Standard Form 85P Form approved

Revised September 1995 OMB No. 3206-0191

U.S. Office of Personnel Management NSN 7540-01-317-7372
85-1602
5 CFR Parts 731, 732, and 736

Questionnaire for Public Trust Positions

Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 7 and the release on
Page 8. If you have any questions, call the office that gave you the form.

Purpose of this Form

The U.S. Government conducts background investigations and These include documentation of any legal name change, Social Security
reinvestigations to establish that applicants or incumbents either card, and/or birth certificate.
employed by the Government or working for the Government under
contract, are suitable for the job and/or eligible for a public trust or You may also be asked to bring documents about information you
sensitive position. Information from this form is used primarily as the provided on the form or other matters requiring specific attention.
basis for this investigation. Complete this form only after a conditional These matters include alien registration, delinquent loans or taxes,
offer of employment has been made. bankruptcy, judgments, liens, or other financial obligations, agreements
involving child custody or support, alimony or property settlements,
arrests, convictions, probation, and/or parole.
Giving us the information we ask for is voluntary. However, we may
not be able to complete your investigation, or complete it in a timely Instructions for Completing this Form
manner, if you don’t give us each item of information we request. This
may affect your placement or employment prospects. 1. Follow the instructions given to you by the person who gave you the
form and any other clarifying instructions furnished by that person to
assist you in completion of the form. Find out how many copies of the
Authority to Request this Information form you are to turn in. You must sign and date, in black ink, the
original and each copy you submit.
The U.S. Government is authorized to ask for this information under
Executive Orders 10450 and 10577, sections 3301 and 3302 of title 5, U. 2. Type or legibly print your answers in black ink (if your form is not
S. Code; and parts 5, 731, 732, and 736 of Title 5, Code of Federal legible, it will not be accepted). You may also be asked to submit your
Regulations. form in an approved electronic format.

Your Social Security number is needed to keep records accurate, because 3. All questions on this form must be answered. If no response is
other people may have the same name and birth date. Executive Order necessary or applicable, indicate this on the form (for example, enter
9397 also asks Federal agencies to use this number to help identify "None" or "N/A"). If you find that you cannot report an exact date,
individuals in agency records. approximate or estimate the date to the best of your ability and indicate
this by marking "APPROX." or "EST."
The Investigative Process
4. Any changes that you make to this form after you sign it must be
initialed and dated by you. Under certain limited circumstances,
Background investigations are conducted using your responses on this agencies may modify the form consistent with your intent.
form and on your Declaration for Federal Employment (OF 306) to
develop information to show whether you are reliable, trustworthy, of
good conduct and character, and loyal to the United States. The 5. You must use the State codes (abbreviations) listed on the back of
information that you provide on this form is confirmed during the this page when you fill out this form. Do not abbreviate the names of
investigation. Your current employer must be contacted as part of the cities or foreign countries.
investigation, even if you have previously indicated on applications or
other forms that you do not want this.
6. The 5-digit postal ZIP codes are needed to speed the processing of
your investigation. The office that provided the form will assist you in
In addition to the questions on this form, inquiry also is made about a completing the ZIP codes.
person’s adherence to security requirements, honesty and integrity,
vulnerability to exploitation or coercion, falsification, mis-
representation, and any other behavior, activities, or associations that 7. All telephone numbers must include area codes.
tend to show the person is not reliable, trustworthy, or loyal.

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

Your Personal Interview Month/Year format. Use numbers (1-12) to indicate months. For
example, June 10, 1978, should be shown as 6/10/78.
Some investigations will include an interview with you as a normal part
of the investigative process. This provides you the opportunity to 9. Whenever "City (Country)" is shown in an address block, also
update, clarify, and explain information on your form more completely, provide in that block the name of the country when the address is
which often helps to complete your investigation faster. It is important outside the United States.
that the interview be conducted as soon as possible after you are
contacted. Postponements will delay the processing of your
investigation, and declining to be interviewed may result in your 10. If you need additional space to list your residences or
investigation being delayed or canceled. employments/self-employments/unemployments or education, you
should use a continuation sheet, SF 86A. If additional space is needed
You will be asked to bring identification with your picture on it, such as to answer other items, use a blank piece of paper. Each blank piece of
a valid State driver’s license, to the interview. There are other paper you use must contain your name and Social Security Number
documents you may be asked to bring to verify your identity as well. at the top of the page.
Final Determination on Your Eligibility Your prospects of placement are better if you answer all questions
truthfully and completely. You will have adequate opportunity to
Final determination on your eligibility for a public trust or sensitive explain any information you give us on the form and to make your
position and your being granted a security clearance is the comments part of the record.
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 any information Disclosure of Information
before a final decision is made.
The information you give us is for the purpose of investigating you for
Penalties for Inaccurate or False Statements
a
The U.S. Criminal Code (title 18, section 1001) provides that knowingly position; we will protect it from unauthorized disclosure. The
falsifying or concealing a material fact is a felony which may result in collection, maintenance, and disclosure of background investigative
fines of up to $10,000, and/or 5 years imprisonment, or both. In information is governed by the Privacy Act. The agency which
addition, Federal agencies generally fire, do not grant a security requested the investigation and the agency which conducted the
clearance, or disqualify individuals who have materially and investigation have published notices in the Federal Register
deliberately falsified these forms, and this remains a part of the describing
permanent record for future placements. Because the position for the system of records in which your records will be maintained. You
which you are being considered is one of public trust or is sensitive, may obtain copies of the relevant notices from the person who gave
your trustworthiness is a very important consideration in deciding you
your suitability for placement or retention in the position. this form. The information on this form, and information we collect
during an investigation may be disclosed without your consent as
permitted by the Privacy Act (5 USC 552a(b)) and as follows:
PRIVACY ACT ROUTINE USES

1. To the Department of Justice when: (a) the agency or any component thereof; or (b) any 5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this system
employee of the agency in his or her official capacity; or (c) any employee of the agency in of records contains information relevant to the retention of an employee, or the retention of a
his or her individual capacity where the Department of Justice has agreed to represent the security clearance, contract, license, grant, or other benefit. The other agency or licensing
employee; or (d) the United States Government, is a party to litigation or has interest in such organization may then make a request supported by written consent of the individual for the
litigation, and by careful review, the agency determines that the records are both relevant and entire record if it so chooses. No disclosure will be made unless the information has been
necessary to the litigation and the use of such records by the Department of Justice is determined to be sufficiently reliable to support a referral to another office within the agency
therefore deemed by the agency to be for a purpose that is compatible with the purpose for or to another Federal agency for criminal, civil, administrative, personnel, or regulatory
which the agency collected the records. action.
2. To a court or adjudicative body in a proceeding when: (a) the agency or any component 6. To contractors, grantees, experts, consultants, or volunteers when necessary to perform a
thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee function or service related to this record for which they have been engaged. Such recipients
of the agency in his or her individual capacity where the Department of Justice has agreed to shall be required to comply with the Privacy Act of 1974, as amended.
represent the employee; or (d) the United States Government is a party to litigation or has
interest in such litigation, and by careful review, the agency determines that the records are 7. To the news media or the general public, factual information the disclosure of which
both relevant and necessary to the litigation and the use of such records is therefore deemed would be in the public interest and which would not constitute an unwarranted invasion of
by the agency to be for a purpose that is compatible with the purpose for which the agency personal privacy.
collected the records. 8. To a Federal, State, or local agency, or other appropriate entities or individuals, or through
3. Except as noted in Question 21, when a record on its face, or in conjunction with other established liaison channels to selected foreign governments, in order to enable an
records, indicates a violation or potential violation of law, whether civil, criminal, or intelligence agency to carry out its responsibilities under the National Security Act of 1947 as
regulatory in nature, and whether arising by general statute, particular program statute, amended, the CIA Act of 1949 as amended, Executive Order 12333 or any successor order,
regulation, rule, or order issued pursuant thereto, the relevant records may be disclosed to the applicable national security directives, or classified implementing procedures approved by the
appropriate Federal, foreign, State, local, tribal, or other public authority responsible for Attorney General and promulgated pursuant to such statutes, orders or directives.
enforcing, investigating or prosecuting such violation or charged with enforcing or
9. To a Member of Congress or to a Congressional staff member in response to an inquiry of
implementing the statute, rule, regulation, or order.
the Congressional office made at the written request of the constituent about whom the record
4. To any source or potential source from which information is requested in the course of an is maintained.
investigation concerning the hiring or retention of an employee or other personnel action, or
10. To the National Archives and Records Administration for records management
the issuing or retention of a security clearance, contract, grant, license, or other benefit, to the
inspections conducted under 44 USC 2904 and 2906.
extent necessary to identify the individual, inform the source of the nature and purpose of the
investigation, and to identify the type of information requested. 11. To the Office of Management and Budget when necessary to the review of private relief
legislation.

STATE CODES (ABBREVIATIONS)

Alabama AL Hawaii HI Massachusetts MA New Mexico NM South Dakota SD

Alaska AK Idaho ID Michigan MI 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
Connecticut CT Kentucky KY Nebraska NE Oregon OR Washington WA
Delaware DE Louisiana LA Nevada NV Pennsylvania PA West Virginia WV
Florida FL Maine ME New Hampshire NH Rhode Island RI Wisconsin WI
Georgia GA Maryland MD New Jersey NJ South Carolina SC Wyoming WY

American Samoa AS District of Columbia DC Guam GU Northern Marianas CM Puerto Rico PR

Trust Territory TT Virgin Islands VI

PUBLIC BURDEN INFORMATION

Public burden reporting for this collection of information is estimated to average 60 minutes per response, including time for reviewing instructions, 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.
Standard Form 85P (EG) Form approved:
Revised September 1995 QUESTIONNAIRE FOR OMB No. 3206-0191
U.S. Office of Personnel Management PUBLIC TRUST POSITIONS NSN 7540-01-317-7372
5 CFR Parts 731, 732, and 736 85-1602
OPM Codes Case Number
USE
ONLY
Agency Use Only (Complete items A through P using instructions provided by USOPM)
A Type of B Extra C Sensitivity/ D Compu/ E Nature of F Date of Month Day Year
Investigation Coverage Risk Level ADP Action Code Action

G Geographic H Position I Position

Location Code Title

J K Location of None Other Address ZIP Code

SON Official
Personel NPRC
Folder At SON
L M Location of None Other Address ZIP Code
SOI Security
Folder At SOI
NPI
N OPAC-ALC O Accounting Data and/or
Number Agency Case Number

P Requesting Name and Title Signature Telephone Number Date

Official
( )
Persons completing this form should begin with the questions below.
1 FULL If you have only initials in your name, use them and state (IO). - If you are a "Jr.," "Sr.," "II," etc., enter this in the 2 DATE OF
NAME If you have no middle name, enter "NMN". box after your middle name. BIRTH

Last Name First Name Middle Name Jr., II, etc. Month Day Year

3 PLACE OF BIRTH - Use the two letter code for the State. 4 SOCIAL SECURITY NUMBER
City County State Country (if not in the United States)

5 OTHER NAMES USED

Name Month/Year Month/Year Name Month/Year Month/Year

#1 To #3 To
Name Month/Year Month/Year Name Month/Year Month/Year
#2 To #4 To

6 OTHER Height (feet and inches) Weight (pounds) Hair Color Eye Color Sex (Mark one box)
IDENTIFYING
INFORMATION Female Male
Work (include Area Code and extension) Home (include Area Code)
7 TELEPHONE
Day Day
NUMBER ( )
Night Night ( )

8 CITIZENSHIP I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. Answer b Your Mother’s Maiden Name
items b and d.
a Mark the box at the right that
I am a U.S. citizen, but I was NOT born in the U.S. Answer items b, c and d.
reflects your curren citzenship
status, and follow its instructions. I am not a U.S. citizen. Answer items b and e.
c UNITED STATES CITIZENSHIP If you are a U.S. Citizen, but were not born in the U.S., provide information about one or more of the following proofs of your citizenship.
Naturalization Certificate (Where were you naturalized?)
County City State Certificate Number Month/Day/Year Issued

Citizenship Certificate (Where was the certificate issued?)

City State Certificate Number Month/Day/Year Issued

State Department Form 240 - Report of Birth Abroad of a Citizen of the United States
Give the date the form was Month/Day/Year Explanation
prepared and give an explanation
if needed.
U.S. Passport
Passport Number Month/Day/Year Issued
This may be either a current or previous U.S. Passport

d DUAL CITIZENSHIP If you are (or were) a dual citizen of the United States and another country, Country
provide the name of that country in the space to the right.

e ALIEN If you are an alien, provide the following information:

City State Date You Entered U.S. Alien Registration Number Country(ies) of Citizenship
Place you Month Day Year
entered the
United States

Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995.
Designed using Perform Pro, WHS/DIOR, Sep 95
Page 1
9 WHERE YOU HAVE LIVED

List the places where you have lived, beginning with the most recent (#1) and working back 7 years. All periods must be accounted for in your list. Be sure to indicate
the actual physical location of your residence: do not use a post office box as an address, do not list a permanent 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 5 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 5-year period, and do not list your spouse, former spouses, or other relatives). Also for addresses in the last 5 years, if the address is "General Delivery," a
Rural or Star Route, or may be difficult to locate, provide directions for locating the residence on an attached continuation sheet.

Month/Year Month/Year Street Address Apt. # City (Country) State ZIP Code
#1 To Present
Name of Person Who Knows You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Street Address Apt. # City (Country) State ZIP Code
#2 To
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Street Address Apt. # City (Country) State ZIP Code
#3 To
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Street Address Apt. # City (Country) State ZIP Code
#4 To
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Street Address Apt. # City (Country) State ZIP Code
#5 To
Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )

10 WHERE YOU WENT TO SCHOOL

List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 7 years. List all College or University
degrees and the dates they were received. If all of your education occurred more than 7 years ago, list your most recent education beyond high school, no matter when
that education occurred.

Use one of the following codes in the "Code" block:

1 - High School 2 - College/University/Military College 3. Vocational/Technical/Trade School

For schools you attended in the past 3 years, list a person who knew you at school (an instructor, student, etc.). Do not list people for education
completely outside this 3-year period.

For correspondence schools and extension classes, provide the address where the records are maintained.
Month/Year Month/Year Code Name of School Degree/Diploma/Other Month/Year Awarded
#1 To
Street Address and City (Country) of School State ZIP Code

Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Code Name of School Degree/Diploma/Other Month/Year Awarded
#2 To
Street Address and City (Country) of School State ZIP Code

Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Code Name of School Degree/Diploma/Other Month/Year Awarded
#3 To
Street Address and City (Country) of School State ZIP Code

Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code Telephone Number
( )

Enter your Social Security Number before going to the next page

Page 2
11 YOUR EMPLOYMENT ACTIVITIES

List your employment activities, beginning with the present (#1) and working back 7 years. You should list all full-time work, part-time work, military service, temporary
military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment. The entire 7-year period must be accounted for without breaks,
but you need not list employments before your 16th birthday.

Code. Use one of the codes listed below to identify the type of employment:
1 - Active military duty stations 5 - State Government (Non-Federal 7 - Unemployment (Include name of 9 - Other
2 - National Guard/Reserve employment person who can verify)
3- U.S.P.H.S. Commissioned Corps 6 - Self-employment (Include business 8 - Federal Contractor (List Contractor,
4- Other Federal employment and/or name of person who can verify) not Federal agency)

Employer/Verifier Name. List the business name of your employer or the name of the person who can verify your self-employment or unemployment in this block. If
military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to reflect changes in
your military duty locations or home ports.

Previous Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same location. After entering the most recent
period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For example, if you
worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent period of employment first,
and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information.
Month/Year Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
#1 To Present
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Position Title Supervisor

PREVIOUS To
PERIODS Month/Year Month/Year Position Title Supervisor
OF
ACTIVITY To
(Block #1) Month/Year Month/Year Position Title Supervisor
To
Month/Year Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
#2 To
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Position Title Supervisor

PREVIOUS To
PERIODS Month/Year Month/Year Position Title Supervisor
OF
ACTIVITY To
(Block #2) Month/Year Month/Year Position Title Supervisor
To
Month/Year Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
#3 To
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Position Title Supervisor

PREVIOUS To
PERIODS Month/Year Month/Year Position Title Supervisor
OF
ACTIVITY To
(Block #3) Month/Year Month/Year Position Title Supervisor
To

Enter your Social Security Number before going to the next page

Page 3
YOUR EMPLOYMENT ACTIVITIES (CONTINUED)
Month/Year Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
#4 To
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Position Title Supervisor

PREVIOUS To
PERIODS Month/Year Month/Year Position Title Supervisor
OF
ACTIVITY To
(Block #4) Month/Year Month/Year Position Title Supervisor
To
Month/Year Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
#5 To
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Position Title Supervisor

PREVIOUS To
PERIODS Month/Year Month/Year Position Title Supervisor
OF
ACTIVITY To
(Block #5) Month/Year Month/Year Position Title Supervisor
To
Month/Year Month/Year Code Employer/Verifier Name/Military Duty Location Your Position Title/Military Rank
#6 To
Employer’s/Verifier’s Street Address City (Country) State ZIP Code Telephone Number
( )
Street Address of Job Location (if different than Employer’s Address) City (Country) State ZIP Code Telephone Number
( )
Supervisor’s Name & Street Address (if different than Job Location) City (Country) State ZIP Code Telephone Number
( )
Month/Year Month/Year Position Title Supervisor

PREVIOUS To
PERIODS Month/Year Month/Year Position Title Supervisor
OF
ACTIVITY To
(Block #6) Month/Year Month/Year Position Title Supervisor
To

12 YOUR EMPLOYMENT RECORD Yes No

Has any of the following happened to you in the last 7 years? If "Yes," begin with the most recent occurrence and go backward, providing date
fired, quit, or left, and other information requested.

Use the following codes and explain the reason your employment was ended:
1 - Fired from a job. 3 - Left a job by mutual agreement following allegations of misconduct. 5 - Left a job for other reasons
under unfavorable circumstances.
2 - Quit a job after being told 4 - Left a job by mutual agreement following allegations of
you'd be fired. unsatisfactory performance.

Month/Year Code Specify Reason Employer’s Name and Address (Include city/Country if outside U.S.) State ZIP Code

Enter your Social Security Number before going to the next page

Page 4
13 PEOPLE WHO KNOW YOU WELL
List three people who know you well and live in the United States. They should be good friends, peers, colleagues, college roommates, etc., whose combined
association with you covers as well as possible the last 7 years. Do not list your spouse, former spouses, or other relatives, and try not to list anyone who is
listed elsewhere on this form.
Name Dates Known Telephone Number
Month/Year Month/Year Day
#1 ( )
To Night
Home or Work Address City (Country) State ZIP Code

Name Dates Known Telephone Number

Month/Year Month/Year Day
#2 ( )
To Night
Home or Work Address City (Country) State ZIP Code

Name Dates Known Telephone Number

Month/Year Month/Year Day
#3 Night ( )
To
Home or Work Address City (Country) State ZIP Code

14 YOUR MARITAL STATUS

Mark one of the following boxes to show your current marital status:
1 - Never married (go to question 15) 3 - Separated 5 - Divorced
2 - Married 4 - Legally Separated 6 - Widowed
Current Spouse Complete the following about your current spouse.
Full Name Date of Birth (Mo./Day/Yr.) Place of Birth (Include country if outside the U.S.) Social Security Number

Other Names Used (Specify maiden name, names by other marriages, etc., and show dates used for each name)

Country of Citizenship Date Married (Mo./Day/Yr.) Place Married (Include country if outside the U.S.) State

If Separated, Date of Separation (Mo./Day/Yr.) If Legally Separated, Where is the Record Located? City (Country) State

Address of Current Spouse (Street, city, and country if outside the U.S.) State ZIP Code

15 YOUR RELATIVES
Give the full name, correct code, and other requested information for each of your relatives, living or dead, specified below.
1 - Mother (first) 3 - Stepmother 5 - Foster Parent 7 - Stepchild
2 - Father (second) 4 - Stepfather 6 - Child (adopted also)

Full Name (If deceased, check box on the Date of Birth Country(ies) of Current Street Address and City (country) of
Code Country of Birth State
left before entering name) Month/Day/Year Citizenship Living Relatives

Enter your Social Security Number before going to the next page

Page 5
16 YOUR MILITARY HISTORY Yes No
a Have you served in the United States military?
b Have you served in the United States Merchant Marine?
List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of service (#1) and work
backward. If you had a break in service, each separate period should be listed.
Code. Use one of the codes listed below to identify your branch of service:
1 - Air Force 2 - Army 3 - Navy 4 - Marine Corps 5 - Coast Guard 6 - Merchant Marine 7 - National Guard

O/E. Mark "O" block for Officer or "E" block for Enlisted.
Status. "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use
an "X": use the two-letter code for the state to mark the block.

Country. If your service was with other than the U.S. Armed Forces, identify the country for which you served.
Month/Year Month/Year Code Service/Certificate No. O E Status
Active Inactive National Country
Active Guard
Reserve Reserve Status
To

To

17 YOUR SELECTIVE SERVICE RECORD Yes No

a Are you a male born after December 31, 1959? If "No," go to 18. If "Yes," go to b.

b Have you registered with the Selective Service System? If "Yes," provide your registration number. If "No," show the reason for your legal
exemption below.
Registration Number Legal Exemption Explanation

18 YOUR INVESTIGATIONS RECORD Yes No

a Has the United States Government ever investigated your background and/or granted you a security clearance? If "Yes," use the codes that
follow to provide the requested information below. If "Yes," but you can't recall the investigating agency and/or the security clearance
received, enter "Other" agency code or clearance code, as appropriate, and "Don't know" or "Don't recall" under the "Other Agency"
heading below. If your response is "No," or you don't know or can't recall if you were investigated and cleared, check the "No" box.
Codes for Investigating Agency Codes for Security Clearance Received
1 - Defense Department 4 - FBI 0 - Not Required 3 - Top Secret 6-L
2 - State Department 5 - Treasury Department 1 - Confidential 4 - Sensitive Compartmented Information 7 - Other
3 - Office of Personnel Management 6 - Other (Specify) 2 - Secret 5-Q
Month/Year Agency Other Agency Clearance Month/Year Agency Other Agency Clearance
Code Code Code Code

b To your knowledge, have you ever had a clearance or access authorization denied, suspended, or revoked, or have you ever been debarred Yes No
from government employment? If "Yes," give date of action and agency. Note: An administrative downgrade or termination of a security
clearance is not a revocation.
Month/Year Department or Agency Taking Action Month/Year Department or Agency Taking Action

19 FOREIGN COUNTRIES YOU HAVE VISITED

List foreign countries you have visited, except on travel under official Government orders, beginning with the most current (#1) and working
back 7 years. (Travel as a dependent or contractor must be listed.)

Use one of these codes to indicate the purpose of your visit: 1 - Business 2 - Pleasure 3 - Education 4 - Other

Include short trips to Canada or Mexico. If you have lived near a border and have made short (one day or less) trips to the neighboring country, you do
not need to list each trip. Instead, provide the time period, the code, the country, and a note ("Many Short Trips").

Do not repeat travel covered in items 9, 10, or 11.

Month/Year Month/Year Code Country Month/Year Month/Year Code Country

#1 To #5 To

#2 To #6 To

#3 To #7 To

#4 To #8 To

Enter your Social Security Number before going to the next page
Page 6
 20 YOUR POLICE RECORD (Do not include anything that happened before your 16th birthday.) Yes No

In the last 7 years, have you been arrested for, charged with, or convicted of any offense(s)? (Leave out traffic fines of less than $150.)
If you answered "Yes," explain your answer(s) in the space provided.

Month/Year Offense Action Taken Law Enforcement Authority or Court (City and county/country if outside the U.S.) State ZIP Code

21 ILLEGAL DRUGS
The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your Yes No
failure to do so could be grounds for an adverse employment decision or action against you, but neither your truthful responses nor information
derived from your responses will be used as evidence against you in any subsequent criminal proceeding.
a In the last year, have you illegally used any controlled substance, for example, marijuana, cocaine, crack cocaine, hashish, narcotics (opium,
morphine, codeine, heroin, etc.), amphetamines, depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.),
or prescription drugs?

b In the last 7 years, have you been involved in the illegal purchase, manufacture, trafficking, production, transfer, shipping, receiving, or sale of
any narcotic, depressant, stimulant, hallucinogen, or cannabis, for your own intended profit or that of another?

If you answered "Yes" to "a" above, provide information relating to the types of substance(s), the nature of the activity, and any other details
relating to your involvement with illegal drugs. Include any treatment or counseling received.
Month/Year Month/Year Controlled Substance/Prescription Drug Used Number of Times Used

To

To

To
22 YOUR FINANCIAL RECORD Yes No

a In the last 7 years, have you, or a company over which you exercised some control, filed for bankruptcy, been declared bankrupt, been subject to a
tax lien, or had legal judgment rendered against you for a debt? If you answered "Yes," provide date of initial action and other information
requested below.

Month/Year Type of Action Name Action Occurred Under Name/Address of Court or Agency Handling Case State ZIP Code

b Are you now over 180 days delinquent on any loan or financial obligation? Include loans or obligations funded or guaranteed by the Federal Yes No
Government.

If you answered "Yes," provide the information requested below:

Month/Year Type of Loan or Obligation and Name/Address of Creditor or Obligee State ZIP Code
Account No.

After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the
following certification and sign and date the release on Page 8.

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 faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or
both. (See section 1001 of title 18, United States Code).
Signature (Sign in ink) Date

Enter your Social Security Number before going to the next page

Page 7
Standard Form 85P Form approved:
Revised September 1995 OMB No. 3206-0191
U.S. Office of Personnel Management NSN 7540-01-317-7372
85-1602
5 CFR Parts 731, 732, and 736

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF INFORMATION

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

I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my
background investigation, 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. This information may include, but is not limited to, my academic, residential,
achievement, performance, attendance, disciplinary, employment history, criminal history record information, and financial and
credit information. I authorize the Federal agency conducting my investigation to disclose the record of my background
investigation to the requesting agency for the purpose of making a determination of suitability or eligibility for a security clearance.

I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of
information, a separate specific release will be needed, and I may be contacted for such a release at a later date. Where a separate
release is requested for information relating to mental health treatment or counseling, the release will contain a list of the specific
questions, relevant to the job description, which the doctor or therapist will be asked.

I Further Authorize any investigator, special agent, or other duly accredited representative of the U.S. Office of Personnel
Management, the Federal Bureau of Investigation, the Department of Defense, the Defense Investigative Service, and any other
authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of
determining my eligibility for assignment to, or retention in a sensitive National Security position, in accordance with 5 U.S.C. 9101.
I understand that I may request a copy of such records as may be available to me under the law.

I Authorize custodians of records and other 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 only for the purposes provided in this Standard Form 85P, and that it 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 or upon the termination of my affiliation with the Federal Government, whichever is sooner.

Signature (Sign in ink) Full Name (Type or Print Legibly) Date Signed

Other Names Used Social Security Number

Current Address (Street, City) State ZIP Code Home Telephone Number
(Include Area Code)

( )
Page 8
Standard Form 85P Form approved:
Revised September 1995 OMB No. 3206-0191
U.S. Office of Personnel Management NSN 7540-01-317-7372
5 CFR Parts 731, 732, and 736 85-1602

UNITED STATES OF AMERICA

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

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

Instructions for Completing this Release

This is a release for the investigator to ask your health practitioner(s) the three questions below concerning your mental health
consultations. Your signature will allow the practitioner(s) to answer only these questions.

I am seeking assignment to or retention in a position of public trust with the Federal Government as
a(n)

(Investigator instructed to write in position

title.)

As part of the investigative process, I hereby authorize the investigator, special agent, or duly accredited representative of the
authorized Federal agency conducting my background investigation, to obtain the following information relating to my mental health
consultations:

Does the person under investigation have a condition or treatment that could impair his/her judgment or
reliability?

If so, please describe the nature of the condition and the extent and duration of the impairment or
treatment.

What is the prognosis?

I understand that the information released pursuant to this release is for use by the Federal Government only for purposes
provided in
the Standard Form 85P and that it 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 1
year from the date signed or upon termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink) Full Name (Type or Print Legibly) Date Signed

Other Names Used Social Security Number

Current Address (Street, City) State ZIP Code Home Telephone Number
(Include Area Code)

( )