SF85_-_Fillable.pdf

Form approved: Standard Form 85 (EG) Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731 and 736

QUESTIONNAIRE FOR

NON-SENSITIVE POSITIONS

0MB No. 3206-0005

NSN 7540-00-634-4035

85-111

E Geographic Location

I OPAC-ALC

Number

KRequesting Name and Title Official

F Position Title

J Accounting Data and/or Agency Case Number

Signature

0FULL

NAME

• If you have only initials in your name, use them and state (10).

• If you have no middle name, enter "NMN".

Last Name First Name

0 PLACE OF BIRTH - Use the two letter code for the State.

City County

Codes Case Number

G

SON

Telephone Number

- If you are a "Jr.," "Sr.," "II," etc., enter this in the box after your middle name.

H

SOI

Date

8DATE OF

BIRTH

Middle Name Jr., II, etc. Month Day

0 SOCIAL SECURITY

State Country (if not in the United States)

OOTHER NAMES USED

Give other names you used and the period of time you used them (for example: your maiden name, name(s) by a former marriage, former name(s), alias(es), or nickname(s)). If the other name is your maiden name, put "nee" in front of it.

Year

Name Month/Year Month/Year Name Month/Year Month/Year #1

Name #2

ar. one b ') ox

QclTIZENSHIP

E) Mark the box at the right that reflects your current citizenship status, and follow its instructions.

To Month/Year Month/Year

To

#3

Name #4

Femalen Male n

I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. (Answer items b and d)

I am a U.S. citizen, but I was NOT born in the U.S. (Answer items b, c and d)

I am not a U.S. citizen. (Answer items band e)

To Month/Year Month/Year

To

0, Your Mother's Maiden Name

8 UNITED STATES CITIZENSHIP If you are a U.S. citizen, but were not born in the U.S., provide information about one or more of the following proofs of your citizenship.

Naturalization Certificate (Where were you naturalized?)

Court City

Citizenship Certificate (Where was the certificate issued?)

City

State Department Form 240 - Report of Birth Abroad of a Citizen of the United States Give the date the form was Month/Day/Year Explanation prepared and give an explanation if needed U.S. Passport

State Certificate Number

State Certificate Number

Passport Number This may be either a current or previous U.S. Passport.

(D DUAL CITIZENSHIP If you are (or were) a dual citizen of the United States and another country, provide the name of that country in the space to the right.

G) ALIEN If you are an alien, provide the following information:

Country

City State Date You Entered U.S.

Place You Entered the United States:

Month

I

Day

I

Year

Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995.

Designed using Perform Pro, WHS/DIOR, Sep 95

Alien Registration Number

Month/Day/Year Issued

Month/Day/Year Issued

Month/Day/Year Issued

Country(ies) of Citizenship

COMPANY NAME___________________

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GHyppolite Sticky Note Unmarked set by GHyppolite

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OwHERE You HAVE LIVED

List the places where you have lived, beginning with the most recent (#1) and working back 5 years. All periods must be accounted for in your list. Be sure to indicate the actual physical location of your residence: do not use a post office box as an address, do not list a permanent address when you were actually living at a school address, etc. Be sure to specify your location as closely as possible: for example, do not list only your base or ship, list your barracks number or home port. You may omit temporary military duty locations under 90 days (list your permanent address instead), and you should use your APO/FPO address if you lived overseas.

For any address in the last 3 years, list a person who knew you at that address, and who preferably still lives in that area (do not list people for residences completely outside this 3-year period, and do not list your spouse, former spouses, or other relatives).

Month/Year Month/Year Street Address Apt.# City (Country) State ZIP Code

#1 To Present

Name of Person Who Knows You Street Address Apt.# City (Country) State ZIP Code

Month/Year Month/Year Street Address Apt.# City (Country) State ZIP Code

#2 To

Name of Person Who Knew You Street Address Apt.# City (Country) State ZIP Code

Month/Year Month/Year Street Address Apt.# City (Country) State ZIP Code

#3 To

Name of Person Who Knew You Street Address Apt.# City (Country) State ZIP Code

Month/Year Month/Year Street Address Apt.# City (Country) State ZIP Code

#4 To

Name of Person Who Knew You Street Address Apt.# City (Country) State ZIP Code

Month/Year Month/Year Street Address Apt.# City (Country) State ZIP Code

#5 To

Name of Person Who Knew You Street Address Apt.# City (Country) State ZIP Code

C)WHERE YOU WENT TO SCHOOL

List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 5 years. List all College or University degrees and the dates they were received. If all of your education occurred more than 5 years ago, list your most recent education beyond high school, no matter when that education occurred.

- Use one of the following codes in the "Code" block:

1 - High School 2 -College/University/Military College 3 -Vocational/Technical/Trade School

- For correspondence schools and extension classes, provide the address where the records are maintained.

#1

Month/Year Month/Year

To

Code

Street Address and City (Country) of School

#2

Month/Year Month/Year

To

Code

Street Address and City (Country) of School

#3

Month/Year Month/Year

To

Code

Street Address and City (Country) of School

Name of School Degree/Diploma/Other

Name of School Degree/Diploma/Other

Name of School Degree/Diploma/Other

State

State

State

Enter your Social Security Number before going to the next page--------------

Month/Year Awarded

ZIP Code

Month/Year Awarded

ZIP Code

Month/Year Awarded

ZIP Code

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• YOUR SELECTIVE SERVICE RECORD Yes No

E) Are you a male born after December 31, 1959? If "No," go to 13. If "Yes," go to b.

0, Have you registered with the Selective Service System? If "Yes," provide your registration number. If "No," show the reason for your legal exemption below.

Reg1strat1on Number Legal Exemption Explanation

.YOUR MILITARY HISTORY Yes No

E) Have you served in the United States military?

0, Have you served in the United States Merchant Marine?

List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of service {#1) and work backward. If you had a break in service, each separate period should be listed.

Code. Use one of the codes listed below to identify your branch of service:

1 -Air Force 2-Army 3- Navy 4 - Marine Corps 5 - Coast Guard

0/E. Mark "O" block for Officer or "E" block for Enlisted.

6 - Merchant Marine 7 - National Guard

Status. "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use an "X"; use the two-letter code for the state to mark the block.

Country. If your service was with other than the U.S. Armed Forces, identify the country for which you served.

MonthNear MonthNear Code Service/Certificate # 0 E Status Active Inactive National

Active Guard Reserve Reserve (State)

To To

• ILLEGAL DRUGS

In the last year, have you used, possessed, supplied, or manufactured illegal drugs? When used without a prescription, illegal drugs include marijuana, cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), stimulants (cocaine, amphetamines, etc.), depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.). (NOTE: Neither your truthful response nor information derived from your response will be used as evidence against you in any subsequent criminal proceeding.)

If you answered "Yes," provide information relating to the types of substance(s), the nature of the activity, and any other details relating to your involvement with illegal drugs. Include any treatment or counseling received.

MonthNear MonthNear Type of Substance Explanation

To To To

Continuation Space

Country

Yes No

Use the continuation sheet(s) (SF86A) for additional answers to items 8, 9, and 10. Use the space below to continue answers to all other items and any information you would like to add. If more space is needed than is provided below, use a blank sheet(s) of paper. Start each sheet with your name and Social Security number. Before each answer, identify the number of the item.

After completing this form you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the following certification and sign and date the release on Page 6 .

Certification That My Answers Are True

My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both. (See section 1001 of title 18, United States Code).

Signature (Sign in ink) Date

Enter your Social Security Number before going to the next page

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Form approved: Standard Form 85 Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731 and 736

0MB No. 3206-0005

NSN 7540-00-634-4035

85-111

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date it in black ink.

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation, to obtain any information relating to my activities from schools, residential management agents, employers, criminal justice agencies, retail business establishments, or other sources of information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, and criminal history record information.

I Understand that, for some sources of information, a separate specific release will be needed, and I may be contacted for such a release at a later date.

I Authorize custodians of records and sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by the Federal

Government only for the purposes provided in this Standard Form 85, and may be redisclosed by the Government only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for two (2) years from the date signed.

Signature (Sign in ink) Full Name (Type or Print Legibly) Date Signed

Other Names Used Social Security Number

Current Address (Street, City) State ZIP Code Home Telephone Number (Include Area Code)

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