SF85 - Fillable-1.pdf

Q U E S TI O N N AI R E F O R

N O N- S E N SI TI V E P O SI TI O N S

F or m a p pr o v e d:

0 M B N o. 3 2 0 6- 0 2 6 1

E G e o gr a p hi c

L o c ati o n

I O P A C- A L C

N u m b er

K R e q u e sti n g N a m e a n d Titl e

Offi ci al

F P o siti o n

Titl e

A c c o u nti n g D at a a n d/ or

A g e n c y C a s e N u m b er

Si g n at ur e

0 F U L L

N A M E

• If y o u h a v e o nl y i niti al s i n y o ur n a m e, u s e t h e m a n d st at e (1 0).

• If y o u h a v e n o mi d dl e n a m e, e nt er " N M N".

L a st N a m e Fir st N a m e

P L A C E O F BI R T H - U s e t h e t w o l ett er c o d e f or t h e St at e.

Cit y C o u nt y

C o d e s C a s e N u m b er

G S O N

T el e p h o n e N u m b er

- If y o u ar e a " Jr.," " Sr.," "II," et c., e nt er t hi s i n t h e b o x aft er y o ur mi d dl e n a m e.

H

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8 D A T E O F

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Mi d dl e N a m e Jr., II, et c. M o nt h D a y

S O CI A L S E C U RI T Y

St at e C o u ntr y

O O T H E R N A M E S U S E D Gi v e ot h er n a m e s y o u u s e d a n d t h e p eri o d of ti m e y o u u s e d t h e m

If t h e ot h er n a m e i s y o ur m ai d e n n a m e, p ut " n e e" i n fr o nt of it.

Y e ar

N a m e M o nt h/ Y e ar M o nt h/ Y e ar N a m e M o nt h/ Y e ar M o nt h/ Y e ar

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N a m e

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Q cl TI Z E N S HI P

M ar k t h e b o x at t h e ri g ht t h at r efl e ct s y o ur c urr e nt citi z e n s hi p st at u s, a n d f oll o w it s i n str u cti o n s.

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M o nt h/ Y e ar M o nt h/ Y e ar

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N a m e

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F e m al e n M al e n

I a m a U. S. citi z e n or n ati o n al b y birt h i n t h e U. S. or U. S. t errit or y/ p o s s e s si o n.

I a m a U. S. citi z e n, b ut I w a s N O T b or n i n t h e U. S.

I a m n ot a U. S. citi z e n.

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M o nt h/ Y e ar M o nt h/ Y e ar

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Y o ur M ot h er' s M ai d e n N a m e

U NI T E D S T A T E S CI TI Z E N S HI P If y o u ar e a U. S. citi z e n, b ut w er e n ot b or n i n t h e U. S., pr o vi d e i nf or m ati o n a b o ut o n e or m or e of t h e f oll o wi n g pr o of s of y o ur citi z e n s hi p.

N at ur ali z ati o n C ertifi c at e

C o urt Cit y

Citi z e n s hi p C ertifi c at e

Cit y

St at e D e p art m e nt F or m 2 4 0 - R e p ort of Birt h A br o a d of a Citi z e n of t h e U nit e d St at e s

Gi v e t h e d at e t h e f or m w a s M o nt h/ D a y/ Y e ar E x pl a n ati o n pr e p ar e d a n d gi v e a n e x pl a n ati o n if n e e d e d

U. S. P a s s p ort

St at e C ertifi c at e N u m b er

St at e C ertifi c at e N u m b er

P a s s p ort N u m b er T hi s m a y b e eit h er a c urr e nt or pr e vi o u s U. S. P a s s p ort.

(D D U A L CI TI Z E N S HI P If y o u ar e ( or w er e) a d u al citi z e n of t h e U nit e d St at e s a n d a n ot h er c o u ntr y, pr o vi d e t h e n a m e of t h at c o u ntr y i n t h e s p a c e t o t h e ri g ht.

G) A LI E N If y o u ar e a n ali e n, pr o vi d e t h e f oll o wi n g i nf or m ati o n:

C o u ntr y

Cit y St at e D at e Y o u E nt er e d U. S.

Pl a c e Y o u E nt er e d t h e U nit e d St at e s:

M o nt h D a y Y e ar

E x c e pti o n t o S F 8 5, S F 8 5 P, S F 8 5 P- S, S F 8 6, a n d S F 8 6 A a p pr o v e d b y G S A S e pt e m b er, 1 9 9 5.

D e si g n e d u si n g P erf or m Pr o, W H S/ DI O R, S e p 9 5

Ali e n R e gi str ati o n N u m b er

M o nt h/ D a y/ Y e ar I s s u e d

M o nt h/ D a y/ Y e ar I s s u e d

M o nt h/ D a y/ Y e ar I s s u e d

C o u ntr y(i e s) of Citi z e n s hi p

P a g e 1

C O M P A N Y N A M E _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ scervantes Polygon scervantes Polygon scervantes Polygon scervantes Polygon scervantes Polygon scervantes Polygon scervantes Polygon scervantes Typewritten Text scervantes Polygon

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HERE YOU HAVE LIVED

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List the places where you have lived, beginning with the most recent (#1) and workin� All periods must be accounted for in your l ist. Be sure to indicate the actual physical location of your residence: do not use a post office box as an address:�rmanent 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).

Montrvrear Montrvrear Street Aooress Apt.# city (Country) state ZIP code

To Present

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

Monhu ,ear Mont,u,ear :;tree! "uuress Apt.# City (Country) State ZIP Code

To Street Address

To Apt.# City (Country) State ZIP Code

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

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

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

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

To

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

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

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

1 · High School 3 - VocationaVTechnicaVTradeSchool

- For correspondence schools and exlension clas rovide the address where the records are maintained.

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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

Month/Year #3

Name of School

Name of School Degree/Diploma/Other

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 Month/Year scervantes Polygon scervantes Polygon scervantes Line scervantes Line scervantes Oval

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• Y O U R S E L E C TI V E S E R VI C E R E C O R D Y e s N o

Ar e y o u a m al e b or n aft er D e c e m b er 3 1, 1 9 5 9 ? If " N o," g o t o 1 3. If " Y e s," g o t o b.

H a v e y o u r e gi st er e d wit h t h e S el e cti v e S er vi c e S y st e m ? If " Y e s," pr o vi d e y o ur r e gi str ati o n n u m b er. If " N o," s h o w t h e r e a s o n f or y o ur l e g al e x e m pti o n b el o w.

R e g1 str at1 o n N u m b er L e g al E x e m pti o n E x pl a n ati o n

. Y O U R MI LI T A R Y HI S T O R Y Y e s N o

H a v e y o u s er v e d i n t h e U nit e d St at e s milit ar y ?

H a v e y o u s er v e d i n t h e U nit e d St at e s M er c h a nt M ari n e ?

Li st all of y o ur milit ar y s er vi c e b el o w, i n cl u di n g s er vi c e i n R e s er v e, N ati o n al G u ar d, a n d U. S. M er c h a nt M ari n e. St art wit h t h e m o st r e c e nt p eri o d of s er vi c e { # 1) a n d w or k b a c k w ar d. If y o u h a d a br e a k i n s er vi c e, e a c h s e p ar at e p eri o d s h o ul d b e li st e d.

C o d e. U s e o n e of t h e c o d e s li st e d b el o w t o i d e ntif y y o ur br a n c h of s er vi c e:

1 - Air F or c e 2- Ar m y 3- N a v y 4 - M ari n e C or p s 5 - C o a st G u ar d

0/ E. M ar k " O" bl o c k f or Offi c er or " E" bl o c k f or E nli st e d.

6 - M er c h a nt M ari n e 7 - N ati o n al G u ar d

St at u s. " X" t h e a p pr o pri at e bl o c k f or t h e st at u s of y o ur s er vi c e d uri n g t h e ti m e t h at y o u s er v e d. If y o ur s er vi c e w a s i n t h e N ati o n al G u ar d, d o n ot u s e a n " X"; u s e t h e t w o-l ett er c o d e f or t h e st at e t o m ar k t h e bl o c k.

C o u nt r y. If y o ur s er vi c e w a s wit h ot h er t h a n t h e U. S. Ar m e d F or c e s, i d e ntif y t h e c o u ntr y f or w hi c h y o u s er v e d.

M o nt h N e ar M o nt h N e ar C o d e S er vi c e/ C ertifi c at e # E St at u s

A cti v e I n a cti v e N ati o n al

A cti v e G u ar d R e s er v e R e s er v e

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T o

• I L L E G A L D R U G S

I n t h e l a st y e ar, h a v e y o u u s e d, p o s s e s s e d, s u p pli e d, or m a n uf a ct ur e d ill e g al dr u g s ? W h e n u s e d wit h o ut a pr e s cri pti o n, ill e g al dr u g s i n cl u d e m arij u a n a, c o c ai n e, h a s hi s h, n ar c oti c s ( o pi u m, m or p hi n e, c o d ei n e, h er oi n, et c.), sti m ul a nt s ( c o c ai n e, a m p h et a mi n e s, et c.), d e pr e s s a nt s ( b ar bit ur at e s, m et h a q u al o n e, tr a n q uili z er s, et c.), h all u ci n o g e ni c s ( L S D, P C P, et c.). ( N O T E: N eit h er y o ur tr ut hf ul r e s p o n s e n or i nf or m ati o n d eri v e d fr o m y o ur r e s p o n s e will b e u s e d a s e vi d e n c e a g ai n st y o u i n a n y s u b s e q u e nt cri mi n al pr o c e e di n g.)

If y o u a n s w er e d " Y e s," pr o vi d e i nf or m ati o n r el ati n g t o t h e t y p e s of s u b st a n c e( s), t h e n at ur e of t h e a cti vit y, a n d a n y ot h er d et ail s r el ati n g t o y o ur i n v ol v e m e nt wit h ill e g al dr u g s. I n cl u d e a n y tr e at m e nt or c o u n s eli n g r e c ei v e d.

M o nt h N e ar M o nt h N e ar T y p e of S u b st a n c e E x pl a n ati o n

T o

T o

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C o nti n u ati o n S p a c e

C o u ntr y

Y e s N o

U s e t h e c o nti n u ati o n s h e et( s) ( S F 86 A) f or a d diti o n al a n s w er s t o it e m s 8, 9, a n d 1 0. U s e t h e s p a c e b el o w t o c o nti n u e a n s w er s t o all ot h er it e m s a n d a n y i nf or m ati o n y o u w o ul d li k e t o a d d. If m or e s p a c e i s n e e d e d t h a n i s pr o vi d e d b el o w, u s e a bl a n k s h e et( s) of p a p er. St art e a c h s h e et wit h y o ur n a m e a n d S o ci al S e c urit y n u m b er. B ef or e e a c h a n s w er, i d e ntif y t h e n u m b er of t h e it e m.

Aft er c o m pl eti n g t hi s f or m y o u s h o ul d r e vi e w y o ur a n s w er s t o all q u e sti o n s t o m a k e s ur e t h e f or m i s c o m pl et e a n d a c c ur at e, a n d t h e n si g n a n d d at e t h e f oll o wi n g c ertifi c ati o n a n d si g n a n d d at e t h e r el e a s e o n P a g e 6 .

C e rtifi c ati o n T h at M y A n s w e r s A r e T r u e

M y st at e m e nt s o n t hi s f or m, a n d a n y att a c h m e nt s t o it, ar e tr u e, c o m pl et e, a n d c orr e ct t o t h e b e st of m y k n o wl e d g e a n d b eli ef a n d ar e m a d e i n g o o d f ait h. I u n d er st a n d t h at a k n o wi n g a n d willf ul f al s e st at e m e nt o n t hi s f or m c a n b e p u ni s h e d b y fi n e or i m pri s o n m e nt or b ot h. ( S e e s e cti o n 1 0 0 1 of titl e 1 8, U nit e d St at e s C o d e).

Si g n at ur e ( Si g n i n i n k) D at e

E nt e r y o u r S o ci al S e c u rit y N u m b er b ef or e g oi n g t o t h e n e xt p a g e

P a g e s scervantes Line scervantes Line scervantes Polygon scervantes Polygon scervantes Polygon

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Si g n at ur e F ull N a m e D at e Si g n e d

Ot h er N a m e s U s e d S o ci al S e c urit y N u m b er

C urr e nt A d dr e s s St at e ZI P C o d e H o m e T el e p h o n e N u m b er

P a g e 6

S (D n d a G) F o rm 8 5

R e vi s ed D e ce m ber 2 0 1 3 U, S. Offi ce of P e rs o n n el M a n a g e m e nt 5 C F R P a rts 7 3 1 a n d 7 3 6

F or m Ap pr o v e d 0 M B N o. 3 2 0 6-- 0 2 61

C o m pl et e All B o x es scervantes Typewritten Text Complete All Boxes scervantes Polygon

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