Attachment 7.1.2 SF 85.pdf

General Electronic Form Notes/Notices (all Sections)

This document is for reference only and is not a form for completion. Individuals will be invited into the applicable eApplication system to complete the form. The questions/content captured in this document are intended to display what data will be captured from the individual and the additional questions (Branch questions) to be presented based on the individual responses to previous questions during data capture.

Question numbering and “electronic form navigation notes” have been made throughout this form to help facilitate review and navigation. These items are subject to change based on the data collection or processing systems this form may be implemented in.

Additionally numbering and electronic form notes are not to be considered part of the content of the form. Only the section numbers are applicable as the official numbering for this form.

Screens may vary based on html style formatting, java scripting, data capture formatting, system functionality, validation, and navigation.

Systems that are used for the collection of the “Questionnaire for Non-Sensitive Positions (SF 85)” data for investigative purposes are subject to OMB review and approval.

Standard Form 85 Revised November 2021 U.S. Office of Personnel Management 5 CFR parts 731 and 736

Form approved:

OMB No. 3206-0261

Office of Personnel Management

Questionnaire for Non-Sensitive Positions, SF 85

Questionnaire for Non-Sensitive Positions Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the office that provided you the form.

All questions on this form must be answered completely and truthfully in order that the Government may make the determinations described below on a complete record. Penalties for inaccurate or false statements are discussed below. If you are a current civilian employee of the federal government: failure to answer any questions completely and truthfully could result in an adverse personnel action against you, including loss of employment; with respect to Sections 17 and 20, however, neither your truthful responses nor information derived from those responses will be used as evidence against you in a subsequent criminal proceeding.

Purpose of this Form This form will be used by the United States (U.S.) Government in conducting background investigations and reinvestigations of persons under consideration for, or retention of, non-sensitive low risk positions as defined in 5 CFR 731. It is also used for determining fitness of individuals under consideration for, or retention in positions in the excepted service when the duties to be performed are equivalent to a low risk position. This form may also be used by agencies in determining whether a subject should be issued a Federal credential for access to federally controlled facilities and information systems . For applicants, this form is to be used only after a conditional offer of employment has been made, unless OPM has provided for an exception. This form is not to be used for National Security sensitive positions.

Providing this information is voluntary. If you do not provide each item of requested information, however, we will not be able to complete your investigation, which will adversely affect your eligibility for a position or your ability to obtain or retain Federal or contract employment, or logical or physical access. It is imperative that the information provided be true and accurate, to the best of your knowledge. Any information that you provide is evaluated on the basis of its currency, seriousness, relevance to the position and duties, and consistency with all other information about you. Withholding, misrepresenting, or falsifying information may affect your eligibility for positions, physical and /or logical access required to perform duties, or your ability to obtain or retain Federal or contract employment. In addition, withholding, misrepresenting, or falsifying information may affect your eligibility for physical and logical access to federally controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also negatively affect your employment prospects and job status, and the potential consequences include, but are not limited to, removal, debarment from Federal service, or prosecution.

This form may become a permanent document that may be used as the basis for future investigations, determinations of suitability or fitness for Federal employment, fitness for contract employment, or eligibility for physical and logical access to federally controlled facilities or information systems. Your responses to this form may be compared with your responses to previous questionnaires.

The investigation conducted on the basis of information provided on this form may be selected for studies and analyses in support of evaluating and improving the effectiveness and efficiency of the investigative and adjudicative methodologies. All study results released to the general public will delete personal identifiers such as name, Social Security Number, and date and place of birth.

Authority to Request this Information Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under Executive Orders13764, 13741, 10577, 13467, and 13488, as amended; sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 6, 731, and 736 of title 5, Code of Federal Regulations (CFR), Homeland Security Presidential Directive (HSPD) 12, and Federal information processing standards.

Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397, as amended by EO 13478.

The Investigative Process Background investigations for non-sensitive positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and will not present an unacceptable risk,. The information that you provide on this form and your Declaration for Federal Employment (OF 306) may be confirmed during the investigation.

The investigation may extend beyond the time covered by this form, when necessary to resolve issues. Your current employer may be contacted as part of the investigation, although you may have previously indicated on applications or other forms that you do not want your current employer to be contacted. If you have a security freeze on your consumer or credit report file and a credit report is required by the agency requesting your investigation, then we may not be able to complete your investigation, which can adversely affect your eligibility for positions, physical and /or logical access required to perform duties, or your ability to obtain Federal or contract employment. To avoid such delays, you must request that the consumer reporting agencies lift the freeze in these instances.

In addition to the questions on this form, inquiry also is made about your adherence to security requirements, your honesty and integrity, falsification, misrepresentation, and any other behavior, activities, or associations that tend to demonstrate a person is not reliable or trustworthy, or poses an unacceptable risk to the life, safety, or health of employees, contractors, vendors or visitors to a Federal facility; the Government’s physical assets or information systems; personal property; records, or, the privacy of the individuals whose data the Government holds in its systems. After an eligibility determination is made, you may also be subject to reinvestigations to ensure your continuing suitability for employment.

The information you provide on this form may be confirmed during the investigation, and may be used for identification purposes throughout the investigation process.

Your Personal Interview Some investigations may include an interview with you as needed as part of the investigative process. The investigator may ask you to explain your answers to any question on this form. This provides you the opportunity to update, clarify, and explain information on your form more completely, which often assists in completing your investigation. If contacted, it is imperative that the interview be conducted as soon as possible after contact is made by the investigator. Postponements will delay the processing of your investigation, and declining to be interviewed may result in your investigation being delayed or canceled.

For the interview, you will be required to provide photo identification, such as a valid state driver's license. You may be required to provide other documents to verify your identity, as instructed by your investigator. These documents may include certification of any legal name change, Social Security card, passport, and/or your birth certificate. You may also be asked to provide documents regarding information that you provide on this form, or about other matters requiring specific attention.

Instructions for Completing this Form

1. Follow the instructions provided to you, by the office that gave you this form and any other clarifying instructions, provided by that office, to assist you with completion of this form.

You must sign and date, in ink, the original and each copy you submit. You should retain a copy of the completed form for your records.

2. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form by checking the associated "Not Applicable" box, unless otherwise noted.

3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you may select the country name by using the country dropdown feature.

4. When entering a U.S. address or location, select the state or territory from the "States" dropdown list that will be provided. For locations outside of the U.S. and its territories, select the country in the "Country" dropdown list and leave the "State" field blank.

5. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated system approved by the U.S. Postal Service to assist you with Zip Codes.

6. For telephone numbers in the U.S., ensure that the area code is included.

7. All dates provided in this form must be in Month/Day/Year or Month/Year format. The month and day should be entered as a two character numbers (i.e., 01 for January and 29 for 29th day of the month). The year should be entered as a four character number (i.e., 1978 or 2001). If you are unable to report an exact date, approximate or estimate the date to the best of your ability, and indicate this by checking the "Estimated." box.

Final Determination on Your Eligibility Final determination on your eligibility for a position and/or physical or logical access to federal facilities and information is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity to explain, refute, or clarify any information before a final decision is made, if an unfavorable decision is considered. The United States Government does not discriminate on the basis of prohibited categories, including but not limited to race, color, religion, sex (including pregnancy and gender identity), national origin, disability, and sexual orientation, when making determinations of eligibility for non-sensitive positions, physical and/or logical access required to perform duties.

Penalties for Inaccurate or False Statements The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a felony which may result in fines and/or up to five (5) years imprisonment. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified these forms, and this remains a part of the permanent record for future placements. Your prospects of placement are better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any information you provide on this form and to make your comments part of the record.

Disclosure Information

The information you provide is for the purpose of investigating you for a position, and the information will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. The information you provide on this form, and information collected during an investigation, may be disclosed without your consent by an agency maintaining the information in a system of records as permitted by the Privacy Act [5 U.S.C.

552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register. You will not receive prior notice of such disclosures under a routine use. The Defense Counterintelligence and Security Agency, the Government's primary investigative service provider, has established its routine uses in the Federal Register at the following address: Federal Register. If another agency is conducting your investigation, it will inform you of its routine uses.

f.

Public Burden Information Public burden reporting for this collection of information is estimated to average 120 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to U.S. Office of Personnel Management, Attn: Forms Manager, OMB Number 3206-0261 1900 E Street, NW, Washington, DC 20415. The OMB clearance number, 3206-0261, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

--------------------End of Instructions Pages -------------------https://www.federalregister.gov/documents/2018/10/17/2018-22508/privacy-act-of-1974-system-of-records

Persons Completing This Form Should Begin After Carefully Reading The Preceding Instructions.

I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject to the penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), or removal and debarment from Federal Service.

YES NO

Agency Use Block “AUB”

Investigating agency user only Codes: (FIPC CODES) Case Number:

For Competitive Service initial appointments only: As a reminder, agencies are responsible for reviewing information provided on the

OF 306, resume, and other documentation provided as part of the hiring process to identify possible discrepancies with information provided on the standard form questionnaire. Agencies must notify their Investigative Service Provider of any discrepancies that may exist between the forms, and request resolution of the conflict through the investigation process.

In this situation the discrepant documents must be forwarded with the questionnaire to OPM for Action.

A – Type of Investigation B – Extra coverage / advanced results C –Risk level D – Nature of action code E – Date of action F – Geographic location G – Position code H – Position title I – SON (Submitting Office Number ) J – Location of Official Personnel Folder _ None _ NPRC _ At SON _e-OPF _ Other Other address / web address of e-OPF Zip Code K – SOI (Security Office Identifier) L – Location of Security Folder _ None _ NPI _ At SOI __ Other Other address Zip Code M – IPAC N – TAS O – Obligating document number P - BETC Q – Accounting data and /or Agency case number R – Investigative requirement _Initial _Reinvestigation S – Requesting Official: Name, Title, Signature, Email Address, Telephone, Date T – Secondary Requesting Official: Name, Title, Email Address, Telephone Number U – Applicant Affiliation _ FED CIV _ CON _ MIL _ Other V – Deployment/PCS (if Imminent):

From Est.-To Dates, Est., Permanent Relocation, Reason(s) for temporary duty assignment or PCS, point of contact at location, Telephone number (Include Ext.), Address/Unit/Duty location (Include City or Post Name) Agency Special Instructions for the Investigative Service Provider: Cage Code Contracting Number

For Reference Only

Section 1 – Full Name Provide your full name. If you have only initials in your name, provide them and indicate “Initial only”. If you do not have a middle name, indicate “No Middle Name”. If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Last First Middle Suffix

Section 2 – Date of Birth Provide your date of birth. Date _ _-_ _-_ _ _ _ Est. □ Section 3 – Place of Birth Provide your Place of birth. City County State Country Section 4 – SSN Provide your U.S. Social Security Number. □ Not applicable _ _ _-_ _-_ _ _ _ Section 5 – Other Names Used Provide your other names used and the period of time you used them (for example: your maiden name, name(s) by a former marriage (s), former name(s), alias (es), or nickname(s)).

Have you used any other names? YES NO Branch If Yes to “Other Names”

(Multiple Entries Allowed)

Provide your other name used and the period of time you used it [for example: your maiden name, name by a former marriage, former name, alias, or nickname]. If you have only initials in your name, provide them and indicate “Initial only.” If you do not have a middle name, indicate “No Middle Name” (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Provide other name used. Last First Middle Suffix Maiden name? Yes No Provide dates used. From Date (Estimated) To Date (Estimated/Present) Provide the reason(s) why the name changed. Reason: (Free Text) Do you have additional names to enter? Yes (Yes adds another entry) No (Required to pass validation)

Section 6 – Your Identifying Information Provide your Identifying Information Height (feet) (inches) Weight (in pounds) Hair Color Eye Color Sex (M/F) Section 7 – Your Contact Information Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your background investigation.

Provide your contact information.

Email addresses may be used as a contact method, and identify subject in records.

Home email address Email (Free Text) Work email address Email (Free Text)

Home telephone number Extension Time Day Night Both _ Check box if International or DSN phone number

Work telephone number Extension Time Day Night Both _ Check box if International or DSN phone number

Mobile/Cell telephone number Extension Time Day Night Both _ Check box if International or DSN phone number

Section 8 – U.S. Passport Information Do you possess a U.S. passport (current or expired)? YES NO

Branch

If Yes to “passport”

Provide the following information for the most recent U.S. passport you currently possess:

Provide your U.S. passport number Passport (Free Text) Click here for U.S. State Department passport help.

Provide the issue date of passport. Date (Estimated) Provide the expiration date of passport. Date (Estimated) Provide the name in which passport was first issued. Last name:

First name: Middle name: Suffix

Section 9 – Citizenship Select the box that reflects your current citizenship status and click Save.

Provide your current citizenship status: □ I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.

□ I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country. □ I am a naturalized U.S. citizen. □ I am a derived U.S. citizen. □ I am not a U.S. citizen.

Provide your Mother’s Maiden Name Last Name/First Name/ Middle Name/Suffix

Branch

Foreign Born to U.S. Parents in a Foreign Country

You answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.

Provide type of documentation of U.S. citizen born abroad.

FS 240, DS 1350, FS 545, Other (Provide explanation)

Explanation

Provide document number for U.S. citizen born abroad: Document Number (Free Text) Provide the date the document was issued. Date __-__-____ Estimated □ Provide the place of issuance. City State Country Provide the name in which document was issued. Last name: First name:

Middle name:

Suffix

Provide your Certificate of Citizenship number. Certificate Number (Free Text) Provide the date the certificate was issued. Date __-__-____ Estimated □ Provide the name in which the certificate was issued. Last name: First name:

Middle name:

Suffix

Were you born on a U.S. military installation? YES NO

Branch If Yes

You answered that you were born on a U.S. military installation.

Provide the name of the base. Name (Free Text) http://travel.state.gov/passport

Branch

Citizenship Naturalization U.S Citizen

You answered that you are a naturalized U.S. citizen.

Provide the date of entry into the U.S. Date __-__-____ Estimated □ Provide the location of entry into the U.S. City State Provide country(ies) of prior citizenship. Country (Allows for Multiples) Do/did you have a U.S. alien registration number? YES NO Branch If Yes Provide your U.S. alien registration number on

Certificate of Naturalization-utilize USCIS, CIS, or INS registration number, I-551, I-766.

Alien Registration Number (Free Text)

Provide your Certificate of Naturalization number (N550 or N570). Certificate of Naturalization Number (Free Text) Provide the name of the court that issued the Certificate of Naturalization Court (Free Text) Provide the address of the court that issued the Certificate of Naturalization Street City State Zip Provide the date the Certificate of Naturalization was issued. Date __ -__-____ Estimated □ Provide the name in which the Certificate of Naturalization was issued. Last name:

First name:

Middle name:

Suffix

Provide the basis of naturalization. - Based on my own individual naturalization application,

- Other (Provide explanation)

Explanation

Branch Citizenship Derived

You answered that you are a derived U.S. citizen.

Provide your alien registration number (on Certificate of Citizenship — utilize USCIS, CIS or INS registration number) Alien Registration Number (Free Text) Provide your Permanent Resident Card number (I-551) Permanent Resident Card number (I-551) (Free Text) Provide your Certificate of Citizenship number (N560 or N561) Certificate of Citizenship number (N560 or N561) (Free Text) Provide the name in which the document was issued. Last name: First name: Middle name: Suffix:

Provide the date document was issued Date __-__-___ Estimated __ Provide the basis of derived citizenship. -By operation of law through my U.S. citizen parent .-Other (Provide explanation) Explanation

Branch

Citizenship Not a U.S.

citizen

Not a U.S. Citizen Provide your residence status. Status (Free

Text) Provide your date of entry into the U.S.

Date __ -__-____ Estimated □

Provide your country (ies) of citizenship. Allow multiple

Provide your place of entry in the U.S. City (Free Text) State

Provide your alien registration number. (I-1551, I-766) Registration Number (Free Text) Provide document expiration date (I-766 ONLY). Date__-__-____ Estimated □ Provide type of document issued. (I-94, U.S. Visa-red foil number, I-20, DS-2019, etc.)

I-94, U.S. Visa (red foil number), I-20, DS-2019, Other (Provide explanation)

Explanation

Provide document number: Document Number (Free Text) Provide the name in which the document was issued. Last name: First name:

Middle name:

Suffix

Provide the date document was issued. Date Estimated

Provide document expiration date.

Date Estimated

Section 10 – Dual/Multiple Citizenship Do you now or have you EVER held dual/multiple citizenships? YES NO

Branch

Dual/Multiple Citizenship

(Multiple Entries Allowed)

You answered “Yes” to having EVER held dual/multiple citizenship Provide country of citizenship During what period of time did you hold citizenship with this country?

Provide the date range that you held this citizenship; beginning with the date it was acquired through its termination or “Present,” whichever is appropriate.

From Date (Estimated)

To Date (Estimated/Present)

How did you acquire this non-U.S. citizenship you now have or previously had? How (Free Text)

Branch If Present/Current

Do you currently hold citizenship with this country? YES NO Provide explanation:

Summary of dual/multiple citizenships you have listed: Allow multiple Select Country Value Dates of Citizenship Actions Do you have an additional citizenship to provide? YES (Yes adds another entry) NO (Required to validate)

Section 11 – Where You Have Lived

Enter residence information. (Multiple Entries Allowed) Provide dates of residence. From Date (Estimated ) To Date

(Estimated /Present) Is/was this residence: □ Owned by you □ Rented or leased by you □ Military housing □ Other (Provide explanation) Explanation (Free Text)

List the places where you have lived beginning with your present residence and working back 5 years. Residences for the entire period must be accounted for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you were not physically located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list residence before your 18th birthday unless to provide a minimum of 2 years residence history. You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.

For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew you for residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for periods of residence.

Provide the street address. Street address and City Provide the country if outside the United States; otherwise provide State and Zip Code

State Zip Code Country

Branch Physical Location

You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:

Street Address/Unit/Duty Location: City or Post Name Provide State for ports in United States, or Country location. State and Zip Code or Country

Branch

APO/FPO

Address

You have indicated an address outside of the United States.

Do/did you have an APO/FPO address while at this location? Yes No Branch You have indicated that you have or had and APO/FPO while at this location.

Provide APO/FPO address: Address APO or FPO APO/FPO State Code Zip Code

Branch

Person Who Knew you

(if address dates within last 3 years)

Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.

Provide the full name: Last name:

First name:

Middle name:

Suffix Provide date of last contact: Date MM-YYYY_ Estimated

Provide your relationship to this person (select all that apply) □ Neighbor □ Friend □ Landlord □ Business associate

□ Other (Provide explanation) Explanation (Free Text)

Provide the following contact information for this person :

Provide evening phone number for this person:

Number/Extension __Check box if International or DSN phone number _I don’t know

Provide daytime phone number for this person: Number/Extension __Check box if International or DSN phone number _I don’t know

Provide cell/mobile phone number for this person: Number/Extension Time __Day __Night__Both __Check box if International or DSN phone number _I don’t know

Provide e-mail address for this person: Email (Free Text) _I don’t know Provide street address for this person (including apartment number).

Street address City

Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

Branch Physical Location

You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:

Street Address/Unit/Duty Location: City or Post Name Provide State for ports in United States, or Country location. State and Zip Code or Country

Branch

APO/FPO

Address

You have indicated an address outside of the U.S.

Does the person who knew you have an APO/FPO address? YES NO Branch If Yes Provide APO/FPO address: Address APO or FPO APO/FPO State Code Zip Code

Do you have an additional residence to report? YES (Yes adds another entry) NO (Required to validate)

Section 12 – Where You Went to School Do not list education before your 18th birthday, unless to provide a minimum of two years education history. (Multiple Entries Allowed) Have you attended any schools in the last 5 years? YES NO

Branch

If Yes to Attending Schools

Have you received a degree or diploma more than 5 years ago? YES NO

Branch

If Yes to Receiving Degree

Provide the dates of attendance. From Date (Estimated) To Date (Estimated/Present) Select the most appropriate box to describe your school. □ High School □ College/University/Military College

□ Vocational/Technical/Trade School □ Correspondence/Distance/Extension/Online School Provide the name of the school: Name (Free Text) Provide the street address of the school. For correspondence/distance/ extension/online schools, provide the address where the records are maintained. For assistance determining the school address, refer to Accreditation Records

Street address City

Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods completed more than 3 years ago. For correspondence/distance/extension/ online schools, list someone who knew you while you received this education Provide the name of person who knows/knew you at school: □ I don’t know Last name:

First name:

Initial Only □ No First Name □

Provide current address for this person (including apartment number). Street City Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

Provide telephone number for this person. Number/Extension Time Day Night Both __Check box if International or DSN phone number ___ I don’t know

Provide email address for this person: □ I don’t know Email (Free Text) Did you receive a degree/diploma? YES NO

Branch If Yes to Receiving Degree

Provide type of degrees(s)/diploma(s) received and date(s) awarded:

Degree/diploma • High School Diploma

• Associate’s • Bachelor’s • Master’s • Doctorate

• Professional Degree (e.g. MD, DVM, JD) • Other

Other degree/diploma Other Degree (Free Text) Month / Year Date

Estimated http://ope.ed.gov/accreditation/search.aspx

Do you have additional education to enter (include education within the last 5 years, as well as degrees or diplomas more than 5 years ago)?

YES (Yes adds another entry)

NO (Required to validate)

Section 13a – Employment Activities – Employment & Unemployment Record List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 5 years. The entire period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military duty station. Provide separate entries for employment activities with the same employer but having different physical addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.

(Multiple Entries Allowed) Select your employment activity: □ Active military duty station □ National Guard/Reserve □ USPHS Commissioned Corps

□ Other Federal employment □ State Government (Non-Federal employment) □ Self-employment □ Unemployment

□ Federal Contractor □ Non-government employment (excluding self-employment) □ Other (Provide explanation) Other Type Explanation (Free Text) Provide dates of employment. From Date (Estimated) To Date (Estimated/Present)

Branch

If Employment Type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps

Active Duty, National Guard/Reserve, or USPHS Commissioned Corps Select the employment status for this position: □ Full-time □ Part-time Provide your assigned duty station during this period.

Duty station (Free Text) Provide your most recent rank/position title.

Rank/position (Free Text)

Provide address of duty station. Street address City Provide Country if outside the United States; otherwise, provide State and Zip Code.

State Zip Code Country

Telephone number Number/Extension Time Day Night Both __Check box if International or DSN phone number

Branch Physical Location

You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:

Street Address/Unit/Duty Location: City or Post Name:

Provide state for ports in the United States, or country location. State Zip

Code Country

Branch

APO/FPO

Address

You have indicated an address outside of the United States. Do you or did you have an APO/FPO address while at this location?

YES NO

Branch If Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code Provide the name of your supervisor. Supervisor name (Free Text) Provide the rank/position title of your supervisor. Supervisor rank/position (Free Text) Provide the email address of your supervisor. □ I don’t know Supervisor email (Free Text) Provide the physical work location of your supervisor. Street address City Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

Provide supervisor telephone number Number/Extension Time Day Night Both __Check box if International or DSN phone number

Branch Physical Location

You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your supervisor:

Street Address/Unit/Duty Location: City or Post Name:

Provide state for ports in the United States, or country location. State and Zip Code or Country

Branch

APO/FPO

Address

You have indicated an address outside of the United States. Did/does your supervisor have an APO/FPO address while at this location?

YES NO

Branch if Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code

Branch

If Employment Type is Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other

Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other Provide most recent position title. Position (Free Text) Select the employment status for this position: □ Full-time □ Part-time Provide the name of your employer Employer name (Free Text) Provide the address of employer Street address City Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

Provide telephone number Number/Extension Time Day Night Both __Check box if International or DSN phone number

Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment as entries below). Not Applicable □ (Multiple Entries Allowed) Dates of employment From Date (Estimated) To Date (Estimated/Present) Position title Position (Free Text) Supervisor Supervisor (Free Text) Is/was your physical work address different than your employer’s address? YES NO

Branch Physical Location

Provide the work address where you are/were physically located. Street Address City Provide Country if outside the United States; otherwise provide State and Zip Code

State Zip Code Country

Provide the telephone number Number/Extension Time Day Night Both __Check box if International or DSN phone number

Branch Physical Location

You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:

Street Address/Unit/Duty Location: City or Post Name:

Provide state for ports in the United States, or country location. State Zip Code Country

Branch

APO/FPO

You have indicated an address outside of the United States. Do you or did you have an APO/FPO address while at this location?

YES NO

Address Branch if Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code Provide the name of your supervisor. Supervisor name (Free Text) Provide the position title of your supervisor. Supervisor position (Free Text) Provide the email address of your supervisor. □ I don’t know Supervisor email (Free Text) Provide the physical work location of your supervisor. Street address City Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

Provide the telephone number for this supervisor. Number/Extension Time Day Night Both __Check box if International or DSN phone number

Branch Physical Location

You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your supervisor:

Street Address/Unit/Duty Location: City or Post Name:

Provide state for ports in the United States, or country location. State and Zip Code or Country

APO/FPO

Address

You have indicated an address outside of the United States. Did/does your supervisor have an APO/FPO address while at this location?

YES NO

Branch if Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code

Branch

If Employment Type is Self- Employment

Self-Employment Provide most recent position title. Position (Free Text) Select the employment status for this position: □ Full-time □ Part-time Provide the name of your employment Employment name (Free Text) Provide the address of employment Street address City Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

Provide telephone number Number/Extension Time Day Night Both __Check box if International or DSN phone number

Is your physical work address different than your employment address? YES NO

Branch Physical Location

Provide the work address where you are/were physically located.

Street address City

Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code

Country

Provide telephone number Number/Extension Time Day Night Both __Check box if International or DSN phone number

Branch Physical Location

You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data:

Street Address/Unit/Duty Location: City or Post Name:

Provide state for ports in the United States, or country location. State Zip Code Country

Address

You have indicated an address outside of the United States. Do you or did you have an APO/FPO address while at this location?

YES NO

Branch if Yes Provide APO/FPO address: Address APO/FPO APO/FPO State Zip Code Provide the name of someone that can verify your self-employment. Last First Provide the address of this verifier. Street address City Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

Provide the telephone number for this person Number/Extension Time Day Night Both __Check box if International or DSN phone number

Branch Verifier Physical Location

You have indicated an APO/FPO address for your self-employment verifier; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data for this person Street Address/Unit/Duty Location: City or Post Name:

Provide state for ports in the United States, or country location. State Zip Code Country

Branch Verifier

APO/FPO

Address

You have indicated an address outside of the United States. Does your self-employment verifier have an APO/FPO address?

YES NO

Branch if Yes Provide APO/FPO address for this person: Address APO/FPO APO/FPO State Zip Code

Branch If Employment Type is Unemployment

Unemployment Provide the name of someone who can verify your unemployment activities and means of support Last name:

First name:

Provide the address of this verifier. Street address City Provide Country if outside the United States; otherwise, provide State and Zip Code

State Zip Code Country

Provide the telephone number for this person Number/Extension Time Day Night Both _Check box if International or DSN phone number

Branch Verifier Physical Location

You have indicated an APO/FPO address for your unemployment verifier; provide physical location data with either street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data for this person:

Street Address/Unit/Duty Location: City or Post Name:

Provide state for ports in the United States, or country location. State Zip Code Country

Branch You have indicated an address outside of the United States. Does your unemployment verifier YES NO

Verifier

Address have an APO/FPO address?

Branch if Yes Provide APO/FPO address for this person: Address APO/FPO APO/FPO State Zip Code

Provide the reason for leaving the employment activity. Reason (Free Text)

Branch

If Employment Type is Active Duty, National Guard/Reserve, USPHS

Commissioned Corps, Other Federal employment, State Government, Federal Contractor, Non-government employment, Self- Employment, Unemployment, or Other

For this employment have any of the following happened to you in the last five (5) years? YES NO

• Fired • Quit after being told you would be fired • Left by mutual agreement following charges or allegations of misconduct • Left by mutual agreement following notice of unsatisfactory performance

Branch

If Fired, Quit, Left by Mutual Agreement, or Left After Unsatisfactory Performance

(Multiple Entries Allowed)

Select the type of incident: • Fired • Quit after being told you would be fired

• Left by mutual agreement following charges or allegations of misconduct

• Left by mutual agreement following notice of unsatisfactory performance Branch If Fired

Provide the reason for being fired. Reason (Free Text) Provide the date you were fired. Date (Estimated)

Branch If Quit

Provide the reason for quitting. Reason (Free Text) Provide the date you quit after being told you would be fired.

Date (Estimated)

Branch Provide the charges or allegations of misconduct. Charges (Free Text) Provide the date you left following charges or allegations of misconduct.

Date (Estimated) If Left after Charges

Branch If Left Unsatisfactory performance

Provide the reason(s) for unsatisfactory performance. Reason (Free Text) Provide the date you left by mutual agreement following a notice of unsatisfactory performance.

Date (Estimated)

In the last five (5) years do you have another reason for leaving to report for this employment?

YES (Yes adds another entry)

NO (Required to validate)

For this employment, in the last five (5) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?

YES NO

Branch If Disciplined, Warned, Reprimanded, or Suspended (Multiple Entries Allowed)

Officially reprimanded, suspended, or disciplined for misconduct.

Provide the month and year you were warned, reprimanded, suspended or disciplined.

Date/ Estimated □

Provide the reason(s) for being warned, reprimanded, suspended or disciplined Reason (Free Text) Do you have another instance of discipline or a warning to provide? another entry)

YES (Yes adds NO (Required to validate)

Do you have an additional employment activity to enter? YES (Yes adds another entry) NO (Required to validate) Section 13b – Employment Record Have any of the following happened to you in the last five (5) years at employment activities that you have not previously listed? (If Yes, you will be required to add an additional employment in Section 13a) • Fired from a job? • Quit a job after being told you would be fired?

• Have you left a job by mutual agreement following charges or allegations of misconduct?

• Left a job by mutual agreement following notice of unsatisfactory performance?

• Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace, such as violation of a security policy?

YES NO

Section 14 – Selective Service Record Were you born a male after December 31, 1959? YES NO

Branch

If Yes to Born Male After 12/31/1959

Selective Service Registration Have you registered with the Selective Service System (SSS)? I don’t know YES NO

Branch If Yes

The Selective Service website can help provide the registration number for persons who have registered. Note: Selective Service Number is not your Social Security Number Provide registration number: Registration number (Free Text)

Branch If No

You responded 'No' to having registered with the Selective Service System (SSS) Provide explanation Explanation (Free Text)

Branch If I Don’t Know

You responded 'I don't know' to having registered with the Selective Service System (SSS) Provide explanation Explanation (Free Text)

Section 15 – Military History Have you EVER served in the U.S. Military? YES NO

Branch

If Yes to Serving in the U.S.

Military

(Multiple Entries Allowed)

You responded ‘Yes’ to having served in the U.S. Military:

Provide the branch of service you served in: State of service, if

National Guard Provide your status

Officer or enlisted:

Not Applicable Officer Enlisted

Provide your service number (Free Text)

Number (Free Text)

□ Army □ Army National Guard

□ Navy □ Air Force □ Air National Guard □ Marine Corps □ Coast Guard □□ Active Duty □ Active

Reserve □ Inactive Reserve Provide your dates of service From Date (Estimated) To Date (Estimated/Present) Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard? YES NO

Branch

If Yes to Discharged

You responded ‘Yes’ to being discharged from U.S. military service, to include Reserves or National Guard.

Provide the type of discharge you received: □ Honorable □ Dishonorable □ Under Other than Honorable Conditions

□ General □ Bad Conduct □ Other (provide type) Provide other discharge type: Discharge explanation (Free Text) Provide the date of discharge listed above Date (Estimated)

Branch If Discharge Not Honorable Provide the reason(s) for the discharge. Reason(s) (Free Text) Do you have additional military service to report? YES (Yes adds NO (Required to another entry) validate) In the last 5 years, have you been subject to court martial or other disciplinary procedure under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain’s mast, https://www.sss.gov/

Article 135 Court of Inquiry, etc?

If Yes to Military Discipline

You responded ‘Yes’ to having been subject to court martial or other disciplinary procedure under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain’s mast, Article 135 Court of Inquiry, etc in the last 5 years.

Provide the date of the court martial or other disciplinary procedure. Date (Estimated) Provide a description of the Uniform Code of Military Justice (UCMJ) offense(s) for which you were charged.

Description (Free Text)

Provide the name of the disciplinary procedure, such as Court Martial, Article 15, Captain’s mast, Article 135 Court of Inquiry, etc.

Name (Free Text)

Provide the description of the military court or other authority in which you were charged (title of court or convening authority, address, to include city and state or country if overseas).

Description (Free Text)

Provide the description of the final outcome of the disciplinary procedure, such as found guilty, found not guilty, fine, reduction in rank, imprisonment, etc.

Description (Free Text)

In the last 5 years do you have an additional instance of military discipline to report?

YES (Yes adds another entry) NO (Required to validate)

Have you EVER served as a civilian or military member in a foreign country’s military, intelligence, diplomatic, security forces, militia, other defense force, or government agency?

YES NO

Branch

If Yes to Serving in a Foreign Military

(Multiple Entries Allowed)

You responded ‘Yes’ to having EVER served as a civilian or military member in a foreign country’s military, intelligence, diplomatic, security forces, militia, other defense force, or government agency.

During your foreign service, which organization were you serving under: □ Military (Army, Navy, Air Force, Marines, etc.), Specify

□ Intelligence Service □ Diplomatic Service □ Security Forces □ Militia □Other Defense Forces, Specify □ Other Government Agency, Specify Provide the name of the foreign organization. Name (Free Text) Provide your period of service From Date (Estimated) To Date (Estimated/Present) Provide the name of the country Provide your highest position/rank held Position held (Free Text)

Provide the division/department/office in which you served. Division (Free Text) Provide a description of the circumstances of your association with this organization.