Attachments 1-10.pdf

SECTION 3 – LIST OF ATTACHMENTS

ATTACHMENT 1 ‐ PHILIPPINES TRANSMITTING STATION, TINANG, CONCEPCION, TARLAC

GOVERNMENT FURNISHED PROPERTY

ATTACHMENT 2 ‐ PHILIPPINES TRANSMITTING STATION, TINANG, CONCEPCION, TARLAC

CONTRACTOR FURNISHED PROPERTY

ATTACHMENT 3 – SAMPLE MAINTENANCE RECORD FOR EQUIPMENT

ATTACHMENT 4 – ANTENNA FIELD MAINTENANCE SERVICES SITE DRAWINGS (10

PAGES)

ATTACHMENT 5 ‐ GARDENING SERVICES SITE DRAWINGS (2 PAGES)

ATTACHMENT 6 – MACHINE SAFETY AND MAINTENANCE INSPECTION FORMS (4 PAGES)

ATTACHMENT 7 – RSO OVERSEAS VETTING QUESTIONAIRE (OVQ) FORM

ATTACHMENT 8 – QUALITY ASSURANCE MONITORING FORM

ATTACHMENT 9 – CUSTOMER FEEDBACK FORM

ATTACHMENT 10 – CONTRACT DEFICIENCY REPORT FORM

ATTACHMENT 1

GOVERNMENT FURNISHED PROPERTY

Assigned Government Furnished Property – The Government shall make the below listed property available to the Contractor for performance under the contract. This property shall be under Contractor control throughout the life of this contract. All Government‐furnished property is in good operating condition.

Assigned Government Furnished Property GFE/GFM Quantity

Backpack sprayer GFE 2

GFCI All Weather Extension Wire GFM 4

Hose, size ¾” to 1” diameter GFM 10

Lawn sprinkler/sprayer hose attachment GFM 8

Backpack blower GFE 1

Walk behind vacuum/blower GFE 1

Hedge Trimmer GFE 1

Tractor – 90 HP FWD GFE 2

Tractor – 120 HP FWD GFE 2

Rear Mounted Boom Mower – 14' reach GFE 2

Batwing (Attachment to Tractor Mower) GFE 3

Sickle Bar Attachment for tractor GFE 1

Power washer GFE 3

As‐Available Government Furnished Property – The Government shall make the below listed property available to the Contractor on an “as‐needed / as‐available basis” for performance under the contract. This property shall be under Government control, except when issued to the Contractor. Unless otherwise specified, these items shall be returned to the Government prior to the end of each working day. All requests for "Government‐furnished property" shall be approved by the COR. All Government‐furnished property is in good operating condition.

As‐Available Government Furnished Property GFE/GFM Quantity

Pole Pruner GFM 1

Chain Saw GFE 2

Tractor Dump Trailer – 6 ton GFE 1

Pressure washer GFE 1

Skid‐steer loader – Caterpillar GFE 1

Skid‐steer loader auger attachment GFM 1

Skid‐steer loader attachment ‐ Blade, Dozer, 6‐Way, 79” GFM 1

Skid‐steer loader Attachment ‐ Forks, 42” Pallet w/ Carriage forklift attachment GFM 1

Skid‐steer loader Attachment ‐ Broom, Hydraulic Angle GFM 1

Skid‐steer loader Attachment – backhoe BH150 GFM 1

Skid‐steer loader Attachment ‐ Auger, Direct DR 2” GFM 1

Skid‐steer loader Attachment ‐ Backhoe Mounting Group GFM 1

Chainsaw protective pants GFM 2

Chainsaw protective gloves GFM 2

Tractor – 75HP or more Tractor – JD 5715 4WD (1) / JD 6603 (2) / 5090E (1) GFE 4

Chainsaw Protective Helmet GFM 2

Backhoe/Excavator GFM 1

Consumables – For all Government‐Furnished Equipment (GFE), the Government shall provide all components, single parts and sub‐assemblies, replacement parts including GFE‐related tools as well as routine maintenance expendables such as spark plugs, filter elements, flushing oil, engine oil, fuel filters, gasket, O‐ rings, seal rings, lubrication rings, bolts, nuts, screws, fuses, cable assemblies, brake pads, exhaust pipes, manifolds and bearing components. The Government shall also provide all types of fuel (diesel and unleaded gas), fuel containers, additive (2T oil), lubrication supplies, batteries, and chargers necessary for all types of

GFE.

ATTACHMENT 2

CONTRACTOR FURNISHED PROPERTY

The Contractor shall provide all the below listed equipment, materials, tools, supplies and clothing, required to perform the standard services as specified in this contract. Such items include, but are not limited to, uniforms, personnel equipment, tools of trade, cleaning supplies, equipment and any other operational or administrative items required for the performance of the duties and requirements of this contract. The quantity indicated for each item is the required minimum. The Contractor shall maintain sufficient parts and spare equipment for all the below listed Contractor‐furnished materials to ensure uninterrupted service.

Uniforms. Minimum of five (5) t‐shirts or shirts and one (1) pair of protective footwear per year. The Contractor shall not pass on the cost of the uniforms and footwear to the contract employees but should include it as part of their prices set forth in Section 1‐The Schedule, Subsection 2.0‐Pricing.

(1) Personal Protective Equipment (PPE). PPE must always be serviceable. Damaged or otherwise unserviceable items shall be replaced at no additional cost to the Government.

(a) Protective Eye Guard or Safety Goggles – 1 per Contractor personnel

(b) Safety Shoes – 1 per Contractor personnel

(c) Protective Face Shield – 18 ea.

(d) Safety Apron – 16 ea.

(e) Safety Earplugs – 1 per Contractor personnel

(f) Safety Gloves – 1 per Contractor personnel

(g) Raincoat – 1 per Contractor personnel

(h) Safety Gas Mask – 1 per Contractor personnel

(2) Pesticide

(3) Fertilizer

(4) Garbage / Trash Collection and Hauling Vehicle

(5) Walk Behind Mower – 2ea.

(6) Portable Mower ‐14ea.

(7) Zero‐Turn Riding Mower ‐3ea

(8) Consumables – For all Contractor‐Furnished Equipment (CFE), the contractor shall provide all components, single parts and sub‐assemblies, replacement parts including CFE‐related tools as well as routine maintenance expendables such as spark plugs, filter elements, flushing oil, engine oil, fuel filters, gasket, O‐rings, seal rings, lubrication rings, bolts, nuts, screws, fuses, cable assemblies, brake pads, exhaust pipes, manifolds and bearing components. The Contractor shall also provide all types of fuel (diesel and unleaded gas), fuel containers, additive (2T oil), lubrication supplies, batteries, and chargers necessary for all types of CFE.

ATTACHMENT 3

SAMPLE MAINTENANCE RECORD FOR EQUIPMENT

Quarterly Maintenance Record ‐ Petrol Garden Equipment

Equipment: Quarter

Serial Number: Month 1 Month 2 Month 3

Assembly

Components for Preventive Maintenance H o u rs o f

O p er at io n

W ee k

W ee k

W ee k

W ee k

W ee k

W ee k

W ee k

W ee k

W ee k

W ee k

Engine Change oil & filter 100

Service air and fuel filter 100

Blade Sharpen blade cut

Replace blade

Spark Plug Clean and check gap

Replace

Inspection

Inspect unit

Clean debris from cool air pass

Make adjustment

Daily lubrication

Add'l Manufacturer Maintenance Specification

History of Breakdown / Parts Replacement:

ATTACHMENT 4

ANTENNA FIELD MAINTENANCE SERVICES SITE DRAWINGS (10 PAGES)

ATTACHMENT 5

GARDENING SERVICES SITE DRAWINGS (2PAGES)

ATTACHMENT 6

PRE‐OPERATION SAFETY &

MAINTENANCE INSPECTION

PRE‐OPERATION SAFETY & MAINTENANCE

INSPECTION

The Periodic Maintenance Checklist as outlined in the Operator's Manual has been completed and any necessary maintenance items have been addressed.

The Periodic Maintenance Checklist as outlined in the Operator's Manual has been completed and any necessary maintenance items have been addressed.

Operator: Date: Operator: Date:

Model No: Serial No: Hours: Model No: Serial No: Hours:

FROM THE GROUND [x] [x] FROM THE GROUND [x] [x]

IN THE OPERATOR'S STATION [x] [x] IN THE OPERATOR'S STATION [x] [x]

FLUIDS [x] LEVEL ADDED/REPLACED AMOUNT FLUIDS [x] LEVEL ADDED/REPLACED AMOUNT

*IF EQUIPPED *IF EQUIPPED

Overall Machine Appearance

ROPS,GrabBars,Steps,HandHolds

Frame / Undercarriage

Lights, Harnesses, Electrical Items

Tires, Rims, Wheel Locks / Tracks

Under the Machine

Belts, Hoses, Hydraulic Cylinders

Engine Compartment Cleanliness

Cooler Cores

Safety Alert Labels

Overall Machine Appearance

ROPS,GrabBars,Steps,HandHolds

Frame / Undercarriage

Lights, Harnesses, Electrical Items

Tires, Rims, Wheel Locks / Tracks

Under the Machine

Belts, Hoses, Hydraulic Cylinders

Engine Compartment Cleanliness

Cooler Cores

Safety Alert Labels

COMMENTS COMMENTS

Cab Windows*

Overall Cleanliness

Operator's Manual (Present)

Seat, Seat Belt, Buckle, Mount

Mirrors, Rear Camera*

Windshield Wipers*

Defroster*

Gauges, Indicator Lights, Switches

Fuel

Fire Extinguisher*

Horn*

Park Brake

Brakes

Steering

Travel Alarm*, Back Up Alarm

Diagnostic Trouble Codes

Cab Windows*

Overall Cleanliness

Operator's Manual (Present)

Seat, Seat Belt, Buckle, Mount

Mirrors, Rear Camera*

Windshield Wipers*

Defroster*

Gauges, Indicator Lights, Switches

Fuel

Fire Extinguisher*

Horn*

Park Brake

Brakes

Steering

Travel Alarm*, Back Up Alarm

Diagnostic Trouble Codes

Engine Oil

Hydraulic Oil

Transmission Oil

Engine Coolant

Washer Fluid

Fuel

DEF*

Engine Oil

Hydraulic Oil

Transmission Oil

Engine Coolant

Washer Fluid

Fuel

DEF*

To order more, contact your dealer or visit JohnDeere.com/SafetyChecklist. To order more, contact your dealer or visit JohnDeere.com/SafetyChecklist.

If observed condition of a component could affect safe operation, DO NOT OPERATE. Follow the company Lockout/Tagout Procedure or refer tothe instructions in the Operator's Manual

The responsible Operator, filling out this checklist, has been adequately trained to both complete the Pre-Operation Safety & Maintenance Inspection and to operate the equipment. The Operator confirms understanding of the safety standards for each component and is capable of properly addressing any observed issues using the correct procedure(s). This checklist is NOT intended to replace the Operator's Manual. It is the responsibility of the Operator to have read the Operator's Manual prior to completing this checklist or operating the machine. Individual companies may have their own required checks. Those checks may, or may not, be included in this list. It is the responsibility of the operator to check with the appropriate competent person for details. For additional information, refer to the Operator's Manual.

© 2016 Deere & Company, its affliates, and/or its suppliers John Deere's green and yellow color scheme, the leaping deer symbol, and John Deere

If observed condition of a component could affect safe operation, DO NOT OPERATE. Follow the company Lockout/Tagout Procedure or refer tothe instructions in the Operator's Manual

The responsible Operator, filling out this checklist, has been adequately trained to both complete the Pre-Operation Safety & Maintenance Inspection and to operate the equipment. The Operator confirms understanding of the safety standards for each component and is capable of properly addressing any observed issues using the correct procedure(s). This checklist is NOT intended to replace the Operator's Manual. It is the responsibility of the Operator to have read the Operator's Manual prior to completing this checklist or operating the machine. Individual companies may have their own required checks. Those checks may, or may not, be included in this list. It is the responsibility of the operator to check with the appropriate competent person for details. For additional information, refer to the Operator's Manual.

© 2016 Deere & Company, its affliates, and/or its suppliers John Deere's green and yellow color scheme, the leaping deer symbol, and John Deere are trademarks of Deere & Company All Rights Reserved DKTCCHECK (l7-07) are trademarks of Deere & Company All Rights Reserved DKTCCHECK (l7-07)

Zero Turn - Mower

Maintenance Schedule

Refer to Figure 4-24, Figure 4-25, Figure 4-26, Figure 4-27, Figure 4-28, Figure 4-29, & Figure 4-30

SERVICE AT

INTERVALS INDICATED

WEEKLY

OR 50

HOURS

MONTHLY

OR 100

HOURS

ANNUALLY

OR 500

HOURS

Verify safety start interlock system Prior to each use

Check coolant level Prior to each use

Visually inspect unit for loose hardware and/or damaged parts Prior to each use

Visually inspect tires Prior to each use

Check oil level, engine (1) Prior to each use or every 4 hours

Clean air intake screen (8) Prior to each use or every 4 hours

Clean oil heat exchanger (8) Prior to each use or every 4 hours

Check radiator screen (8) Prior to each use or every 4 hours

Check fuel level Prior to each use

Blades - sharpen & securely fastened Prior to each use

Discharge chute - securely in place &in lowest position Prior to each use

Clean engine and pump compartment Daily

Check air cleaner service indicator (5) Daily

Visually inspect radiator core X

Grease deck pusher arms X

Grease pump idler X

Grease deck height pivots X

Grease gauge wheel bearings X

Change engine oil and filter (1) (4) X

Clean cylinder and head fins (a) X

Check battery connections X

Check tire pressure with a gauge X

Check hydraulic oil level X

Clean engine exterior (a) X

Check pump and deck belt tension and condition (6) X

Check fuel system (7) X

Check hydraulic lines X

Check fuel valve and grommet (7) X

Tighten lug nuts on wheels (2) X

Change fuel filter (7) X

Clean or replace hydraulic fill cap X

Change hydraulic oil filter & oil (3) X

Drain & replace engine coolant X

Clean radiator core (8) X

Check ROPS mounting hardware (9) X

NOTES:

1. Initial oil change is after 50 hours of operation. Thereafter, change oil after every 100 hours operation. Change more often under dusty or dirty conditions and dur-ing hot weather periods.

2. Torque initially and after first 2 hours of operation.

3. Perform initial hydraulic oil filter change after 50 hours (one week) of operation.

4. Change engine oil filter per the engine manufacturer's recommendations. Refer to Engine Owner's Manual for recommendations and other maintenance items.

5. Service more often under dusty or dirty conditions. Use caution when servicing to prevent dust contamination in the engine. Do not clean filter element. Replace with a new one.

6. Pump drive belt only - Inspect every 100 hours and replace if worn or cracking is noticed. Otherwise, replace every 400 hours or 2 years whichever comes first.

7. Check fuel system for any cracks or leaks including, but not limited to, fuel line hoses, fuel valve, vent line hoses, vent valve, vapor valve, carbon canister, and grommets. Repair as needed.

8. More often under dusty or dirty conditions and during hot weather.

9. Inspect ROPS after the first 20 hours of operation and then after every 500 hours of operation or yearly whichever comes first.

REFERENCES: Refer to Engine Owner's Manual

NOTE: After completing maintenance cycle (500 hours), repeat cycle.

603695 4-13 REV H

A thorough, regular visual inspection of the machine is necessary to maintain machine performance, availability, an every shift or make the inspection after every 10 hours.

• Inspect the area around the machine and under the machine. Look for loose bolts, trash buildup, oil leaks, coolant leaks, broken parts, or worn parts.

Remove accumulated trash, dirt, grease, or oil from the machine.

For more information, please refer to the Operation & Maintenance Manual (O&MM) or any other applicable manuals and instructions for this product.

If you have questions, please contact your local Cat dealer.

FROM THE GROUND

Lights Broken lamps, lenses, operation

Grab irons, steps, handholds Condition and cleanliness, damage

Tires, rims nflation, leaks, damage, wear, loose lugnuts/valve stems/ aps

Tracks and drive lugs Damage, deep cuts, abrasions, embedded foreign matter, proper adjustment

Sprocket rings and sleeves Damage (consult O&MM for replacement)

Idlers and bogies Damage, wear, mounting bolts

Undercarriage Dirt, debris, tension, excessive damage

Electrical and hydraulic lines Damage, leaks

Hydraulic oil luid level

Hydraulic cylinders, tubes, hoses, and fittings

Damage, leaks, mounting hardware uel tank Fuel level, damage, leaks; drain water and sediment

Lift arms Cracks, welds, debris

Work tool Debris between lift arm and work tool, damage

Body Structural damage, cracks, welds

Diesel exhaust fluid (DEF) tank (if equipped)

Fluid level, check for debris buildup

Overall machine Loose or missing nuts & bolts, loose guards, cleanliness, fluid eaks

ENGINE COMPARTMENT

Engine oil Fluid level, condition of oil

Engine coolant Fluid leve

Air filter Restriction indicator (if equipped)

Radiator

Fin blockage, leaks

All hoses

Cracks, wear spots, leaks

All belts

Tension, wear, cracks

Batteries and hold downs

Cleanliness, loose nuts and bolts, connections

Covers and guards Trash or dirt buildup, leaks

Overall engine compartment Trash or dirt buildup, leaks

SKID STEER LOADER/MULTI TERRAIN LOADER/COMPACT TRACK LOADER

Safety & Maintenance Inspection Operator/Inspector Date Time _

Serial Number Machine Hours safety. Make the pection at the be nning of

What are you inspecting? What are youlooking for? Evaluator Comments

ON THE MACHINE, OUTSIDE THE CAB

Lights, lenses

Housing or lens damage, cleanliness

Mirrors, windows

Damage, cleanliness, movement

Windshield wipers & washers

Wear, damage to arm, fluid level

ROPS Damage, loose mounting bolts

INSIDE THE CAB

Seat

Adjustment‐height/weight, able to reach pedals

Seat belt & mounting Damage, wear, adjustment, age of seat belt, installation date

Fire extinguisher (if equipped) Charge, damage, inspection tag current

Windows and mirrors

Condition, clean and adjust

Horn, backup alarm, lights

Proper function

All switches, gauges, and controls

Correct operation, damage, cleanliness

Floor pedals and controls

Functional and clear of debris

Cab air filter

Dirt, dust

ROPS

Damage, loose mounting bolts

Overall cab interior Cleanliness, free from debris

NOTES

Inspected by: Date: Time:

© 2016 Caterpillar. All Rights Reserved. CAT, CATERPILLAR, BUILT FOR IT, their respective logos, “Caterpillar Yellow,” the “Power Edge” trade dress as well as corporate and product identity used herein, are trademarks of Caterpillar and may not be used without permission.

SKID STEER LOADER/MULTI TERRAIN LOADER/COMPACT TRACK LOADER

Safety & Maintenance Inspection What are you looking for? What are you inspecting?

ATTACHMENT 7

OVERSEAS VETTING QUESTIONNAIRE

You must digitally sign before submitting Please make sure to sign upon completion. Be aware this will lock the form from further editing.

DS-7801 Page I of 17 04-2024v7_0

General Instructions

Alli questions in this form must be answered completely and truthfully in order that the Government may make,the,determinatiions described below on a complete record. P,enaltiies for inaccurate or false statements are di1-cussed below. If you are a omrent Federal or contractor employee of tihe federal!government: failure to answer any questions,completelly and tnrthfullly oould resulit in an adverse personnel action against you, iindluding loss of employment.

Purpose of this !Form

This fonm willl be used by the United states (U.S.) Government in conducting background investigations, reinvestJigations, and continuous evaluations of persons for elfgibility for logiical aooess, physical aocess, credentialing. and fitness to perform work overseas for or on behalif of the

U.S. Government as Locally Employed (LE) Staff (see 3 FAM 7121) and locally-hired third party oontractors employed overseas at a U.S. Mission.

For applicants, this form is to be used only after a conditional!offer of emp!loyment has been made. This form is not to be used for National Security sensitive positions.

Providing this1informatJion is voluntary. If you do not provid,eeach item of requested infonmation, however, we will not be able to complete your investigation, which willl adversely affect your ability to obtain or retain Federal or contract emp!loyment or logical! or physical! aooess, It is imperative that the information provided be true and accurate, to the best of your knowledge..Any infonmation that you pnovide is evaluated on the basis of its currency, seriousness, rellevance to the positiion and duties, and consistency with all other information about you, Withholding, miisrepr,esentiing, or falsifying information may affect your abiliity to obtain or retaIin Federal or oontract employment. In add1ition, withholding, miisrepresentiing, or falsifying informat[on may affect your eligibil1ity for physical and logical!aocess to federally controlled facilities or information systems. Withholding, misreprese,nting, or fallsifying infonmation may also negatively affect your empl!oyment prospects and job status, and the potential consequences include, but are not l1imited to, removal, debarment from federal service, or prosecution.

This fonm Iis a permanent document that may be used as the basis for fotrure Iinvestigations, suitability or fitness for Federal employme,nt, fitness for contract employment, o,re:ligibili� for phys'ical and logical access to foderallly contnolled facilirties or information systems. Your responses to this form may be compared w,ith your responses to previous questionnaires,.

The investigation conducted on the basis of information provided on this form may be,selected for studies and analysesIin support of evaluating and improving th,ee,ffectiveness and efficiency of the investfgative and adjudicative methodol!ogies. /1111study results re.leased to the general pub!lic willl dellete personaII identifiiers such as name, social security number,,and date and place of birth.

Authority to Request tlhis lnfomiation

Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this infonmat1ion under the Omnibus Diplomatic Security and Antiterrorism Act of 1'986 and Executive Order 13457, as amended, Your Social Securify Number (SSIN) is needed to identify records unique to you. Altlhough disclosure of your SSN is not mandatory, fail:ure to disclose your SSIN may prevent or dellay t1he prooessing of your background investigation. The authonity for soHcitJing and verifying your SSNI is Executive Order 9397, as amended.

The Investigative Process

Baokground investigations for overseas positions are conducted to gather information to determine whether you are reliable, tru.stworthy, of good conduct and character, and loyal to the,U.S, The information you pnovide in this fonm willl be confinmed duning your investigation. Be aware t1hat the

U.S. Government reserves the right to accomp!lish a final adjudication at any point dur1ing your investigation. The investigatiion may extend beyond the time covered by thiis fo nm, when neoessary to reso!lve i:ssues. Your curren,ternpl!oyer may be contacted as part of the investigation, regardless of whether you have previouslly indiicated in other applications or forms that you do not want your curr,e,nt emp'loyer contacted. If you have a security freez,e on you,rconsumer or crediit re.port file, we may not be,able, to compl!e,te your investigation, which can adversely affect your abillity to obtain or reta'in Federal!or oontract employment. To avoid such delays, you must request thatthe consumer reporting agencies lift the freeze in these instances.

In addition to the questions on this form, inquiiry also is made about your adherence to security r,equiremenrts, hone.sty and integrity, vulnerabillity to exploitation or coercion, falsffication, misr,eprese,ntation, and any other behavior, activities, or associations that tend to demonstrate a pe,rson is not rel1iable,,trnstworthy, or loyal, Federall agency records checks may be conducted on your spouse,c, ohabiitant(s), and immediate famill;' members.

After an el'igiibility determ1ination has been completed, you also may be subject to oontinuous e'iilluat1ion, which may include periodic reinvestigat1ions,,to detenmine whether retention in your pos'ition is dearly consistent with tlhe interests of the Department of State.

Your Personal lntervie\!11

Some investiigations willl include an interview with you as a routine part of the investigative prooess, The investigator may ask you to exp!lain your answers to any question on this form. Thiis provides you the opportunity to update, clarify,.and exp!lain 1informatJion on your form more completely, whiioh often assists in completing your investigation. It is imperative that the interview be conducted immediate!'{ after you ar,e contacted, Postponements wiilll dellay the processing of your investfgation, and dedining to be interviewed may resulit in your investigation being delayed or canceled.

For tlhe,interview,,you wiill be requiired to provide photo ide.ntilfication, such as a V'illid driver's license. You may be required to provide otlher documents to ve,rify your identity, as instructed by your iinvestigator.

These documents may includ,ecertification of any 1:egal name,change, Social Security card, passport, and/or your birth oertificate. You may also be asked to provide documents r,egardiing iinfonmatiion that you provide on this form, or about other matters requiiring specific attention. These matters incllude {a) alien registration or naturalization doouments; [b) delinquent loans or taxes, bankruptciies, judgments,,liens, or other financial obligations; (c) agreements involving chiild cu.stod,yor support, al'imony, or prope,rty settllements; {d) arrests, convictions, probation, and/or parole; or (e) other matters descnitied in court records.

Instructions for Coml)leting this !Form

1. Folllow the instructiions, provided to you by the ofttoe that gave you tlhis form and any other darifying iinstructions provided by that oftioe to assist you with compl!e.tion 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. Type or le�ibly print your answers in ink. If the form is not legible,,it willl not be acoepted. You may allso be asked to submit your form us'ingthe appnoved electronic format.

3. All questions on this form must be answered. If no r,esponse is necessary or appl'icab'le,,indicate this on t1he form with "Ill/A,• unless otherwi1se noted.

4. Any changes fhat you make to this fonm, after you sign it, must be initialed and dated by you, Under extremely limited circumstances, agencies may modify your response(s) with your consent.

5. You must use the Locat[on codes (abbre.viat1ions), immediate,ly following the Privacy.Act Routine Uses, when you fi11 out this form. Do not abbreviate the names of cities or foreign countries,

6. Plaoe of birth r,equires Country entry, even ifin the U.S.

DS-7801 Page2 of 17 04.2024! v7.0

7. For telephone numbers,e, nsure that the area code is induded.

8. Allidates prOlliided in this form must be in Month/Day/Year or Month/ Year format. Use numbers (01-12) to ind1icate months. For exampl!e,July 29, 1968, should be written as 07/29/l!'J68, If you are unable to report the exact date, provide an estimated date which iis the best of your abil1ity to recalll, and then enter "EST" in that iield.

Final Determination on Your Eliglibility

Final determinatiion on your eligibillity for position is�he responsibility of t1he Federal agency t1hat requested your investigation and the agency t1hat conducted your investigation. You w1ill be proV1ided the opportunity to explain, refute, or darify any information befor,e a fina'I decision is made, if an unfavorable decis1ion is oonsidered. The United States Government does not discriminate on the basis of race, color,,r,el'ig1ion, sex, national!

orfgin, diiSabil1ity,,or sexual onientation when granting access to classifiied information.

Penalties for Inaccurate or False Statements

71he U.S. Criminal Code (title 18,section 1001) provides that knowingly falsifying or concealing a material!fact is a felbny which may result in fines and/or up to five (5) years impriIsonment. In add'itton,,Federal! agendes generalI'{ fire or di.squal1ify individuals who have materially and deliberately falsified these forms,,and this remains a par,tof the permanent record for futur,e placements, Your prospects of p'lacement are better if you answer all questionstruthfully and oompletely. You willl have adequate opportunity to explain any information you provide on this form and to ma�e your comments part of the,record.

Disclosure Information

The information you provide is for the purpose of investigating you for a posIition, and the information willllbe protected from unautliloriied disdosur,e. The oolllection, maintenance, and di1sdosure of background investigative informat[on are,governed by the Privacy Act, wher,e, appltcab!le. The agency that requested the investIigation and the agency that conducted t1he investigation have published notices in the Federal! Regiister describing�he systems of r,eoords in which your records will be maintained.

The information you provide on thi1s form, and iinformation collected during an Iinvestigation, may be disclosed without your consent by an agency maintaining t1he informat1ion in a system of records as permitted by ilie Privacy Act [5 U.S.C. 552a(b)l,,and by routine uses, a list of which are published by �he agency in the Federal!R�gister, Routine Uses

1. To the Department of Justice,when:: (al the age,ncy or any component thereof; or (b) any employee of t1he agency in his or her official!capacity;

or (c) any employee of t1he agency in his or her 1indiviidua,cl apacity where the Department of Justiice has agreed to represent the employee; or (d) the United States Govem ment, is a party to IIitigation or has interest in such litigation, and by careful review, the agency determines that t1he records ar,e both relevant and necessary to the litigat1ion and the use of such reoords by �he Department of Justioe iIs therefore deemed by ilie agency to be for a purpose that iscompatible with the purIpose for which the agency oollected the records.

2. To a court or adjudicative bod'{ iin a proceeding w'hen: (a) the agency or any component t1hereof; or (b) any emp!loyee of the agency in his or her officia'I capacirty; or (c) any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent th,eemplbyee; or (d) the United States Government is a party to l1itigation or has inter,est in sudh litigation, and by car,eful review, the agency determines that 1:Jhe reoords are both relevant and neoessary to the litigation and the use of such reoordls is therefore deemed by the agency to be for a purpose that is compatible with the pu�pose for which the agency oollected the records.

3. Except as noted in Sectiions 23 and 27, when a reoord on its face,,or in conjunction with other reoords, indicates a vio!latton or potential v[olation of law, whe,fuer ci111il, criminal, or regulatory in nature,, and whether arising by gene,ral statute, particular program statute, regulation, rulle, or order issued pursuant iliereto, the relevant records may be di1;closed to the appropriate Federal, foreign, state, local,,t1nibal, or other public authority responsible for enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule, regulation, or order.

4. To any sour,ce or potential source from which information is requested in the course of an investigatIion concerning the hiring or retention of an employee or other personnel!action,,or the issuing or retention of a security dearanee, contract, grant, license,, or oilier beneliit, to 1:Jhe extent necessary to identify the ind'ividual, inform �he source of the nature and purpose of the investigation, and to identify the type of information r,equested.

5. To a Federal, state, llocal, foreign, tribal, orotihe,r public authority the fact that thlis system of reoords contains information relevant to the retentiion of an emp'loyee, or ilie retention of a seouMity clearance, contract, lioense, grant,,or other benefit. The other agency or ltoensing organization may then make a request supported by written consent of the individual for the entire record if Iit so chooses. No disclosure willl be made unl!ess the information has been determined to be sufficiently reliable to support a referra'I to another office within the agency or to another Federal agency for oriminal,,civil, administrative,,personnel!, or regulatory actIion.

6. To contractors, grantees,, experts, oonsultants,,or volunteers when necessary to perform a function or service related to t1his re.cor,d for whiioh they have been engaged. Such r,eciptents shall be r,equired to compl11with the Privacy Act of 1974, as amended.

7. To �he news media or the general pub'lic, factual information the, di.sclosur,e of which would be in the public interest and whiioh would not constitute an unwarranted invasion of personal privacy.

8. To a Federal, state, or locall agency, or o�her appropriat,ee,ntities,or individua'ls, or through estab!lished !liaison channels to selected foreign governments,,in order to enable an intelligence agency to canry out Iits respon'libilities under �he NattonallSecurity Act of1947 as amended, the OIA Act of 1949 as amended, Executive Order 12333 or any sucoessor order,,appllicable nat1ional security directives, or dlassified implementing procedures approved by t1he Atitomey Generali and promulgated pursuant to such statutes, orders or diirectives.

9. To a Member of Congress or to a Congressional staff member in response to an inquiryoftheCongressiona'I office made at the written request of the constituent about whom the record is maintained, 10,To �he National Archives and Records Adlminisl:Jratiion for records management inspections conducted in accordance with 44 U.S.C. 2904 and 2906,.

lLTot1he Office of Management and Budget when necessary to the review of private rel1ief legislation, DS-7801 Page 3 of 17 04.2024! v7 0

INIFORMATION PIROVIDIEID BY THE FEDERAl BUREAU OF IINVIESTIGATION

Privacy Act Statement

This privacy act statement is located on tlhe back of the FD-258 fingerprint card.

Authority: The FBl's aoquisition, preseliVation, and exchange of fingerprints and associated 1information is generally authorirzed under 28 U.S.C.534.

Depending on tlhe nature of your application, supp'lemental authorities indude Federal statutes, state statutes pursuant to Pub. L. 92-544, Presidential! Executive Orders, and federal regulations. Providing your iiingerprints and associated information is voluntary; however, failure to do so may affect complet1ion or approval oii your application.

Principal! Purpose: Certain determinations, such as employment, licensing.,.

and security dearances, may be prediicated on fingerprint-based background checks. Your fingerprints and associated infonmat1ion/b[ometrics may be• provided to the employing, investigating,.or otherwise r-esponsib'le•agency, and/or the FBI fur the purpose oii comparing your fingerprints to other iiingerprints in the FBl's N'ext Generation Identification {NGI] system or its suocessor systems {including civiil, criminal!, and l'atent fingerprint repositories) or otlher availablle r,ecords oii the emp'loying, iinvestigating, or otherwise responsiblle agency. The ml may re,tain your fingerprints and associated information/biometriosiin NGI after the completion ofthis application and,. while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your iiingerprints and associated information/biometrics are retained in NGI, your information may be disdosed pursuant to your consent, and may be dicSdosed without your consent as permitted by the

Privacy Act of 1974 and all applkable Routine Uses as may be published at any time iin tihe Federal Register, including the Routine,Uses for the NGI system and the FBl's Blanket Routine Uses. Routine uses indude, but are,not limited to,.disclosures to: employing, governmental or autlhorized non-governmental agencies responsiblle,for employment,.contracting.,.licensiing., seourity clearances, and other suitability determinatiions; local, state, tribal, or federal llaw enforcement agencies; criminal justice agencies; and agencies respon.siblle for national security or publiic safety.

Noncriminal Justice Applicant's Privacy Rights

As an appllicant who i1s the subject of a nationa'I fingerprint-based criminal hi�ory record check for a noncnim1inal Justice purpose (such as an application for employment or a license, an immigration or naturalizatiion matter, seourity clearance, or adoption), you have ce.rtain rights which are diiScussed below ..All notices must be provided to you in writing1. l1hese oblligations are pursuant to the Privacy Act of 1974, Titlle 5, United states Gode (U.S.C.) Section 5S2a, and Title 28 Gode oii Federal Regulations (CFR), 50,12, among otherauthonities,

* You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or llater) w'he,n you submiit your fingerprints and assodiated pe,rsonal informat[on, ThiiSPrivacy Act Statement must explain the authority for collecting your fingerprints and assodiated information and whether your finge,�prints and assodiated information willl be searched, shared, or retaiined.2

* You must be ad1.1ised in writing of the procedures for obtaining a change, correction, or update of your FBI criminal history recondas set forth at

28 CFR 16.34.

* You must be provided the opportunity to complete or challlenge the aocuracy of the information in your FBI oriminal history recor,d (iii you have such a recordl.

* If you have a oriminall history record, you shoulld be affonded a reasonable amount of time to correct or complete the reoord (ordedineto do so) befor,e the officials de.nyyou tlhe employment, Hcense, or otlher benefit based on information in the FBI oriminal history record.

* If agency pollicy permits,.t1he officials may provide you with,acopy of your

FBI criminal history record for review and possible challenge. If agency pollicy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting finge,�prints and a fee to the FBI. lnfurmat1ion regarding this process may be obtained at https:// www.fbi.gov/services/cjis/identity-history-summary-chedks and https:/lwww.edo.cJis.gov.

* If you decide to challlenge the acouracy or completeness of your FBI criminal hi�ory record, you should send your challlenge to the agency that contributed the questioned 1information to the FBI. AltiernatJive:ly, you may send your challenge directly to the FBI by submitting a request via https://www ..edo.cji&.gov. The FBI willl then forwandyour challlenge to the agency that contributed the questioned information and request the agency to venify or correct the challenged entry, Upon receipt of an official oommunication from that agency, the FBI w,ill make any necessary dhanges/conrectlions to your record in accordance with the information srupplied by that agency. (See 28 OFR16.30 t1hrough 16.34.)

* You have the right to expect that officials receiving the results of the criminal hiiStory record check will use it onlly for autlhorized purposes and wiiill not r,etain or di1sseminate it in violatiion of fede-ral statute, regulation or executive order,.or rule, procedur,e or standard established bytlhe National Orime Prevention and Privacy Compact Gouncil,3

1 Written notification incl�de, electronic n.otiflrnlion,.but exdudesoral rnmilic:ation 2 hnps:f/www.f!Ji.gov/services/cjis/mmpact-rnunoil/pri�a.cy-act-statemernt

J See 5 U.SC. 552A(IB),;28 U.S.C. 534{1BI; 34 ll.S.C. 40316 (tormerllydied a,s 42.ll.S.C.

14616), Article IVlcl; 28 CFR 20.2.llc),.20.33(d) and 906.2{d).

DS-7801 Page4 of17 04.2024 v7.0

PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING IBE PRECEDING INSTRUCTIONS.

I have read the instructions and I understand that if I witlhhold,.misrepresent, m fa'lsify information on thi:sform,.I am subject to the penalties for inaccurate or fallse statement (per U.S. Criminal!Code, Tirtle•18, section 10011, or removal and debarment from Federall or QYes QNo contract employment.

SECTION 1- Personal Information

Surname (Family Name} Given name {First Name) Middlle Name (other Name)

Date of Birth

(MM/DD/YYYY)

Sex

QMale 0 Femalle

Place of Birth if born in the US, enter the state postal! abbreviation (such as CA, NYI in tlhe state field

City/Town/Village state/Province/Territory Country

Have you •ever used another birth date in !legal dooume,ntation? QYes QNlo lA- Former Names/Aliases

Have you been known by any other names? lo Yes Q No

1B - Citizenship & Identification lB..1- Citirnnship (Click to the right to add/remove countries of citizenship) I+I -

Provide the name of the country and the period of time you held citiz.emhip wiith this country (iif multiple proofs of citizenship are being entered fm the SAMECOUNTIRY: click"+",.enter the same country and time period, and adld the addiitional IDiinformatiion) □ Country of Citizenship From To Present

□Est. □Est.

Proof of Citiz.enship

ID Type m Number Issuing Authority I Date Issued I Date Expires

The•name the citizenship was issued under

Surname (Family Name} Given name (First Name} Middlie Name (other Name}

1B.2 - Forms of ldentifii1cation (Provide as many as possible by clicking'+' to the right) I+I -

ID Type I IDNumber I Issuing Authority I Date Issued I Date Expires

1JB.3 - P•ermanent Resident Card

Have you ever been issued a Permanent Resident Card (Alien Registration Number or USCIS Number) by the us Governme,nt? QYes QNo

18..4 - Social Security Number

Have you ever been issued a Sooial Security Number by the !JS Government? QY•e5 QNo

1C - Physical Description

Hair Eye Height {meters or feet/inches) Weight (kilograms or pounds)

I I m ft in I lbs kg

Describe any unique featur•es or ide,nlJifying marks on your body. (Example:: I have star shaped scars on my left shoulder and chin.)

1D - Contact & Social Media

1D..1- Contact Information

Please provide your current contact information IHome Email lworlkEmail

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DS-7801 Page6 of17 04-2024!v70

Phone Number Phone Type Phone Nlumber Phone Type Phone !Number Phone Type

1D.2 - Social M:edia Membership I+I - Provide all social media t1hat you ourrently use. Select 'Other' if one you use isn't l'isted in the drop-down and write it the soc1ial media name.

Username Media Site

I

SECTION 2 - Residency History

IUst tlhe pllaces where you have lived begiinning wmh your current residence and working back seve,n years. Residences for tlhe entiire period must be accounted for witlhourt breaks. lnd1icate the actual physical!location of your residenoe,.not a Post Office box or a permanent residence where you wer,e not physically located. If you split your time between one or more residences during a time period, you must llist alll reside,nces. Do not list r,esidence before your 18a. b:irthday unlless you ar,e do:ing this to provide a minimum of two years residence history.

You are not required to li1st temporary !locations of lless than 90 days that did not serve as your permanent or mailing address.

for your current address provide a person who knows you at tlhat address, and who preferably still lives in that area. Do not li1st people who knew you well for residences oompletely outs'ide this period, and do not list your spouse,.cohabitant or other rellatives.

I-lave you llived in the United states for more than si!X(6) mont1hs continuously during the past seven {7) years? QYes QNo

2A- Current Residence

Provide the dates in whioh you lived in tlhis reside,nce, If you do not recalll the exact date enter your best estimate and mark the "Est" box

From {MM/DD/YYYY)

□Est.

Res1ide,ncy Status:

Qowned ORented/leased by you

0 Millitary Housing Qother

Street (Bldg or Apt)

Oty/liown/ViiiIage I State/Province[rerritory I Posta,cl ode• I Country

2A.2 - Neighbor's Contact lnformati"011, Surname (family Name} Given name {First Name} Middle Name (other Name)

Home Email Work Ema1ill

Phone Number Phone Type Phone Number Phone Type Phone Number Phone Type

Street (Bldg or Apt)

City/liown/ViiiIage state/Pro111ince{Territory Postal Code Country

2B - Prior R,esidenoes I+I -

2B.1- Residence lnfom1ation

Provide the dates in which you lived in thiis r,esidence. If you do not recall the e•xact dat,eenter your best estimate and mark the "Est" box

From (MM/DD/YYYY) To

0 Est 0 Est.

Res1idency status:

Qowned 0 Rented/Leased by you

0 Millitary Housing QOther

Street (Bldg or Apt)

City/liown/Villlage State/Province{Territory Postal Code Country

2B.2:- Neighbor's Contact Information

OVERSEAS VETTI re QUESTIONNAIRE

Surname (Family Name) Given name (First Name) Middlle Name (other Name)

Horne Email Work Email

Phone Numtier Phone Type Phone Number Phone lype Phone Number Phone lype

Street [Blldg or Apt)

City/Town/Vil11age I State/Province/Territory

I Postal Code

I Country

SECTION 3 - Education History

Have you attended an educationa'I institution in the last seven years? QYes QNo

Did you attend an educational Iinstitution more than seven years ago? QYes QNo

SECTION 4 • Employment History

If you have never held a job/work positJion before, proceed immediatelly to the next section. IHhi&is not the case please llist alll of your employment activities, including unemployme,nt and self-employment, beginniing with the present and working back seve,n years. lhe entire,period must be accounted for without breaks. If the emp!loyment activity was military duty, l'ist separate employme,nt activity periods to show each change of mil1itary duty station.

Provide separate entries for employment activities witlh the same employer but having difi,erent physical!addresses. Do not l1i,set mployment before your 18th birthdlay unless to provide a minimum of 2 year,semployment h•istory.

4A - Employment (All employment in the last 7 years) I+I -

Sel!ect the type of ernpl!oyment (emp!loyed, unemployed, miilitary) and enter tlhe time period related to it (If you do not recall the exact date enter your best estimate,and mark the '"Est" box). You must account for the last 7 years wiith no interruptions lype from

Est.

lo DPresent

□Est.

Emp'loyer Email WmlkTitle

Provide the organization's address and a supervisor's contact 1informat1ion (if unemployed, provide contact info for someone who can verify).

Street (Blldg or Apt)

City/Town/Villlage state/Province/Territory Postal Code Country

Supervisor's Work ntle Supervisor's Surname (Family Name) SuperviiSor's Given Name (First Name)

Supervisor Email Phone Numbe,r Phone Type

Reason for Leaving?

Any Discipllinary Action Taken Against You?

4B - Additional Employment Information

Have you served in tlhe US Miilitary Service more than 7 years ago? QYes QNo

Have you worked for a government (exduding the US) organization/millitary more than seven {7) years ago? QYes QNo

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OVERSEAS VETTI -G QUESTIO-NAIRE

SECTION 5 - Social References

Provide contact information for three (3) persons who are not family rellat[ons and are not llisted in other sections of this form

SA - Social Ref,er,ence 1 (Provide contact information for a person who knew you during the past seven (7} years.)

How long have you known this person?

From

To D Present

0 Est.

Surname (Family Name) Given name {First Name) Middlle Name (other Name)

Work Emaill Home Email other Emaill

Phone Number Phone Type Phone Number Phone Type Phone Nlumber Phone Type

Street (Bldg or Apt)

Ciity/Town/Villlage state/Proviince/Tenitory I Postal Code I Country

SB - Social Reference 2 (Provide contact information for a person who knew you during the past seven (7) years.)

0 Est.

Surname (Family Name) Given name (First Name) Middlle Name (other Name)

Work Emaill Home Email other Emaill

Phone Number Phone Type I Phone,Number Phone Type I Phone,Number Phone Type street (Bldg or Apt)

Ciity/Town/Villlage I State/Province/Territory I Postall Code I Country

SC - Social Reference 3 (Provide contact information for a person who knew you during the past seven (7) years.)

0 Est.

Surname (Family Name) Given name (First Name) Middlle Name (other Name)

Work Emaill Home Emaill Other EmaiiI

Phone Number Phone Type Phone Number Phone Type Phone Nlumber Phone Type st1reet (Bldg or Apt)

Ciity/Town/Villlage I State/Province/Territory I Postal Gode I Country

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OVERSEAS VETTI .G QUESTIONNAIRE

Section 6 • Marital Status/DomesticUnion Status/Domestic Partnership Status

Provide your current status (check all that apply)

D Married/Cohab:iting/Se,parated I□ rnvorned/Widowedl I□ Single (never married)

SECTION 7 - Relationships

7A - Parents

7A.1- Parent ,(Click to the right to add/remove parents) I + I - Relatioriship to you D Parent D Step-Parent D r;oster Parent D Guardian D Parent-in-law

Surname (Family Name} Given name (First Nome} Ma1iden Name/Middlle N'ame

Date ofBirth I Birth City/lownNillage B1irth State/Province/lernitory Birth Country

Citizenship {Click to the right to odd/remove countries of citizenship} I+I -

Country of Citizenship

Provide contact infonmation □ Deceased

Phone Number Phone Type Contact Emaill

Provide a current address if different from your own street [Bldg or Apt)

City/lown/Viiill'age I State/Province/lerritory I Postal Codie I Country

7B - Siblings

7B..1- Sibling (Click to tllle rigl,t to add/remove sibli11g] I + I - Relation.ship to you 0 Sibling 0 Hatf0sibling D Step-sib'ling

Surname (Family Name} Given name (First Name} Maiiden Name/Middlle N'ame

Date of Birth I B.irth City/lownNillage B1irth State/Province/lernitory Birth Country

Citizenship {Click to the right to add/remove countries of citizenship} I+I -

Country of Citizenship

Provide contact infonmation □ Under 18? □ Deceased

Phone Number Phone Type Contact Emaill

Provide a curr,ent address if different from your own street [Bldg or Apt)

City/lown/Viiill'age I State/Province/lerritory I Postal Codie I Country

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OVERSEAS VETTI 'G QUESTIO 'NAIRE

7C - Children

7C.1- Child (Olick to the right to add/remove children I + I - Relationship to you

Child

Stepchild

Surname (Family Name} 'Given name (First Nome} Maiden Name/Middlle Name

Date of Birth I Birth City/liown,Nillage 8iirth State/Province/lierritory Birth Country

Citi�enship (Click to the right to odd/remove countries of citizenship) I+I -

Country of Citiienship

Provide contact information

□ Under 18?

□ Deceased

Phone Number Phone Type Contact Emaill

Provide a current address if diifferent from your own

Sllreet (Bldg or Apt)

City/Town/Village I State/Province/Territory I Postal Code I Country

SECTION 8 • ForeignTravel

Have you traveled outside the country in the past seven (7) years? QYes QNo

SECTION 9 - Prior lnvestications

Has the United States Goverinment (or any foreign government) EVER1investrgated you? QYes QNo

SECTION 10 • General Questions lOA - Financial lOA.1- Have you expe,rienced difficulty paying your bills dur1ing the past seven [7) years? QYes QNo lOA.2 - Has the financial difficulty mentioned in the pr,evious question been resolved?