronymic Name, Married Name, etc.)

DATES NAME TYPE COUNTRY

FROM TO

LIST ANY SPECIFIC IDENTIFICATION ELEMENTS USED IN YOUR HOME COUNTRY. (E.g. NÜFÜS, CEDULA, SSAN, etc.)

2. CITIZENSHIPS (LIST ALL CITIZENSHIPS EVER HELD)

DATES COUNTRY AQUIRED BY

FROM TO

Jan/ present Birth

3. RESIDENCE (TO INCLUDE PRIMARY AND SECONDARY)

DATES STREET, NUMBER, ZIP CODE, CITY, COUNTRY

FROM TO

Jan/ present See above

4. CURRENT EMPLOYMENT

POSITION / TITLE EMPLOYED SINCE COMPANY (NAME AND COMPLETE ADDRESS)

5. MISCELLANEOUS YES NO

Have you ever been arrested, detained or questioned by any law enforcement authority?

Have you or had you an addiction related to narcotics, alcohol or gambling?

Have you been involved in any act of sabotage, espionage, treason, terrorism, sedition, or other act aiming to overthrow or alter the form of government by unconstitutional means?

I certify that the information contained herein is accurate and complete to the best of my knowledge.

Signature Date