Fd-816.pdf

FD-816 (1-22-93)

ACCESS OF NON-FBI PERSONNEL TO FBI FACILITES

BACKGROUND DATA INFORMATION FORM

(COMPLETE ALL ITEMS)

Name (Type or Printed Legibly) Other Names Used (Maiden name and alias)

Residence (Include City and state) Social Security Number

Sex Male Female

Date of Birth (Month, Day, Year) Place of Birth

Company Name & Address Supervisor & Telephone Number

U.S. Citizenship: By Birth By Naturalization By Other Location Naturalized Date Naturalized

Alien Registration Number Location Registered Date Registered

Have you ever been charged with or convicted of any felony offense? Yes No

Have you ever been charged with or convicted of a firearms or explosive offense? Yes No

Are there currently any charges pending against you for any criminal offense? Yes No

Have you ever been charged with or convicted of any offense(s) related to alcohol or drugs Yes No

In the last 10 years have you been arrested for, charged with, or convicted for any offense(s)?

Not listed above? (Leave out traffic fines less than $100) Yes No

If yes, or if you have doubts (e.g-expungement, pardon, etc.) furnish details on back of form.

Attach additional sheet, if necessary.

Have you ever lived in or visited a foreign country? Yes No If yes, furnish details. Attach additional sheet if necessary

CERTIFICATION THAT MY ANSWERS ARE TRUE

I have read and understand each of the above questions. My statements on this form, and any attachments to this form, 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 and will be reason to deny access to all FBI facilities.

Signature __________________________________________________________ Date ______________ (Sign in ink)