Sect_J_EXHG_Iraq-Vetting-V3_9-12.pdf

Embassy of the United States of America

U.S. Embassy LES Vetting Request

Requesting Contractor HR Representative: (If applicable.)

SuffixMiddle NameFirst NameLast Name

Email AddressTelephone NumberCompany Name

Page 1 of 19DS/SI/PSS, November 2011

Agency Use Only (Subject's Information.)

SuffixMiddle Name (Father's Name)First Name (Given Name) Last Name (Grandfather's Name)

Office or Division NameOrganization Working ForPosition Title

Signed By Date

Requesting Government Agency Representative:

SuffixMiddle NameFirst NameLast Name

Full Name (Print)

Email AddressTelephone NumberAgency Name

RECERT Initial APP Escort Authorization Requested

Agency Use Only (Requestor Information.)

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name)

Passport Number

National Jensiya / SSN #

Suffix

Country of Birth

Subject should complete the following sections as applicable.

Food Ration Card #

Local Jensiya (Iraqi Identification Card) # Military Book #

Tribal Name (Ashira)

Date of Birth Single

Married

Remarried

Widowed

Divorced

Separated

Marital Status

Sex Male

Female

Telephone Number Email Address

Hair Color

Eye Color

Height

Weight

Current Address

Current Address (Continued)

Date of U.S. Naturalization (If applicable)

To be completed by Subject.

Page 2 of 19DS/SI/PSS, November 2011

ATTACH PASSPORT SIZED

PHOTOGRAPH HERE

Aliases #1 Last Name (Grandfather's Name), First Name (Given Name), Middle Name (Father's Name) - If Applicable.

Country(ies) of Citizenship

Aliases #2 Last Name (Grandfather's Name), First Name (Given Name), Middle Name (Father's Name) - If Applicable.

Describe any identifying marks/tattoos:

Additional Comments:

Page 3 of 19DS/SI/PSS, November 2011

EMERGENCY POINT OF CONTACT.

Provide the following information of a person to be contacted in the event of an emergency.

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Current Address

Tribal Name (Ashira) Email AddressTelephone Number

RESIDENCES.

Dates Street and Number City (District/Province) Country

From To

CITIZENSHIP.

Dates Country How Citizenship was Acquired

EDUCATION.

Dates Name of School Degree Obtained

Start End

Beginning with the most recent, list each country of which you have been a citizen, giving dates and the manner of acquisition.

Beginning with the most recent, list all the places you have lived going back seven (7) years.

Beginning with the most recent, list all educational institutions you have attended, including non-degree programs.

Page 4 of 19DS/SI/PSS, November 2011

EMPLOYMENT.

Start Date End Date Position Title Company Supervisor

Address: Telephone Cell/Additional Phone Email

List all employment activities, including unemployment and self-employment, beginning with the present and working back seven

(7) years. The entire period must be accounted for without breaks.

Start Date End Date Position Title Company Supervisor

Address: Telephone Cell/Additional Phone Email

Start Date End Date Position Title Company Supervisor

Address: Telephone Cell/Additional Phone Email

Start Date End Date Position Title Company Supervisor

Address: Telephone Cell/Additional Phone Email

Start Date End Date Position Title Company Supervisor

Address: Telephone Cell/Additional Phone Email

Page 5 of 19DS/SI/PSS, November 2011

REFERENCES.

Provide (5) five people who know you well. They should be friends, peers, colleagues, roommates, associates, etc., who are collectively aware of your activities outside of your workplace, school or neighborhood, and who are NOT relatives or supervisors. At LEAST three

(3) references must be Iraqi Nationals unrelated to yourself.

Page 6 of 19DS/SI/PSS, November 2011

Reference #1.

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Reference #2.

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Reference #3.

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

REFERENCES. (Continued.)

Provide (5) five people who know you well. They should be friends, peers, colleagues, roommates, associates, etc., who are collectively aware of your activities outside of your workplace, school or neighborhood, and who are NOT relatives or supervisors. At LEAST three

(3) references must be Iraqi Nationals unrelated to yourself.

Reference #4.

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Reference #5.

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Page 7 of 19DS/SI/PSS, November 2011

PERSONS RESIDING WITH YOU.

Are there any persons residing with you, other than those named in the following sections: IMMEDIATE FAMILY, OTHER RELATIVES, REFERENCES or EMERGENCY POINT OF CONTACT? If YES, provide the following details: (Please use the continuation pages provided if additional fields are required.)

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Current Address

Tribal Name (Ashira) Email AddressTelephone Number

NO YES

IMMEDIATE FAMILY.

Father.

Mother.

Please use the continuation pages provided if additional fields are required. List all children regardless of age. List occupations for anyone over the age of fifteen (15).

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Spouse.

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Page 8 of 19DS/SI/PSS, November 2011

IMMEDIATE FAMILY. (Continued.)

Former Spouse.

Page 9 of 19DS/SI/PSS, November 2011

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Please check applicable box. Child Brother Sister

Page 10 of 19DS/SI/PSS, November 2011

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Please check applicable box. Child Brother Sister

Page 11 of 19DS/SI/PSS, November 2011

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Please check applicable box. Child Brother Sister

OTHER RELATIVES. (List grandparents, uncles, aunts, nieces, nephews, cousins, and in-laws over the age of fifteen (15) including those who reside outside the same Province as the Subject.)

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Grandparent Aunt Uncle

Please check applicable box. Please use the continuation pages provided if additional fields are required.

Nephew Niece Cousin In-law

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Page 12 of 19DS/SI/PSS, November 2011

Grandparent Aunt Uncle Nephew Niece Cousin In-law

OTHER RELATIVES. (Continued.)

MILITARY SERVICE.

Dates Branch of Service Highest Rank Held Date of Discharge

Reason/Type of Discharge Country

Start

List any military/militia/organized group bearing arms service past or present, provide branch of service, dates of service and highest rank held.

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Page 13 of 19DS/SI/PSS, November 2011

Last Name (Grandfather's Name)First Name (Given Name) Middle Name (Father's Name) Suffix

Date of BirthPlace of Birth

Current Address

Occupation

Tribal Name (Ashira)

Email AddressTelephone Number

Please check applicable box. Please use the continuation pages provided if additional fields are required.

LANGUAGE.

Language

Excellent

Good

Fair

Speak

Excellent

Good

Fair

Read

Excellent

Good

Fair

Write

Excellent

Good

Fair

Understand

Language

Excellent

Good

Fair

Speak

Excellent

Good

Fair

Read

Excellent

Good

Fair

Write

Excellent

Good

Fair

Understand

Language

Excellent

Good

Fair

Speak

Excellent

Good

Fair

Read

Excellent

Good

Fair

Write

Excellent

Good

Fair

Understand

Language

Excellent

Good

Fair

Speak

Excellent

Good

Fair

Read

Excellent

Good

Fair

Write

Excellent

Good

Fair

Understand

Language

Excellent

Good

Fair

Speak

Excellent

Good

Fair

Read

Excellent

Good

Fair

Write

Excellent

Good

Fair

Understand

TRAVEL.

Dates Country Purpose

Start End

Provide any foreign travel that has occurred in the last ten (10) years for Initial Applications and two (2) years for Recertifications.

Please indicate any languages spoken and the extent of your competence, e.g., Excellent, Good, Fair.

Page 14 of 19DS/SI/PSS, November 2011

MEMBERSHIPS.

List societies, associations, clubs and other organizations of which you are now or have been a member of.

Provide full name of organization

Street City Zip Code Country

From Date (Month/Year) To Date (Month/Year) Provide all, if any, positions held in the organization.

Provide a description of the nature of and reasons for your involvement with the organization.

Provide the full name of the organization.

Street City Zip Code Country

From Date (Month/Year) To Date (Month/Year) Please provide all, if any, positions held in the organization.

Provide a description of the nature of, and reasons for your involvement with the organization.

Are ANY of these associations/organizations advocates of anti-U.S. sentiments or hostile/violent terrorist acts? If yes, list those in the space provided below:

NO

YES

Check "YES" or "NO" in the column to the left. If you answer "YES" to any of these questions, provide additional information in the space provided.

Page 15 of 19DS/SI/PSS, November 2011

QUESTIONS.

Have you EVER been arrested or detained by any police or military authority?

NO

YES

Have you EVER used, possessed, supplied, or manufactured illegal drugs?

NO

YES

NO

YES

Have you associated or sympathized with persons who are attempting to commit, or who are committing, any of the above acts?

NO

YES

Have you associated or sympathized with persons or organizations that advocate terrorist actions against the U.S.

Government, or any state or subdivision, by force or violence?

NO

YES

Have you or any member of your family ever been associated with any group that participated (or will participate) in hostile action against the U.S. or its allies?

NO

YES

Have any of your family, friends, or associates ever been employed by or offered employment by an intelligence or security service?

NO

YES

CERTIFICATION.

Signed By Date

I certify that to the best of my knowledge and belief the information given in this form is correct and complete and that I will notify the Regional Security Office of any material changes.

Applicant's Full and Complete Name Written in Native Language (Print)

I certify that I translated OR helped the applicant with questions on this form to the best of my ability.

Signed By Date

Full Name (Print)

Check "YES" or "NO" in the column to the left. If you answer "YES" to any of these questions, provide additional information in the space provided below.

Have you been involved in any act of sabotage, espionage, treason, terrorism, sedition, or other acts of violence against any person, group, or government?

Page 16 of 19DS/SI/PSS, November 2011

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 U.S. Department of State, to make appropriate inquiries into my background for the purpose of making an informed determination regarding my suitability for access to U.S. Embassy property and facilities.

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 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 five (5) years from the date signed.

DateSigned By

First (Given), Middle (Father's), Last (Grandfather's) Name (Print)

Telephone Number

Present Address

I Understand that this release is voluntary. However, if I withhold this permission to make appropriate inquiries, no security determination can be made, which would make me ineligible for U.S. Embassy access.

Cell Phone / Additional Contact Number

National Jensiya / SSN #

Page 17 of 19DS/SI/PSS, November 2011

U.S. DEPARTMENT OF STATE

DRUG CERTIFICATION

I am aware that the U.S. Department of State (DOS) does not allow the use, possession, or trafficking of illegal drugs (marijuana, narcotics, hallucinogens, and other drugs listed in the Controlled Substances Act) by individuals who hold a DOS access authorization (security certification), regardless of the type of position occupied.

Unless lawfully prescribed for my use by a licensed physician, I agree that I will not buy, sell, accept as a gift, experiment with, traffic in, use, possess or be involved with the illegal drugs cited above at any time, in any country, in any job in which I have been given a DOS security certification. Involvement includes knowingly being in the presence of others who are in the possession of these illegal drugs.

I understand that the use of marijuana, listed in Schedule I of the Controlled Substances Act, remains subject to prosecution by the Drug Enforcement Administration, even if it may be legal under the terms of a state law or proposition. Such use or involvement which continues to be in contravention of the Federal Drug-Free Workplace Act will result in the review of my eligibility for DOS security certification. (62 FR 6164, February 11, 1997)

I understand that if I break this agreement, I may lose my DOS security certification. I also understand that if I lose my DOS security certification, I may lose my job. This agreement shall be in effect at all times while I possess a DOS security certification, to include anytime my security certification has been reinstated.

Embassy of the United States of America

DateSigned By

First (Given), Middle (Father's), Last (Grandfather's) Name (Print)

Telephone Number

Present Address

Cell Phone / Additional Contact Number

National Jensiya / SSN #

Page 18 of 19DS/SI/PSS, November 2011

U.S. DEPARTMENT OF STATE

Adjudication Memorandum

In accordance with RSO policy, RSO Vetting utilizes an approved Adjudications Scoring Sheet for LES vetting. One element of that sheet includes the opportunity for mitigation (subtracting) of points for years of good service with the U.S. Government.

In order for an applicant to qualify for these points, RSO Vetting must have a signed memorandum from the sponsor/ employer. The onus to provide this memorandum lies entirely on the sponsor. Vetting will NOT follow-up or request these memorandums. The memorandum must be provided with the Vetting Application at the time of Intake.

Embassy of the United States of America

DateU.S. Citizen's Supervisor's Name (Signature)

SuffixMiddle Name (Father's Name)First Name (Given Name) Last Name (Grandfather's Name)

Office or Division NameOrganization Working ForPosition Title

U.S. Citizen's Supervisor's Name (Print)

Carefully read this memorandum and fill out the required information, then sign and date it in black ink.

U.S. Embassy LES Vetting Request Requesting Contractor HR Representative: (If applicable.)

Page of DS/SI/PSS, November 2011 Agency Use Only (Subject's Information.)

Signed By Date Requesting Government Agency Representative:

Full Name (Print) Agency Use Only (Requestor Information.)

Subject should complete the following sections as applicable.

Single Married Remarried Widowed Divorced Separated Marital Status Sex Male Female To be completed by Subject.

Page of DS/SI/PSS, November 2011

ATTACH PASSPORT SIZED PHOTOGRAPH HERE

Describe any identifying marks/tattoos:

Additional Comments:

Page of DS/SI/PSS, November 2011

EMERGENCY POINT OF CONTACT.

Provide the following information of a person to be contacted in the event of an emergency.

RESIDENCES.

Dates Street and Number City (District/Province) Country From To

CITIZENSHIP.

Dates Country How Citizenship was Acquired

EDUCATION.

Dates Name of School Degree Obtained Start End Beginning with the most recent, list each country of which you have been a citizen, giving dates and the manner of acquisition.

Beginning with the most recent, list all the places you have lived going back seven (7) years.

Beginning with the most recent, list all educational institutions you have attended, including non-degree programs.

Page of DS/SI/PSS, November 2011

EMPLOYMENT.

Start Date End Date Position Title Company Supervisor Address:

Telephone Cell/Additional Phone Email List all employment activities, including unemployment and self-employment, beginning with the present and working back seven (7) years. The entire period must be accounted for without breaks.

Start Date End Date Position Title Company Supervisor Address:

Telephone Cell/Additional Phone Email Start Date End Date Position Title Company Supervisor Address:

Telephone Cell/Additional Phone Email Start Date End Date Position Title Company Supervisor Address:

Telephone Cell/Additional Phone Email Start Date End Date Position Title Company Supervisor Address:

Telephone Cell/Additional Phone Email Page of DS/SI/PSS, November 2011

REFERENCES.

Provide (5) five people who know you well. They should be friends, peers, colleagues, roommates, associates, etc., who are collectively aware of your activities outside of your workplace, school or neighborhood, and who are NOT relatives or supervisors. At LEAST three (3) references must be Iraqi Nationals unrelated to yourself.

Page of DS/SI/PSS, November 2011 Reference #1.

Reference #2.

Reference #3.

REFERENCES. (Continued.)

Provide (5) five people who know you well. They should be friends, peers, colleagues, roommates, associates, etc., who are collectively aware of your activities outside of your workplace, school or neighborhood, and who are NOT relatives or supervisors. At LEAST three (3) references must be Iraqi Nationals unrelated to yourself.

Reference #4.

Reference #5.

Page of DS/SI/PSS, November 2011

PERSONS RESIDING WITH YOU.

Are there any persons residing with you, other than those named in the following sections: IMMEDIATE FAMILY, OTHER RELATIVES, REFERENCES or EMERGENCY POINT OF CONTACT? If YES, provide the following details: (Please use the continuation pages provided if additional fields are required.)

IMMEDIATE FAMILY.

Father.

Mother.

Please use the continuation pages provided if additional fields are required. List all children regardless of age. List occupations for anyone over the age of fifteen (15).

Spouse.

Page of DS/SI/PSS, November 2011 IMMEDIATE FAMILY. (Continued.)

Former Spouse.

Page of DS/SI/PSS, November 2011 Please check applicable box.

Please check applicable box.

IMMEDIATE FAMILY. (Continued.)

Page of DS/SI/PSS, November 2011 Please check applicable box.

Please check applicable box.

Please check applicable box.

Page of DS/SI/PSS, November 2011 IMMEDIATE FAMILY. (Continued.)

Please check applicable box.

Please check applicable box.

Please check applicable box.

OTHER RELATIVES. (List grandparents, uncles, aunts, nieces, nephews, cousins, and in-laws over the age of fifteen (15) including those who reside outside the same Province as the Subject.)

Please check applicable box. Please use the continuation pages provided if additional fields are required.

Page of DS/SI/PSS, November 2011 OTHER RELATIVES. (Continued.)

MILITARY SERVICE.

Dates Branch of Service Highest Rank Held Date of Discharge Reason/Type of Discharge Country Start List any military/militia/organized group bearing arms service past or present, provide branch of service, dates of service and highest rank held.

Page of DS/SI/PSS, November 2011 Please check applicable box. Please use the continuation pages provided if additional fields are required.

LANGUAGE.

Speak Read Write Understand Speak Read Write Understand Speak Read Write Understand Speak Read Write Understand Speak Read Write Understand

TRAVEL.

Dates Country Purpose Start End Provide any foreign travel that has occurred in the last ten (10) years for Initial Applications and two (2) years for Recertifications.

Please indicate any languages spoken and the extent of your competence, e.g., Excellent, Good, Fair.

Page of DS/SI/PSS, November 2011

MEMBERSHIPS.

List societies, associations, clubs and other organizations of which you are now or have been a member of.

Check "YES" or "NO" in the column to the left. If you answer "YES" to any of these questions, provide additional information in the space provided.

Page of DS/SI/PSS, November 2011

QUESTIONS.

CERTIFICATION.

Signed By Date I certify that to the best of my knowledge and belief the information given in this form is correct and complete and that I will notify the Regional Security Office of any material changes.

Applicant's Full and Complete Name Written in Native Language (Print) I certify that I translated OR helped the applicant with questions on this form to the best of my ability.

Signed By Date Full Name (Print) Check "YES" or "NO" in the column to the left. If you answer "YES" to any of these questions, provide additional information in the space provided below.

Page of DS/SI/PSS, November 2011

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 U.S. Department of State, to make appropriate inquiries into my background for the purpose of making an informed determination regarding my suitability for access to U.S. Embassy property and facilities.

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 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 five (5) years from the date signed.

Date Signed By I Understand that this release is voluntary. However, if I withhold this permission to make appropriate inquiries, no security determination can be made, which would make me ineligible for U.S. Embassy access.

Page of DS/SI/PSS, November 2011 Embassy of the United States of America

UNITED STATES OF AMERICA

U.S. DEPARTMENT OF STATE

DRUG CERTIFICATION

I am aware that the U.S. Department of State (DOS) does not allow the use, possession, or trafficking of illegal drugs (marijuana, narcotics, hallucinogens, and other drugs listed in the Controlled Substances Act) by individuals who hold a DOS access authorization (security certification), regardless of the type of position occupied.

Unless lawfully prescribed for my use by a licensed physician, I agree that I will not buy, sell, accept as a gift, experiment with, traffic in, use, possess or be involved with the illegal drugs cited above at any time, in any country, in any job in which I have been given a DOS security certification. Involvement includes knowingly being in the presence of others who are in the possession of these illegal drugs.

I understand that the use of marijuana, listed in Schedule I of the Controlled Substances Act, remains subject to prosecution by the Drug Enforcement Administration, even if it may be legal under the terms of a state law or proposition. Such use or involvement which continues to be in contravention of the Federal Drug-Free Workplace Act will result in the review of my eligibility for DOS security certification. (62 FR 6164, February 11, 1997) I understand that if I break this agreement, I may lose my DOS security certification. I also understand that if I lose my DOS security certification, I may lose my job. This agreement shall be in effect at all times while I possess a DOS security certification, to include anytime my security certification has been reinstated.

Embassy of the United States of America Date Signed By Page of DS/SI/PSS, November 2011

UNITED STATES OF AMERICA

U.S. DEPARTMENT OF STATE

Adjudication Memorandum In accordance with RSO policy, RSO Vetting utilizes an approved Adjudications Scoring Sheet for LES vetting. One element of that sheet includes the opportunity for mitigation (subtracting) of points for years of good service with the U.S. Government. In order for an applicant to qualify for these points, RSO Vetting must have a signed memorandum from the sponsor/employer. The onus to provide this memorandum lies entirely on the sponsor. Vetting will NOT follow-up or request these memorandums. The memorandum must be provided with the Vetting Application at the time of Intake.

Embassy of the United States of America Date U.S. Citizen's Supervisor's Name (Signature) Carefully read this memorandum and fill out the required information, then sign and date it in black ink.

8.2.1.4029.1.523496.503679