17._ATTACHMENT_13_SF_85.pdf

RFP HSFLGL-17-R-00001

Lodging Management Services

FLETC, Glynco Georgia

Standard Form 85 Revised December 2013 U.S. omce of Personnel Management 5 CFR Parts 731 and 736

Attachment 13

Form approved:

0MB No. 3206-0261

Questionnaire f9r Non-Sensitive Positions

Follow instructions folly or we cnnnot process your form. Be sure to sign and date the certification statement on Page 5 and the release on Page 6. !fyou have any questions, call cite office that gave you the fom1.

Purpose of this Form

The U.S. Government conducls background investigations to establish tbat applicants or incumbents either employed by the Government or working for the Government under contract, are suitable for the job.

lnfonnation from this form is used primarily as the basis for this investigation. Complete this fonn only after a conditional offer of employment has been made.

Giving us the infonuation we ask for is voluntnry. However, we rnoy not be able to complete your investigation, or complete it in a timely mnnner, if you don't give us each item of information we request. This may affect your placement or employment prospects.

Authority to Request this Informntion

The U.S. Government is authorized Co ask for this information under Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code;

and pans 5, 731, aud 736 of Title 5, Code ofFedernl Regulations.

Your Social Security Number is needed to keep .records nccumtc, because other people may have the same name Rnd birth date. Executive

Order 9397 nlso Mks Federal ngcncies to use this number to help identify individunls in ngency records.

The lnvesllgatlve Process

Background investigations nre conducted using your responses on this form and on your Declarnt!on for Fcdcrnl Employment (OF 306) to develop infonnation lo show whether you are reliable, lmstworihy, und of good conduct and character. Your current employer must be contacted as part of the investigation, even if you have previously indicated on applicnlions or other fomts that you do not want this.

lnstrncllons for Complellng this Form

1. Follow the instmctions given to you by the person who gave you the form and any other clarifying instmctions f\tmisbed by that person to assist you in completion of the form. Find out bow many copies of the fonn you nre to htm in. You must sign and date, in blnck ink, the original and each copy you submit.

2. Type or legibly print your answers in black Ink (if your form is not legible, it will not be accepted). You may also be asked to submit your form in an approved electronic fonnat.

3. All questions on this fmm must be answered. If no response is necessary or applicable, indicate this on the fonu (for exaill.ple, enter 11None11 or 11N/A"). If you find that you cannot report ,m exnct date, approximotc or estimate the date to the best of your Rbility and indicate this by marking "APPROX." or "EST."

4. · Any changes that you make to this fo1m after you sign it must be initialed and dated by you. Under certain limited circumstances, agencies may modify the form consistent with your intent.

5. You must use the Stnte codes (abbreviations) listed on the back of

Ibis page when you fill out this form. Do not abbreviate the names of cities or foreign countries.

6. The 5-digit postal ZIP codes are needed to speed the processing of your investigation. The office that provided the form will nssist you in completing the ZIP codes.

7. All telephone numbers must include area codes.

8. All dates provided on this form must be in Month/Day/Year or

Month/Year format. Use numbers (1-12) to indicole months. For example, June I 0, 1978, should be shown as 6/!0n8.

9. Whenever "City (Country)" is shown in on nddress block, also provide in that block the name of the country when the address is outside the United Stales.

I 0. If you need additional space to list your residences or employments/self-employments/unemployment or education, you should use a continuation sheet, SF 86A. If additional space is needed to answer other items, use a blank piece of paper. Eacb blank piece of paper you use must contain yom· name nnd Soclnl Security Numbel' at the top of the page.

RFP HSFLGL-l7-R-00001

FLETC, Glynco Georgia

Finni Detcrmlnntion on Your Eliglblllty

Final detem1ination on your eligibility for a position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity personally to explain, refute, or clarify nny infonnation before a final decision is made.

Pcnnlties for lonccurnte or Folse Stntcmcnts

Attachment 13 all questions trnthfidly and completely. You will have adequate opportunity to explain any infonnation you give \IS on the form and to make your comments part of the record.

Disclosure oflnfornmtion

The information you give us is for the purpose of determining your suitability for Federal employment; we will protect it from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative lnfonnation is governed by the Privacy Act. The agency

The U.S. Criminal Code (title 18, section IOOJ) provides that knowingly which requested the investigation and the agency which conducted the ---falsifying or concealing a material-fact-is a felony,vhich,nay-resulritr--invcstigation-have1mblished ,iotices-iwthe-Federnl-Register describing� fines of up to $!0,000, nnd/or 5 years Imprisonment, or both. In the systems of records in which your records will be mnintained. You addition, Federnl ngencies generally fire, or disqualify Individuals who may obtain copies of the relevant notices from the person who gave you hnve materially nnd deliberately falsified these forms, and this remains a Ibis form. The information on this form, and infonnAtion we collect part of the pcmianent record for foture plncements. Your during nn investigation may be disclosed without your consent ns tmstworthiness is n very important consideration in deciding your pennitted by the Privacy Act (5 USC 552n(b)) and a, follows:

suitability. Your prospects of placement are better if you answer

PRIVACY ACT ROUTINE'USES

1. To the Department of Justlee when: (a) lhe agency or any component lhereot, or

(b) any employee ot the agency In hfs or her offidal capacity; or (c) any employee of lhe agency In his or her lndlvldual capacity where U,e Department of JusUce has agreed to represent lhe employee; or (d) the United States Government, Is a party to liUgallon or has Interest In such liUgaUon, and by careful review, the agency determines thal the records are bolh relevant and necessary to the lltlgallon and the use of such re<'.Ords by the Department of JusUce Is therefore deemed by the agency to be for e purpose that Is compatible with the purpose for which the agency collected the records.

2. To a court or edJudk:aUVe body In a proceeding when: (a) the agency or any component thereo� or (b) any employee of the agency In his or her official capacity;

or (c) any employee of the agency In his or her lndMdual capacity where the Departmenl of Justice has agreed to represent the employee; or (d) the United States Government Is a party to litlgatlon or has Interest In such liUgaUon, and by careful review, the agency determines that the records are bolh relevant and nec.essary lo the /lllgallon and the use of such records Is therefore deemed by the agency to be for a purpose that Is compallble with Iha purpose for which the agency collected the records.

3. Except as noted In Quesllon 14, when a record on Its race, or In conjunction with other records, Indicates a vlolatlon or potenllal vlolaUon of law, whether civil, crimlnal, or regulatory 1n nature, and \Vhelher arising by general statute, partlcular program s1atute, regulation, 111le, or Ofder Issued pursuant thereto, the relevant records may be disclosed to the oppropriale Federal, foreign, State, focal, trlbal, or other pubHc authority responsible for enforcing, Investigating or prosecuting such v!olaUon or charged with enforcing or Implementing the statute, rule, regulallon, or order.

4. To any source or potential source from which lllfoonatlon Is requested lo the course of an lnvestlgatlon concerning the hiring or retention of an employee or other personnel action, or the Issuing or retention of a security clearance, cor,ttact, granl, llcense, or other benefit, lo the extent necessary to Identity the lndMdual, Inform the source of the nature end purpose of the lnvesllgaUon, and to Identify the type of lnformaUon requested.

6. To a Federal, Stale, local, foreign, tribal, or o!her public authority the (act that this syslem of records conlalns Information relevant lo the relenllon of en employee, or the retenUon of a security clearance, contracl, llceose, granl, or other benent The other agency or llcenslng organization may then make a request supported by written consenl of the lndMdual (or U1e entire record If i l so chooses. No disclosure w\U be made unless the ln(ormaUon has been delennlned to be sufficfenUy reliable to support a referral to another offlce within the agency or to another Federal agency ror almlnal, civil, admlnlslrative, personnel, or regulalory acUon.

6. To conttactors, grantees, experts, consultants, or volunteers when necessary to perf0<m a (unction or service related to this record for which they have been engaged. Such reclplenls shall be required to comply with the Privacy Act of 1974, as amended.

7. To the nev,s medla or the general pubflc, factualtnrormaUOn the dlsclosure or which would be In the public Interest and which would nol consutule an unwarranted Invasion of personal privacy.

8, To a Federal, �tale, or focal agency, or other appropriate enliUes oi Individuals, or through eslablJshed llalson channels to selected foreign governments, In order to enable an Intelligence agency to carry out Its responslbtlJUes under the National Security Act of 1947 as amended, the CIA Acl or 1949 as amended, Executive Order 12333 or any successor Ofder, eppl!cable naUonal security directives, or classified lmplemenUng procedures app,oved by the AUorney General and promuJgated pursuant to such slatules, orders or directives.

9, To a Member of Congress or lo a Congressional staff member In response to an Inquiry or the Congressklnal office made at the written request of the consUtuenl about whom lhe record Is malntalned.

1 o. To the NaUonal Archives and Records AdmlnistraUon for records management lnspecUoos conducted under H USC 2904 end 2006.

11. Tolhe Orflce of Managemenl and Budget when necessary lo the review of private ,enet leglslalton.

STATE CODES (ABBREVIATIONS)

Alabama AL Hawan HI Massachusetts MA New Mexico NM SouUl Dakota SD Afaska AK Idaho ID Michigan Ml New York NY Tennessee TN Arizona AZ Illinois IL Minnesota MN North Carolina NC Texas TX Arkansas AR Indiana IN Mississippi MS North Dakota ND Utah UT California CA Iowa IA Missouri MO Ohio OH Vermont VT Colorado co Kansas KS Montana MT Oklahoma OK Virginia VA Connecilcut CT Kentucky KY Nebraska NE Oregon OR Washington WA Delaware DE Louisiana LA Nevada NV Pennsylvanla PA Wast Virginia WI

Florida FL Maine ME New Hampshire NH Rhoda Island RI I.Nisconsln \',I Georgia GA Ma,ytand MD New Jersey NJ South Caronna SC W,,omlng W(

American Samoa AS Dlsltlct of Columbia DC Guam GU Northern Marianas CM Puerto Rico PR Trust Territory n Virgin Islands VI

PUBLIC BURDEN INFORMATION

Public reporting burden for this collection of Information Is estimated to average 30 minutes per response, Including lime for reviewing lnstrucllons, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information. Send comments regarding the burden estimate or any other aspect of this collection of Information, Including suggestions for reducing this burden to Reports and Forms Management Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Room CHP-500, Washington, D.C. 20415. Do not send your completed form to this address.

2 of8

FLETC, Glynco Georgia

Standard Form 85 Revised December 2013 U.S. Office of Personnel Management 5 CFR Parts 731 and 736

QUESTIONNAIRE FOR

NON-SENSITIVE POSITIONS

Attachment 13

Form approved:

0MB No. 3200,0261

OPM Codes Case Number

USE

I I

ONLY

A Typeof d I

B Extra J

C Nalura or d

D Oateor .I Month Day I Year ��vesUgaUon _ _ Coverage_ Action Code Action ---

E Geographic F Pos!Uon G Locatlon

I TIiie

I

SON

I

SOI I

I IPAC J AccounUng Data and/or

I Agency Case Number

K Reques\lng Nama and TIUe omc1., I S!gnature Telephone Number Date

I I< I

0FULL

NAME

• 1ryou haveonty lnltlals In your name, use them and slate (10).

• If you have no m!ddle name, en!er"NMN".

- If you are a "Jr,," "Sr.," "It," etc,, enter this In the box ofter your mlddle name.

f}DATEOF

BIRTH

Last Name

I First Name

QPLACE OF BIRTH • Use the IVIO letter code for the State.

Middle Name

City

I County

I State

I Country (ii not In the unned Slates}

Jr., II, etc. Month I Day

I Year

K:• SOCIAL SECURITY

eg�����,���:suy:�sed and Iha period or lime you used lhem (for example: your maiden nsme, name(s) by a former ma"lage, former nsme(s), allas(es), or nfckname(s)). If lhe other name Is your maiden name, pul "nee• In front of ll.

ame Mon ear Month/Year Name MonlhNear MonthNear #1

Name #2 a one be i X

@CITIZENSHIP

(!) Ma,k the box al the rlght that renect, your current citizenship stalus, and foRow lls Instructions.

To Month/Year Month/Year

To

#3

Name #4

Female II Male II 1 am a U.S. citizen or national by b!rth In lhe U.S. or U.S. territory/possession. (Answer (tams bandd)

1 am a U.S. ciUzen, but I was NOT born In lhe U.S. (Answer Items b, candd)

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

To Month/Year Monthffear

To

(]) Your Mothers Malden Name

8 UNITED STATES CITIZENSHIP If you ere e U.S. citizen, but were nol bom In the U.S., provide Information about one or more of lhe following proofs of your citizenship.

NalurallzaUon Certificate (Wlere were you naluraJJzed?)

Court

I City

Citizenship CertlOcale {Wiers was /he certi(icate Issued?)

City

State Department Form 2�0 - Report of Birth Abroad or a Citizen of the Unlled Stales G e lhe dalelhe fotmwas onth/Day/Year ExplanaUon prepared and glve an explanation If needed U.S. Passport

This may be either a current or prevk>us U.S. Passport

(!} DUAL CITIZENSHIP If you are (or were) a dual citizen of the Unlled States and another country, provide the name of lhat country In the spaca lo the right.

Q ALIEN If you ere an aUen, provide the rollowlng Information:

Place You Entered lhe United States:

City State Date You Entered Month Day

3 of8 tale

I Certincate Number

State CertJncale Number

Passport Number countsy

Allen Registration umber

Month/Dey/Year Issued

Monlh/DayNearJssued

Month/DayNear Issued

Count,y�es) or Ctttzen,hlp

FLETC, Glynco Georgia

OwHERE vou HAVE LIVED

Attachment 13 list lhe places where you have lived, beglMlngwlth lhe most recent (#1) and v..>o1klng back 5 years. Al periods must be accounted for In your Hsi. Be sure to Indicate the actual physical locaUon of your residence: do nol use a post ottlce box as an address, do not II st a permanent address when you were aCtually Uvlng at a school address, etc. Be sure to specify your location as closely as possible: for example, do not fist onty your base or ship, list your barracks number or home port You may omit temporary mllitary duty locaUons under 80 days (bl your permanent address Instead), end you should use your APO/FPO address If you fived overseas.

For any address In the last 3 years, 11st a person who knew you at that address, and who preferably still fives In lhat area ( do not llst people f0< residences completety outside this 3-year period, and do not list your spouse, rormer spouses, or other relatives).

---Monlh/Year--Monlh/Year-- StreetAddress-- ---·------ApL.# .• Coly(Counl,y}-----·-- -State- ZIP Code #1 To Pre�P.nt Name of Person Vvho Knows You Street Address Apl.# c,1y (Counlry) Slale ZIP Code

Month/Year Monlh/Veor Street Address Apl.# Clly(Count,y) Slate ZIPCooo #2 To Name of Person I.Mlo Knew You Street Address Apl # Clly(Count,y) Stale ZIP Code

Month/Year Month/Year Street Mdress Apl # City (Count,y) 1.:>tate ZIP Code

113 TO

Name of Person \o\oho Knew You Street Address Apl # cily (Count,y) State ZIP Code

MomruYear Momrvrear Street Address Apt.# Clly (Count,y) 1 olale ZIP Coco 114 To Name or Person 'IA� Knew You Street Address Apl.f cily (Count,y) State ZIP<.;000

MOnWYear Montnrrear Street Address Apl# c11y (Count,y) Stale ZIP Code #5 To Name of Person WlO Knew You Street Address Apl. # City (Counlry) I ::itale ZIP Code

Cl)WHERE YOU WENT TO SCHOOL

.List the schools you have altended, beyond Junior High School, beginning with tho most recent (#1) and working back 5 years. List all College or Unfversity degrees and the dales they were received. If all of your edueallon occurred more lhan 5 years ago, Hsi your most recent educaUon beyond h!gh schoof, no matter when that educaUon occurred .

• Use one of the followlng codes in the •cocte" block:

1 • High School 2 . College/Unlverslly1M;1;1ary College 3. VocallonaVfechnlcaVTradeSchool

• For correspondence schools and extension ciasses, provide the address where the re<:erds are maintained.

treet

#3

Mon ear Month/Vear

To

Code Name o School

Street Address and City (Counlty) of s oo

Degree/Dip m Other

Degree/Dlploma/Olher

State

Sla\a

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

4 of8 ear :war .ed

IPC e t onth/Year Awarded

ZlPC e

Monl ear Awarded

ZIP Code

RFP HSFLGL-l7-R-00001

FLETC, Glynco Georgia Attachment 13

CD YOUR EMPLOYMENT ACTIVITIES

Lisi your employment acUv!Ues, beginning wUh lhe present {#t) and working back 5 years. You should 11st aU full-time work, part-Ume work, mi!Hary service, temporary rnllllary duty locaUons over 80 days, self-employment, other paid work, and an perlods of unemployment The entire 5-year period musl be accovnted tor without breaks, but you need not list employmenls before your 16th birthday.

• Code. Use one of the codes llsted bek)w to Identify lhe type ol employment 1 • Active m!Utary duty stations 5 - State Government (Non-Federal 2 - National Guard/Reseive employrnenl) 3 - U.S.P.H.S. COmmlM1loned COf'Ps 6 • Self-employment (Include business name 4- Other Federal employment and/or name of person who can vertfy)

7 • Unemployment (Include name or 9 • Other person who can verify)

a. Federal Cooltaclor (Usl Contractor, nol Federal agency)

_ ______!_EmployerNerlller Name.-llsl Iha business name or your employer 0< the name of-the-person who can verlfy your-self-employment or unemployment In this block.-U- -- -military service Is being fisted, Include your duty location or home port here as well as your branch of service. You should provide separate llsUngs to reflect changes In your military duty klcal.'ons or homa ports.

• Previous Periods of Aollvlty. Complete these llnes If you WOfked for an employer on more than one occasion at lhe same locaUon. After entering the most recent period of employment In the lnlUal numbered block, provide previous periods of employment at the same locaUon on the addltlonat lines provided. For example, If you worked et XY Plumblng In Denver, CO, during 3 separale periods of Uma, you would enter dates and lnformaUon concerning the most recent period or employment nrst, and provide dales, position tllles, and supervisors for the two previous periods of employment on the Unes below that lnformaUon.

MonUvrear Monuu ear

I Code EmproyerNerifler Name/Military Duty local/On Your Posmon T\Ue/Mllitary Rank

#1 To Present Employer'sNeriner's Street Address Clly(Counl,y) Stale ZIP Code Telephone Number

Street Address of Job Location �f different than Employer's Address) Clly(C-Ount,y) Slale ZIP Code Telephone Number

Supervisor's Name & SlreelAddress �f dirferenl than Job location) Cily (Counliy) State ZIP Code Telephone Number

Month/Year Month/Year PoslllonTiUe Supervisor

PR�VIOUS To PERIODS Month/Year Monlh/Year PoslUon TIUe Supervisor

OF

ACTIVITY To (Block #1) MonthNear Month/Year PoslUon TiUe Supervisor

To Month/Year MonUVYear

I Code Empk)yerNeriner Name1Milll.ary Duty LocaUon rour Position TIUe/Milltary RanK

#2 To Employer'sNerlner's Slteet Address Clly(C-Ount,y) Slale ZIP Code Telephone Number

Street Address of Job Location �f different than Employer's Address) Clly(C-Ountry) State ZIP Code Telephone Number

Supervisor's Name & Slreel Address �f dlfferenl than Job Location) Clly(Counl,y) State ZIP Code Telephone Number

Month/Year MonlhNear Position Title Supervisor

PREVIOUS To PERIODS Month/Year

OF

Month/Year Position Tille Supervisor

ACTIVITY To (B/ock#2} Month/Year Month/Year Position T1Ue Supervisor

To Monuv· ear r.,onuvrear

I Coae EmptoyerNenfler Name/M!1taiy Duly LocaUon Your Poslhon TiUe/Mifitary Rank

#3 To Employer'sNeriner's Slteel Address Clly (Count,y) State ZIP Code Telephone Number

Street Address of Job Local Ion (if different than Employer's Address) Clly(C-Ounl,y) State ZIP Code Telephone Number

Supervisor's Name & Street Address �r different than Job LocaUon) Clly(Counl,y) Slate ZIP Code Telephone Number

MonlhNear MonlhNear PoslUon TIUe Supervisor

PREVIOUS To PERIODS Month/Year MonlhNear PosllionTIUe Supervisor

OF

ACTIVITY To /8/oclr#J) Month/Year MonthNear PoslUonliUe Supervisor

To

Enter your Social Security Num_ber before going to the next page------------�

Page3

5 of8 r I

FLETC, Glynco Georgia

YOUR EMPLOYMENT ACTIVITIES (CONTINUED)

Month/Year Month!Year

I Code Emp1oyer1venfier Name/Military Duty Locatlon

114 To Employer'sNer!ner's Street Address Clly(Country)

Street Address or Job Location Of different lhan Employer's Address) City (Country)

Supervisor's Name & Street Address Qr different than Job Locallon) Cily (Country)

- MonthNear Month/Year -Position Tille PREVIOUS To PERIODS Month/Year Month/Year Poslllon TIiie

OF

ACTIVITY To (B/oc/(#4) M-OnlhNear Month/Year Position TIUe

To MonlhNear Month/Year I Code EmployerNerifier Name/Mll!tary Duty Local!on

115 To Employer'sNerlrler's Street Address Clly (Counliy)

Slreet Address of Job Location {Ir dlfferenl lhan Employer's Address) Clly (Counliy)

Supervlsots Name & Street Address Qt different than Job location) Clly(Coontry)

MonlhNear Monlh/Year PoslllonTIUe

PREVIOUS To PERIODS MonlhNear Month/Year Pos!Uon TIUe

OF

ACTIVITY To (Block#5) Month/Year Month/Year PositJonTlUe

To MonlhNear Month/Year I Code EmployerNeriner Name/Military Duty location

#6 To Employer'sNerifler's Street Address Clly (Counliy)

Street Address of Job Location Qt different than Employer's Address} Clly (Coonliy)

Supervisor's Name & Street Address Qt different than Job Location) Clly (Country)

MonlhNear MonlhNear PoslUon Title PREVIOUS To PERIODS Month/Year Month/Year Pos1Uon TIUe

OF

ACTIVITY To (Block #6) Month/Year Month/Year Posltlon Tille

To

Attachment 13

Your Position TIUe/MJlitary Rank

State ZIP Code Telephone Number

Stale ZIP Code Telephone Number

State ZIP Code Telephone Number

·Supervisor-· --

Supervisor

Supervisor

Your Position TIUe/MIJltary Rank

St,le ZIP Code Telephone Number

State ZIP Code Telephone Number

State ZIP Code Telephone Number

Supervisor

Supervisor

Supervisor

Your Position Title/MIiitary Rank

Stale ZIP Code Telephone Number

State ZIP Code TeJaphone Number

State ZIP Code Telephone Number

Supervisor

Supervisor

Supervisor

• rl���,�� ���eKY��i:�:';e�I and live In lhe United States. They should be good friends, peers, colleagues, college roommates, etc., Whose combined association w!lh you covers as well as posslble the last 6 years. Do not Ost your spouse, fonner spouses, or other relatives, and try not to list anyone who Is listed elsewhere on this form.

ame Dates Known Tele hone Number #1

Month/Year Month/Year To �:hi (

Home oc r Address Slate ZIP Code

Name #2 )·

Home or 'Nork Address State ZIP Code

Name 1/3

Home or Vlork Address Stale ZIP Code

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

FLETC, Glynco Georgia Attachment 13

0 YOUR SELECTIVE SERVICE RECORD Yes No

0 Are you a male born after December 31, 1959? u·No,• go to 13. If "Yes,- go to b.

4l) Have you registered with lhe Selective Servk.e System? If "Yest provide your registration number. If "No,• show Iha reason for your legal exemptlon below.

Reglsttatlon Number Legal ExempUon Explanation

C9 YOUR MILITARY HISTORY Yes No

0 Have you served In lhe Unlted Stales mmtary?

4l) Have you served tn the Unltecf S1at89-MercfianfMarfne?

List all of your military service below, Including service In Reserve, National Guard, and U.S. Merchant Marine. Start with the mosl recent period of service (#1) and work backward. If you had a break In service, each separate period should be Usted.

Code. Use one of the codes llsted bekwJ lo k:lentlfy your branch of service:

1 - >Jr Force 2 • Arrrr/ 3 • Navy 4 -Marine Corps 5 • Coast Guard 6 -Merchant Marine 7 • National Guard

0/E. Mark "O" Mock for orncer or ·E" block for Enlisted.

Status. •x• the appropnale block for the status of your seiVlce during the time thal you served. If your service was In Iha NaUonal Guard, do not use an ·x·; use the l\vo-letter oode for the state to mark the block.

Country. If yoor servlce was wlU1 other than the U.S. Armed Forces, Identify the counlry for which you served.

Month/Year MonthNear Code Servfce/Certlricate # 0

To To

CD ILLEGAL DRUGS

E Status

Active I Active I Inactive I "13;:J' Reserve Reserve (Stale}

I I

In the last year, have you used, possessed, supplled, or manufactured Illegal drugs? Wlen used \Yithout a prescriptfon, Illegal drugs Include marijuana, cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), sllmulanls (cocaine, amphelamJnes, elc.), depressants (barbiturates, meU1aqua!one, tranquilizers, etc.), haUuclnogenlcs (LSD, PCP, etc.). {NOTE: Neither your truthful response nor lnformatfon derived from your response viii be used as evk:lence agalllst you In any subsequent crlmlnal proceeding.)

If you answered "Yes,- provide lnformaUon relating to the types or subslance(s), the nature or the activity, and any olher delans relating to your Involvement with ll!egal drugs, Include any treatment or counsel!ng received.

MonlhNear Month/Year Type of Substance ExptanaUon To To To

Continuation Space

Counlry

Yes No

Use the conUnuallon sheet{s) (SF8SA) f0< additional answers to Items 8, 9, end 10. Use the space below to conUnue answers to an other Items and any 1nr0<mallon you would Ilka to add. U more space Is needed than Is provided belo\v, use a blank sheet(s) of paper. Start each sheet with your name and Socia! Security number. Before each answer, Identify the number or the Item.

After complet!ng this form you shouki review your answers to alt questions to make sure the form Is comptete end accurate, and then sign and date the roHO'>.'lng certiflcallon and sign end 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 failh. I undersland thal a knowing and willful false statement on this form can be punished by fine or Imprisonment or both. (See section 1001 of tille 18, United States Code).

s gnature (Sign In Ink) Date

Enter your Social Security Number before going to the next page

7 of8

FLETC, Glynco Georgia

Standard Form 85 Revised December 2013 U.S. Office of Personnel Management 5 CFR Parts 731 and 736

Form Approved 0MB No. 3206-0261

QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS

-�-�-� --···- · ··� ---�- -·- UNITED STATES OFAMERI...CA.. - -- -- -- ---·-

AUTHORIZATION FOR RELEASE OF INFORMATION

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

Attachment 13

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my background investigation or reinvestigation to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other sources of information to include publically available electronic information. This infonuation may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinaty, employment histoty, and criminal histo1y record infomrntion.

I understand that, for some sow·ces of information, a separate specific release will be needed, and I may be contacted for such a release at a later date.

I Authorize the Social Security Adminish·ntion (SSA) to verify my Social Security Number (to match my name, Social Security Number, and date of birth with information in SSA records and provide the results of the match) to the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my investigation for the pwposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy.

I Autbol'ize custodians ofrecords and other sources of information pe1taining 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 contrmy.

I Understaml that the information released by records custodians and sources of infomiation is for official use by the Federal Government only for the purposes provided in this Standard Fonn 85, and that it may be disclosed by the Government only as authorized by law.

Photocopies of this authorization with my signature are valid. This authorization is valid for two (2) years from the date signed.

Signature (Sign in ink) I Full name (Type or print legibly) Date signed (mmlddlyyyy)

Olher names used Social Security Number

Current street address Apt.# I City (Country) I State I ZIP Code Home telephone number

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