Attachment H - Common Access Card (CAC) Request Instructions.pdf
PDF 2 MB Posted
- Solicitation number
- W912DY26R1103
About this file
This document is Attachment 6 to a federal contract solicitation containing Common Access Card (CAC) instructions for contractor vendors.
The instructions establish procedures for both CAC renewals and new CAC requests for contractor employees requiring logical or physical access to Department of Defense facilities or networks. For CAC renewals, applicants who have held a CAC within the last 24 months or worked continuously under government contracts need only submit a signed CAC Request Form to the PSS-CAC inbox at CEHNC-PSS-CAC@USACE.army.mil, with contract and task order numbers clearly identified. Processing typically takes two weeks. New CAC requests, applicable to applicants without prior CAC sponsorship or more than 24 months without government work, require submission of multiple documents: the August 2023 version OF306 (Declaration for Federal Employment), two fingerprint cards (preferably submitted electronically using codes SOI: DODH, SON: A342, ALC: 21008711), copies of current U.S. passport or birth certificate and driver's license, and a signed verification letter from the contractor's security office confirming document authenticity. New requests initiate a background investigation through the Personnel Security Investigation Portal (PSIP) system and eQIP, with applicants required to complete eQIP submissions within 14 days or face application termination. Processing for new requests takes 4-6 weeks or longer. Following background approval, applicants receive MP ICAM (Mission Partner Identity, Credential, and Access Management) portal access to complete sponsorship applications within 7 days, after which they may obtain their CAC at the nearest RAPIDS site. The Trusted Agent must reverify CAC necessity every 6 months, and CACs must be collected and destroyed upon employee separation or expiration. All required information must be legible, complete, and submitted with encryption or password protection for documents containing personally identifiable information.
View the file
Other files
Show all 18
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
ATTACHMENT 6
CAC Instructions for Vendors
1. Definitions
Trusted Agent (TA)- The TA is a government employee who establishes sponsorship of the CAC applicant after ensuring background vetting is complete.
Mission Partner Identity, Credential, and Access Management) MP ICAM- The sponsorship portal enables the TA to initiate an application, review, revoke, reject and/or grant a sponsorship to the Applicant. It is a secure portal for Applicants to submit required personal identif iable information (PII) to request sponsorship.
Electronic Questionnaires for Investigations Processing (eQIP)- A web-based automated system designed to facilitate the processing of forms used for background investigations. eQIP allows the user to electronically enter, update, and transmit their personal data over a secure internet connection.
NEW CAC Request- This applies if the applicant has never had a CAC or has not worked for the government for the previous 24 months.
CAC Renewal Request- This applies if the applicant has had a CAC within the last 24 months (even if expired).
2. CAC Renewals
Criteria for renewal: The applicant has had a CAC within the last 24 months or has worked continuously under government contracts since their last CAC expired. If the previous CAC was sponsored by a different agency or through a different country, this and the expiration date of the CAC should be noted in the request. Security needs this information to complete their review.
a. Only the CAC Request Form signed by the Security Manager is required.
b. The CAC request form is submitted to the PSS-CAC inbox at CEHNC-PSS-
CAC@USACE.army.mil. Any documentation with PII should be encrypted. If encryption is unavailable, password protect the file and send the password in a separate email.
Alternatively, DOD SAFE can be used to drop off f iles.
c. Make sure the Contract number AND Task Order number is in the ‘Contractor Information’ box at the top of the CAC request form.
d. Once received, the documentation is reviewed for accuracy by the Trusted Agent. If corrections need to be made, the POC that sent the request is notif ied.
3. New CAC Requests Requirements: CAC request form, fingerprints, OF306, verif ication letter, driver’s license and birth certif icate or passport.
a. Make sure the Contract number AND Task Order number is in the ‘Contractor Information’ box at the top of the CAC request form.
**The CAC request form states all requirements**
b. OF306
* August 2023 version is the only accepted version. Previous versions will be rejected.
* It must be completely legible. If the scanned copy is distorted, it will be rejected by security.
mailto:CEHNC-PSS-CAC@USACE.army.mil mailto:CEHNC-PSS-CAC@USACE.army.mil https://safe.apps.mil/
* Take the time to review items #7 thru #15. Each item tells the applicant what information must be submitted if a “Yes” response is checked. If that information is not provided, the form will be rejected.
**Make sure all required information is included. It should be a first-person account with specific explanations. It should not be an emotional narrative.
** Should additional sheets need to be attached the Name, Social Security number and item number need to be on each submitted sheet
Example: “I incurred $$$ of federal tax underpayments for tax years 2016, 2018, and 2020” On (DATE), the IRS approved an installment agreement of $$/month. I am currently paying $$/month and the debt will be paid off in 60 months on (DATE) per my agreement with the IRS.”
* Block 17a can be a hand signed signature and date or a valid electronic signature.
* If Block 17b or any part of Block 18 are filled out, it will be rejected.
c. Fingerprints
* They need to be uploaded electronically by the fingerprinting agency or 2 hardcopies must be sent to HNC.
• If uploading, the fingerprint agency will need these codes:
SOI: DODH
SON: A342
ALC: 21008711
• If sending the fingerprint cards, send to:
U.S. Army Engineering and Support Center
CEHNC-ISM
ATTN: Trusted Agent name Redstone Gateway (RG 300) Redstone Arsenal, AL 35808
FedEx or UPS are the preferred methods of delivery for hardcopies.
Fingerprint cards need to be fully f illed out. Review the cards for accuracy.
At this time, electronic submission by the fingerprinting agency is the preferred method. If sending hardcopies, security has to mail them into PSIP and verify receipt before they can upload the packet to begin the investigation.
Security does not consider it a complete CAC request packet unless both fingerprint cards are included.
Scanned/emailed fingerprints are not accepted.
d. Copy of current U.S. Passport or Birth Certificate and Driver’s License.
e. Verification Letter (Sample attached)
Signed letter of verif ication from the contractor’s security office that the current
U.S. Passport or Birth Certif icate/Driver’s License was verif ied by their office.
If it has been longer than 24 months since an applicant has had a CAC, we will need the break in service dates: date last CAC expired to date hired by current company. Has the employee been employed by the Federal government continuously before they were hired by this contractor? Provide this information when sending the CAC request packet to security.
4. Once a CAC request packet is complete, it will be sent to our Security POC.
a. CAC renewals are usually approved within 2 weeks.
b. New CAC requests can take 4-6 weeks or longer, as a background investigation has to be initiated in PSIP.
5. The new applicant should monitor the email address that was provided on the CAC request form. They will receive an email from eQIP to complete and submit their application for a background check. See applicant guide.
a. If the applicant does not complete and submit the eQIP application within 14 days the application will be terminated.
b. If eQIP responds to the applicant needing more information and it is not provided, the application will be terminated.
6. If the background check results in a denial, the PM will be notif ied by security with any relevant details.
7. If the background check results in an approval, the assigned Trusted Agent will create an application in MP ICAM for the applicant.
a. An email is sent to the applicant with log-in information. They will have 7 days to complete and submit the application in MP ICAM.
b. Once the application is submitted in MP ICAM, the Trusted Agent will approve the application in MP ICAM. Once that is completed, an email is auto generated by MP ICAM instructing the applicant to proceed to the nearest RAPIDS site to obtain their CAC.
**The applicant should not try to obtain a CAC before these steps are completed. They will not be in the system and will be turned away.
8. CAC renewals are not automatic. They must go through the approval process as described above and be re-entered into MP ICAM by the Trusted Agent.
9. Every 6 months, the Trusted Agent must verify with the PM that the applicant still requires a CAC to perform their duties. If this is not done, MP ICAM will automatically revoke the CAC certif icates. Please respond promptly to reverif ication requests from the TA.
10. When the CAC expires or the applicant leaves the employ of the vendor, the security manager should collect the applicant’s CAC and destroy it. Notify the Trusted Agent when this occurs so the sponsorship in MP ICAM can be revoked.
U.S. Army Corps of Engineers, Huntsville Engineering and Support Center Request for Common Access Card (CAC) May 2020
This page become FOR OFFICIAL USE ONLY when filled in. Page 1
Contractor Information Government Information
Company Name: New Request: Renewal:
Security Manager (SM): POC/PM/PgM/COR/KO:
SM Email: Telephone No:
Contract Number: TRUSTED AGENT:
Contract Exp. Date: Telephone No:
KO: email: Telephone No:
***The Contractor listed below requires a NACI or NACLC (w/o a Clearance) to be issued a CAC.
You are required to circle one or the other before submitting to the Security Office.
Full Legal Name:
Date of Birth:
SSN: Place of Birth:
Email: 10 Digit Telephone No:
Type/Date of Investigation: Job Title
Level of Access Required: U.S. Citizen:
Clearance/Date Granted: Verification Provided? Yes No Granted by: Foreign National/List Country:
1. Project Manager/Program Manager/Contract Officer Representative/Contracting Officer or their designated Point-of- Contact (PM/PgM/COR/KO/POC) certify that the above named contractor meets the requirements of DoDM 1000.13-M-V1, January 23, 2014, Enclosure 2, Paragraph 1.b.(1) through
1.b.(3) which states that the contractor requires (1) Both access to a DoD facility and access, via logon, to DoD networks onsite or remotely, (2) Remote access via logon, to a DoD network using
DoD-approved remote access procedures, (3) Physical access to multiple DoD facilities or multiple non-DoD federally controlled facilities on behalf of the DoD on a recurring basis for a period of 6 months or more.
- The primary HNC POC is responsible for providing the completed form to the HNC Security Office at least 10 working days prior to the entrance on duty date of the Contractor employee.
2. The Contractor’s Security Manager (CSM) certifies they have verified the above individual’s security status in JPAS to ensure they meet the security requirements IAW HSPD-12.
- If the individual does meet the security requirements the only submission required is this form.
- I f the individual does not meet the security requirements the CSM will submit a package consisting of:
- Fully completed and signed CAC Request Form - *By signing this form the CSM acknowledges only legible forms and complete packages will be accepted.
- 2 Fingerprint cards (Only acceptable on the FD-258 form unless done electronically).
- Copy of current U.S. Passport or Birth Certificate and Driver’s License
- Signed letter of verification from the contractor’s security office that the current
U.S. Passport or Birth Certificate/Driver’s License was verified by their office.
- Completed OF306 Declaration of Federal Employment.
- **Foreign Nationals – CSM must send a signed memorandum verifying that the applicant has no criminal records/warrants in their country of record.
Cont’d on page 2
U.S. Army Corps of Engineers, Huntsville Engineering and Support Center Request for Common Access Card (CAC) May 2020
This page become FOR OFFICIAL USE ONLY when filled in. Page 2
**If a package is not received complete, the HNC Security Office will send a maximum of 2 notifications
(emails) to the Contractor’s security office within a 2 week period. If no response is received the incomplete package will be destroyed and the process will have to be started from the beginning.
3. Once the HNC Security Office receives the completed package (above) from the HNC
PM/PgM/COR/KO/POC the HNC Security Office will submit a Personnel Security Investigation Portal
(PSIP) request for the applicant. The applicant will receive a notification email from PSIP stating what will be needed to complete the form. The second email the applicant will receive will be the form that needs to be completed. Once received, the PSIP form must be completed in 5 calendar days.
4. CSM also acknowledges that contract employees who fail to respond within the given PSIP time constraints will be terminated.
- When the PSIP process is terminated a written justification – including corrective actions taken - must be provided to the POC/PM/PgM/COR/KO from the CSM.
- To reinitiate the process the POC/PM/PgM/COR/KO must sign the justification indicating their approval before providing a copy to HNC’s Security Office and the Trusted Agent (TA).
5. The Contractor Security Manager will ensure that the CAC is returned to the POC/PM/PgM/COR/KO, who in turn will forward the CAC to the Security Office when the contract employee separates or is terminated and/or is no longer eligible for a CAC IAW above requirements.
* * When a CAC is lost or stolen the Contractor Security Manager will provide written notification detailing the incident to the POC/PM/PgM/COR/KO. The POC/PM/PgM/COR/KO will sign the notification and forward to the Security Office.
** NOTE: In and out processing appointments can be made with the Security Office by calling Ms. Cobb at 256-895-1592 or Ms. Cook at 256-895-1497. The Contractor MUST be vetted before being allowed to in-process.
Printed Name of Contractor Security Manager: Date:
Signature:
Printed Name of POC/PM/PgM/COR/KO: Date:
Signature:
Form Approved:
OMB No. 3206-0182 Declaration for Federal Employment*
(*This form may also be used to assess fitness for federal contract employment)
Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. Most applicants are asked to complete this form after a tentative offer of employment has been made; however, depending on your position, you may be asked to complete this form earlier during the hiring process. Follow instructions that the agency provides. Before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.
All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).
Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").
Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.
Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.
Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.
ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.
Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.
U.S. Office of Personnel Management
5 U.S.C. 1302, 3301, 3304, 3328 & 8716
Optional Form 306 Revised August 2023
Previous editions obsolete and unusable
General Information
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. First, Middle, Last, Suffix)
2. SOCIAL SECURITY NUMBER 3a. PLACE OF BIRTH (Include city and state or country)
3b. ARE YOU A U.S. CITIZEN?
YES NO (If "NO", provide country of citizenship)
4. DATE OF BIRTH (MM / DD / YYYY)
5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.) 6. PHONE NUMBERS (Include area codes)
Day
Night
Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.
7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)
7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)
7c. If "NO," describe your reason(s) in item 16.
(*This form may also be used to assess fitness for federal contract employment)
Military Service
8. Have you ever served in the United States military? YES (If "YES", provide information below) NO
If your only active duty was training in the Reserves or National Guard, answer "NO.”
If you answered "YES," list the branch, dates, and type of discharge for all active duty.
Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge
Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.
For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .
9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?
(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.
YES NO
10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.
YES NO
11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.
YES NO
12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.
YES NO
13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.
YES NO
U.S. Office of Personnel Management
5 U.S.C. 1302, 3301, 3304, 3328 & 8716
Optional Form 306 Revised August 2023
Previous editions obsolete and unusable
(*This form may also be used to assess fitness for federal contract employment)
Additional Questions
14. Do any of your relatives work for the agency or government organization to which you are submitting this form?
(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relativeworks.
YES NO
15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?
YES NO
Continuation Space / Agency Optional Questions
16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).
Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.
APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.
When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.
17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.
17a. Applicant's Signature: Date:
(MM / DD / YYYY)
17b. Appointee's Signature: Date:
(MM / DD / YYYY)
18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.
18a. When did you leave your last Federal job? Date:
(MM / DD / YYYY)
18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?
YES NO DO NOT KNOW
18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.
YES NO DO NOT KNOW
U.S. Office of Personnel Management
5 U.S.C. 1302, 3301, 3304, 3328 & 8716
Optional Form 306 Revised August 2023
Previous editions obsolete and unusable
Appointing Officer:
Enter Date of Appointment or Conversion
MM / DD / YYYY
| Attachment 6-CAC Instructions for Vendors-08272025.pdf |
| REVISED CAC request JUNE 2023.pdf |
| Fingerprint card sample.pdf |
| 2023OF306FILLABLE.pdf |
| Contractor Information: |
| Government Information: |
| Company Name: |
| Security Manager SM: |
| POCPMPgMCORKO: |
| SM Email: |
| Telephone No: |
| Contract Number: |
| TRUSTED AGENT: |
| Contract Exp Date: |
| Telephone No_2: |
| Full Legal Name: |
| Date of Birth: |
| SSN: |
| Place of Birth: |
| Email: |
| 10 Digit Telephone No: |
| TypeDate of Investigation: |
| Job Title: |
| Level of Access Required: |
| ClearanceDate Granted: |
| US CitizenRow1: |
| Granted by: |
| Foreign NationalList Country: |
| Check Box1: Off |
| Check Box2: Off |
| Text3: |
| Text4: |
| Text5: |
| Check Box6: Off |
| Check Box7: Off |
| Printed Name of Contractor Security Manager: |
| Signature: |
| Printed Name of POCPMPgMCORKO: |
| Signature_2: |
| Full Name: |
| Social Security Number: |
| PLACE OF BIRTH Include city and state or country: |
| Are you a U: |
| S: |
| Citizen?: Off |
| Country of Citizenship: |
| DATE OF BIRTH MM DD YYYY: |
| Night: |
| Have you ever served in the U: |
| S: |
| Military: Off |
| BranchRow1: |
| BranchRow2: |
| BranchRow3: |
| From MMDDYYYYRow3: |
| To MMDDYYYYRow3: |
| Have you been convicted imprisoned probation or paroled last 7 years: Off |
| Have you been court martialed in the last 7 years: Off |
| Are you currently under charges: Off |
| Have you been fired or debarred or quit due to a specific problem or quit after being told you would be fired: Off |
| Are you delinquent on any Federal debt: Off |
| Other Names Used 1: |
| Other Names Used 2: |
| Day: |
| Male: Off |
| Have you registered with Selective Service: Off |
| From MMDDYYYYRow1: |
| To MMDDYYYYRow1: |
| Type of Discharge 1: |
| From MMDDYYYYRow2: |
| To MMDDYYYYRow2: |
| Type of Discharge 2: |
| Type of Discharge 3: |
| Continuation of Space or Agency Specific Questions: |
| When did you leave your last Federal job: |
| Did you waive Basic Life Insurance or any type of optional life insurance: Off |
| Do any of your relatives work for the agency or government organization for which you are submitting this form: Off |
| Have you applied or do you receive retirement or pension benefits from the military Federal or D: |
| C: |
| government: Off |
| Date: |
| Date_2: |
| If yes to 18b did you later cancel the waivers: Off |
| Appointing Officer Enter Date of Appointment or Conversion MM DD YYYY: |
File details come from the government source that posted it. Updated .