Attachment_B_-_FD-816.pdf

FD-816 (1-22-93)

ACCESS OF NON-FBI PERSONNEL TO FBI FACILITIES

BACKGROUND DATA INFORMATION FORM

(COMPLETE ALL ITEMS)

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

Residence (Include City and State) Social Security Number

Date of Birth Month/Day/Year Place of Birth Sex G Male

G Female

Company Name & Address Supervisor & Telephone Number

U. S. Citizenship: G By Birth G By Naturalization G 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 G Yes G No

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

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

Have you ever been charged with or convicted of any offense(s) related to alcohol or drugs? G Yes G 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) G Yes G 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 G Yes G 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)