U.S. ARMY MEDICAL DEPARTMENT (AMEDD)
APPLICANT WORKSHEET (Rev. 201207)
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Tips
Ensure all sections contained this application that may apply, are completed. Annotate ‘N/A’ for sections
that do not apply.
Addresses: P.O. Box addresses are unacceptable, must be street addresses.
References: Be sure to include full name, address and phone number of references, do not use the same
reference more than once within the entire application and references cannot be family members (i.e. parent,
sibling, spouse, child, etc.).
Family and Associates: There is a special form after the rest for Spouse and Former Spouse, they need not
be double listed.
All entries need to be legible (if not typed).
Use the TAB key to move through the fields; not the ENTER key.
There are two types of date formats specified by the questions;
o dd-MMM-yyyy (e.g.- 14-JUN-75)
o yyyymmdd (e.g.- 17750614)
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Questionnaire for National Security Positions
Follow instructions completely or your form will be unable to be processed. If you have any questions, contact the
office that provided you the form.
All questions on this form must be answered completely and truthfully in order that the Government may make the
determinations described below on a complete record. Penalties for inaccurate or false statements are discussed below. If
you are a current civilian employee of the federal government: failure to answer any questions completely and truthfully
could result in an adverse personnel action against you, including loss of employment; with respect to Sections 23, 27, and
29, however, neither your truthful responses nor information derived from those responses will be used as evidence
against you in a subsequent criminal proceeding.
Purpose of this Form
This form will be used by the United States (U.S.) Government in conducting background investigations, reinvestigations,
and continuous evaluations of persons under consideration for, or retention of, national security positions as defined in 5
CFR 732, and for individuals requiring eligibility for access to classified information under Executive Order 12968. This
form may also be used by agencies in determining whether a subject performing work for, or on behalf of, the
Government under a contract should be deemed eligible for logical or physical access when the nature of the work to be
performed is sensitive and could bring about an adverse effect on the national security.
Providing this information is voluntary. If you do not provide each item of requested information, however, we will not be
able to complete your investigation, which will adversely affect your eligibility for a national security position, eligibility
for access to classified information, or logical or physical access. It is imperative that the information provided be true and
accurate, to the best of your knowledge. Any information that you provide is evaluated on the basis of its currency,
seriousness, relevance to the position and duties, and consistency with all other information about you. Withholding,
misrepresenting, or falsifying information may affect your eligibility for access to classified information, eligibility for a
sensitive position, or your ability to obtain or retain Federal or contract employment. In addition, withholding,
misrepresenting, or falsifying information may affect your eligibility for physical and logical access to federally
controlled facilities or information systems. Withholding, misrepresenting, or falsifying information may also negatively
affect your employment prospects and job status, and the potential consequences include, but are not limited to, removal,
debarment from Federal service, loss of eligibility for access to classified information, or prosecution.
This form is a permanent document that may be used as the basis for future investigations, eligibility determinations for
access to classified information, or to hold a sensitive position, suitability or fitness for Federal employment, fitness for
contract employment, or eligibility for physical and logical access to federally controlled facilities or information systems.
Your responses to this form may be compared with your responses to previous SF-86 questionnaires. The investigation
conducted on the basis of information provided on this form may be selected for studies and analyses in support of
evaluating and improving the effectiveness and efficiency of the investigative and adjudicative methodologies. All study
results released to the general public will delete personal identifiers such as name, social security number, and date and
place of birth.
Authority to Request this Information
Depending upon the purpose of your investigation, the U.S. Government is authorized to ask for this information under
Executive Orders 10450, 10865, 12333, and 12968; sections 3301, 3302, and 9101 of title 5, United States Code (U.S.C.);
sections 2165 and 2201 of title 42, U.S.C.; chapter 23 of title 50, U.S.C.; and parts 2, 5, 731, 732, and 736 of title 5, Code
of Federal Regulations (CFR).
Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not
mandatory, failure to disclose your SSN will prevent or delay the processing of your background investigation. The
authority for soliciting and verifying your SSN is Executive Order 9397.
The Investigative Process
Background investigations for national security positions are conducted to gather information to determine whether you
are reliable, trustworthy, of good conduct and character, and loyal to the U.S. The information that you provide on this
form may be confirmed during the investigation. The investigation may extend beyond the time covered by this form,
when necessary to resolve issues. Your current employer may be contacted as part of the investigation, although you may
have previously indicated on applications or other forms that you do not want your current employer to be contacted. If
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you have a security freeze on your consumer or credit report file, then we may not be able to complete your investigation,
which can adversely affect your eligibility for a national security position. To avoid such delays, you should request that
the consumer reporting agencies lift the freeze in these instances.
In addition to the questions on this form, inquiry also is made about your adherence to security requirements, honesty and
integrity, vulnerability to exploitation or coercion, falsification, misrepresentation, and any other behavior, activities, or
associations that tend to demonstrate a person is not reliable, trustworthy, or loyal. Federal agency records checks may be
conducted on your spouse, cohabitant(s), and immediate family members. After an eligibility determination has been
completed, you also may be subject to continuous evaluation, which may include periodic reinvestigations, to determine
whether retention in your position is clearly consistent with the interests of national security.
Your Personal Interview
Some investigations will include an interview with you as a routine part of the investigative process. The investigator may
ask you to explain your answers to any question on this form. This provides you the opportunity to update, clarify, and
explain information on your form more completely, which often assists in completing your investigation. It is imperative
that the interview be conducted immediately after you are contacted. Postponements will delay the processing of your
investigation, and declining to be interviewed may result in your investigation being delayed or canceled.
For the interview, you will be required to provide photo identification, such as a valid state driver's license. You may be
required to provide other documents to verify your identity, as instructed by your investigator. These documents may
include certification of any legal name change, Social Security card, passport, and/or your birth certificate. You may also
be asked to provide documents regarding information that you provide on this form, or about other matters requiring
specific attention. These matters include (a) alien registration or naturalization documentation; (b) delinquent loans or
taxes, bankruptcies, judgments, liens, or other financial obligations; (c) agreements involving child custody or support,
alimony, or property settlements; (d) arrests, convictions, probation, and/or parole; or (e) other matters described in court
records.
Instructions for Completing this Form
1. Follow the instructions provided to you by the office that gave you this form and any other clarifying instructions,
provided by that office, to assist you with completion of this form. You must sign and date, in ink, the original
and each copy you submit. You should retain a copy of the completed form for your records.
2. All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form
by checking the associated "Not Applicable" box, unless otherwise noted.
3. Do not abbreviate the names of cities or foreign countries. Whenever you are asked to supply a country name, you
may select the country name by using the country dropdown feature.
4. When entering a U.S. address or location, select the state or territory from the "States" dropdown list that will be
provided. For locations outside of the U.S. and its territories, select the country in the "Country" dropdown list
and leave the "State" field blank.
5. Do not abbreviate the names of cities or foreign countries.
6. The 5-digit postal Zip Codes are required to process your investigation more rapidly. Refer to an automated
system approved by the U.S. Postal Service to assist you with Zip Codes.
7. For telephone numbers in the U.S., ensure that the area code is included.
8. All dates provided in this form must be in Month/Day/Year or Month/Year format. Use the dropdown lists to
select the month and day. The year should be entered as a four character number (i.e., 1978 or 2001.), or selected
from a dropdown list. If you are unable to report an exact date, approximate or estimate the date to the best of
your ability, and indicate this by checking the "Est." box.
Final Determination on Your Eligibility
Final determination on your eligibility for a national security position is the responsibility of the Federal agency that
requested your investigation and the agency that conducted your investigation. You will be provided the opportunity to
explain, refute, or clarify any information before a final decision is made, if an unfavorable decision is considered. The
United States Government does not discriminate on the basis of race, color, religion, sex, national origin, disability, or
sexual orientation when granting access to classified information.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly falsifying or concealing a material fact is a
felony which may result in fines and/or up to five (5) years imprisonment. In addition, Federal agencies generally fire, do
not grant a security clearance, or disqualify individuals who have materially and deliberately falsified these forms, and
this remains a part of the permanent record for future placements. Your prospects of placement or security clearance are
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better if you answer all questions truthfully and completely. You will have adequate opportunity to explain any
information you provide on this form and to make your comments part of the record.
Disclosure Information
The information you provide is for the purpose of investigating you for a national security position, and the information
will be protected from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative
information are governed by the Privacy Act. The agency that requested the investigation and the agency that conducted
the investigation have published notices in the Federal Register describing the systems of records in which your records
will be maintained. The information you provide on this form, and information collected during an investigation, may be
disclosed without your consent by an agency maintaining the information in a system of records as permitted by the
Privacy Act [5 U.S.C. 552a(b)], and by routine uses, a list of which are published by the agency in the Federal Register.
The office that gave you this form will provide you a copy of its routine uses.
Privacy Act Routine Uses
1. To the Department of Justice when: (a) the agency or any component thereof; or (b) any employee of the agency
in his or her official capacity; or (c) any employee of the agency in his or her individual capacity where the
Department of Justice has agreed to 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 both
relevant and necessary to the litigation and the use of such records by the Department of Justice is therefore
deemed by the agency to be for a purpose that is compatible with the purpose for which the agency collected the
records.
2. To a court or adjudicative body in a proceeding when: (a) the agency or any component thereof; or (b) any
employee of the agency in his or her official capacity; or (c) any employee of the agency in his or her individual
capacity where the Department of Justice has agreed to 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 both relevant and necessary to the litigation and the use of such records is therefore deemed by
the agency to be for a purpose that is compatible with the purpose for which the agency collected the records.
3. Except as noted in Sections 23 and 27, when a record on its face, or in conjunction with other records, indicates a
violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by
general statute, particular program statute, regulation, rule, or order issued pursuant thereto, the relevant records
may be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public authority responsible for
enforcing, investigating or prosecuting such violation or charged with enforcing or implementing the statute, rule,
regulation, or order.
4. To any source or potential source from which information is requested in the course of an investigation
concerning the hiring or retention of an employee or other personnel action, or the issuing or retention of a
security clearance, contract, grant, license, or other benefit, to the 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.
5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this system of records contains
information relevant to the retention of an employee, or the retention of a security clearance, contract, license,
grant, or other benefit. The other agency or licensing organization may then make a request supported by written
consent of the individual for the entire record if it so chooses. No disclosure will be made unless the information
has been determined to be sufficiently reliable to support a referral to another office within the agency or to
another Federal agency for criminal, civil, administrative, personnel, or regulatory action.
6. To contractors, grantees, experts, consultants, or volunteers when necessary to perform a function or service
related to this record for which they have been engaged. Such recipients shall be required to comply with the
Privacy Act of 1974, as amended.
7. To the news media or the general public, factual information the disclosure of which would be in the public
interest and which would not constitute an unwarranted invasion of personal privacy.
8. To a Federal, State, or local agency, or other appropriate entities or individuals, or through established liaison
channels to selected foreign governments, in order to enable an intelligence agency to carry out its responsibilities
under the National Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order 12333 or
any successor order, applicable national security directives, or classified implementing procedures approved by
the Attorney General and promulgated pursuant to such statutes, orders or directives.
9. To a Member of Congress or to a Congressional staff member in response to an inquiry of the Congressional
office made at the written request of the constituent about whom the record is maintained.
10. To the National Archives and Records Administration for records management inspections conducted under 44
U.S.C. 2904 and 2906.
11. To the Office of Management and Budget when necessary to the review of private relief legislation.
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Public Burden Information
Public burden reporting for this collection of information is estimated to average 150 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 OPM Forms Officer, U.S. Office of
Personnel Management, 1900 E Street, N.W., Washington, DC 20415. The OMB clearance number, 3206-0005, is
currently valid. OPM may not collect this information, and you are not required to respond, unless this number is
displayed.
PERSONS COMPLETING THIS FORM SHOULD BEGIN AFTER CAREFULLY READING THE
PRECEDING INSTRUCTIONS.
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I
am subject to the penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001),
denial or revocation of a security clearance, and/or removal and debarment from Federal Service.
No
Yes
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Applicant Information
Social Security Number:
Legal Last Name:
Legal First Name:
Legal Middle Name:
Physical Information
Gender:
Height:
Weight:
Last Menstrual Cycle Date (Females only): (dd-MMM-yyyy)
Ethnicity
Primary Race:
Date and Place of Birth
Date of Birth:
Age:
City:
State:
(dd-MMM-yyyy)
Eye Color:
Suffix (Jr., Sr., III, etc.):
Hair Color:
Religion:
County:
Country:
Citizenship [Mark ‘X’ to one that applies]
Federal States Micronesia or Virgin Island NonImmigrant Foreign National
Immigrant Alien
Marshall Islands or Northern Mariana Islands
U.S. Citizen at Birth, Native Born
U.S. Citizen at Birth, Born Abroad of U.S. Parents
U.S. Naturalized
U.S. Non-citizen National-American Samoa or
Guam
Palau or U.S. Minor Outlying islands-NonImmigrant Foreign National
Home of Record address [HOR]
Street:
City:
State:
County:
Zip Code:
Country:
Phone No.HOR:
Current Address
Street:
State:
County:
Zip Code:
Country:
City:
Non Immigrant Foreign National-Other
Where do you want Mail Sent? HOR or Current address:
Contact Method
Home:
Mobile:
Business:
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Driver's License
State:
License No.:
Exp. Date: (dd-MMM-yyyy)
Marital Status (Mark ‘X’ to one that applies)
Never Married
Separated (Legally)
Marriage Annulled
Married
Divorced
Widowed
# of Minor Dependents (Custody):
Total # of Dependents:
ADDITIONAL INFORMATION
Foreign Education? Y/N:
(If Yes, ECFMG, ECFVG, Fifth Pathway or Foreign Medical Graduate):
Registered to Vote? Y/N:
Prior Military Service? Y/N:
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PHYSICAL SCREENING
Complete all questions. Additional information is required for ‘YES’ answers given, the question requiring
additional information will be specified. Refer to the end of the Physical Screening section for further information
needed for all other ‘YES’ answers provided.
1. Asthma, wheezing or inhaler use
2. Dislocated joint, including knee, hip, shoulder, elbow, ankle, or other joint
3. Epilepsy, fits, seizures, or convulsions
4. Sleepwalking
5. Recurrent neck or back pain
6. Rheumatic Fever
7. Foot pain
8. A swollen, painful, or dislocated joint or fluid in a joint (knee, shoulder, wrist, elbow, etc.)
9. Double vision
10. Periods of unconsciousness
11. Frequent or severe headaches causing loss of time from work or school or taking medication to prevent
frequent or severe headaches
12. Wear contact lenses (If so, bring your contact lens kit and solution so you can remove your contact when your
vision is tested at the MEPS; also, if you have a pair of eyeglasses, bring them with you no matter how old.)
13. Fainting spells or passing out
14. Head injury, including skull fracture, resulting in concussion, loss of consciousness, headaches, etc.
15. Back surgery
16. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any reason (inpatient or
outpatient) including counseling or treatment for school, adjustment, family, marriage or any other problem, to
include depression, or treatment for alcohol, drug or substance abuse
17. Skin disease: Eczema
18. Skin disease: Psoriasis
19. Skin disease: Atopic Dermatitis
20. Irregular heartbeat, including abnormally rapid or slow heart rates
21. Allergic to bee, wasp, or other insects stings (itching/swelling all over and/or get short of breath)
22. Heart murmur, valve problem or mitral valve prolapsed
23. Allergic to wool
24. Heart surgery
25. Been rejected for military service (temporary or permanent) for medical or other reasons
26. Any other heart problems
27. High blood pressure
28. Discharged from military service for medical reasons
29. Ulcer (stomach, duodenum, or other part of intestine)
30. Received disability compensation for an injury or other medical condition
31. Hepatitis (liver infection or inflammation)
32. Intestinal obstruction (locked bowels), or any other chronic or recurrent intestinal problem, including small
intestine or colon problems, such as Crohn's disease or Colitis
33. Detached retina or surgery for a detached retina
34. Surgery to remove a portion of the intestine (other than the appendix)
35. Any other eye conditions, injury or surgery
36. Gall bladder trouble or gall stones
37. Jaundice
38. Missing a kidney
39. Allergy to common food (milk, bread, eggs, meat, fish, or other common food)
40. (Females only) Abnormal PAP smear or gynecological problem
41. (Males only) Missing a testicle, testicular implant, or undescended testicle
42. Broken bone requiring surgery to repair (with or without pins, plates, screws, or other metal fixation devices
used in repair)
43. Ruptured or bulging disk in your back or surgery for a ruptured or bulging disk
44. Thyroid condition or take medication for your thyroid
45. Limitation of motion of any joint, including knee, shoulder, wrist, elbow, hip, or other joint
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Y/N
46. Drug or alcohol rehab
47. Kidney, urinary tract or bladder problems, surgery, stones, or other urinary tract problems
48. Sugar, protein, or blood in urine
49. Surgery on a bone or joint (knee, shoulder, elbow, wrist, etc.) including Arthroscopy with normal findings
50. Taking any medications
51. Pain or swelling at the site of an old fracture
52. Perforated ear drum or tubes in ear drum(s)
53. Anemia
54. Ear surgery, to include mastiodectomy or repair of perforated ear drum, hearing loss or need/use a hearing aid
55. Night blindness
56. Arthritis
57. Absence or disturbance of the sense of smell
58. Absence or removal of spleen, or rupture or tear of the spleen without removal
59. Anorexia or other eating disorder
60. Cracked bone or fracture(s)
61. Bursitis
62. Braces (If you wear or are planning on obtaining braces for your teeth, have the orthodontist submit a letter
stating that braces will be removed before active duty date)
63. Loss of finger, toe, or part thereof
64. Loss of the ability to fully flex (bend) or fully extend a finger, toe, or other joint
65. Shoulder, knee, or elbow problem (out of place)
66. Locking of the knee or other joint
67. Giving way of knee or other joint
68. Cataracts or surgery for cataracts
69. Eye surgery, including radical keratotomy, lens implant or other eye surgery to improve your vision
70.
Collapsed lung or other lung condition
71. Bed wetting since age 12
72. Evaluation, treatment, or hospitalization for alcohol abuse, dependence, or addiction
73. Do you use any tobacco products
Type (Cigarette, Cigar, Smokeless Tobacco):
Date last used (dd-MMM-yyyy):
74. Evaluation, treatment, or hospitalization for substance use, abuse, addiction or dependence (including illegal
drugs, prescription medications, or other substances)
75. Taken medication, drugs, or any substance to improve attention, behavior, or physical performance
76. Any illness, surgery, or hospitalization not listed above
77. Do you have a current insurance provider
Name:
Policy No.:
Street address, City, State, Zip Code, Country:
78. Have you had a previous insurance provider
Name:
Policy No.:
Street address, City, State, Zip Code, Country:
79. Do you have a primary care physician provider
Name:
Street address, City, State, Zip Code, Country:
Country Code:
Telephone No.:(
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80. Have you had a previous primary care physician
Extension:
Name:
Street address, City, State, Zip Code, Country:
Country Code:
Telephone No.:(
)
Extension:
81. Painful or 'trick' joints or loss of movement in any joint
82. Do you have any tattoos or body piercings
List:
83. Any deformities of, or missing fingers or toes
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Additional Medical Info
Include question number and explain all ‘YES’ answers that apply to include the following information: From-To
Date(s) in (dd-MMM-yyyy) format, Age, Doctor’s Last name, Explanation, and Treatment Facility Information (Name,
Street address, City, State, Zip Code).
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PERSONAL SCREENING QUESTIONNAIRE
Complete all questions. If additional information is required for ‘YES’ answers given, the question requiring
additional information will be specified. Refer to the end of the Personal Screening Questionnaire section for
additional space if needed.
1. Have you ever been divorced?
2. Are you legally separated?
3. Are you married?
4. Have you ever been married?
5. Do you presently reside with a cohabitant?
6. Have you used any other names?
7. Have you fathered/mothered any children?
How many?
8. Is anyone dependent upon you for financial support?
How many?
9. Do you have custody of any minor children?
How many?
10. Are you now or have you ever been negligent in providing alimony or support for children?
11. Have you served in any branch of Armed Services to include the National Guard?
12. Been rejected for military service (temporary or permanent) for medical or other reasons
Date (dd-MMM-yyyy):
Explanation:
13. Do you have an immediate relative (father, mother, brother or sister) who: is now a prisoner of war or is
missing in action (MIA); or died or became 100% permanently disabled while serving in the Armed Services?
Explanation:
Are you the only living child in your immediate family?
14. Have you ever been rejected for enlistment, reenlistment, or induction by any branch of the Armed Forces of
the United States?
Explanation:
15. Have you ever been required to appear before a medical or state regulating authority, regardless of the result,
concerning your health status as an impaired, hindered, or otherwise restricted practitioner?
Doctor’s Last Name:
Street address, City, State, Zip Code, Country:
Country Code:
Telephone No.: (
)
Explanation:
-
Extension:
16. Have you ever had a license to practice health care profession denied in any state?
17. Have you ever had a license to prescribe narcotics voluntarily or involuntarily refused, revoked, suspended,
or denied or have you ever voluntarily surrendered a license to prescribe narcotics?
Explanation:
18. Have you ever had professional privileges denied, withdrawn, or restricted by any health care facility?
19. Have you ever been asked to resign from a facility or organization staff or professional society?
20. Have you ever been denied membership or renewal or been subject to disciplinary procedures in any health
care organization?
21. Do you currently have Malpractice Insurance?
22. Have you ever had Malpractice Insurance (other than current Malpractice Insurance)?
23. Are you currently a defendant in a Malpractice Claim?
24. Have you ever been a defendant in a Malpractice Claim (other than current Malpractice Claim)?
Include question number and continue explanations below for all ‘YES’ answers that may apply:
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Y/N
MORAL SCREENING QUESTIONNAIRE
Report information regardless of whether the record in your case has been sealed, expunged, or otherwise
stricken from the court record, or the charge was dismissed. You need not report convictions under the Federal
Controlled Substances Act for which the court issued an expungement order under the authority of 21 U.S.C.
844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad. List all
involvement with any agency if you have ever been arrested, charged, cited, held, or detained in any way by any
law enforcement agency (to include juvenile authorities, Police Officers, Sheriff, Department of Natural
Resources, Fish and Game Wardens, Military Police, etc.) regardless of the disposition (whether the case
resulted in no charges filed, fine, probation, dismissal, or other disposition). This includes traffic tickets. Do not
list charges more than once.
We note, with reference to this section, that neither your truthful responses nor information derived from your
responses to this section will be used as evidence against you in a subsequent criminal proceeding. As to this
particular section, this applies whether or not you are currently employed by the Federal government. The
following questions pertain to the illegal use of drugs or controlled substances or drug or controlled substance
activity.
This Question is related to your Security Clearance.
1. Have any of the following happened? (If "Yes", you will be asked to provide details for each offense that
pertains to the actions that are identified below.)

In the past seven (7) years have you been issued a summons, citation, or ticket to appear in court in
a criminal proceeding against you? (Do not check if all the citations involved traffic infractions
where the fine was less than $300 and did not include alcohol or drugs)
 In the past seven (7) years have you been arrested by any police officer, sheriff, marshal or any
other type of law enforcement official?
 In the past seven (7) years have you been charged, convicted, or sentenced of a crime in any court?
(Include all qualifying charges, convictions or sentences in any Federal, state, local, military, or nonU.S. court, even if previously listed on this form).
 In the past seven (7) years have you been or are you currently on probation or parole?
 Are you currently on trial or awaiting a trial on criminal charges?
Felony Offense? Y/N:
Date of Offense (dd-MMM-yyyy):
Offense Action:
Action Taken:
Amount Fine: $
Name of Parties Involved:
Explanation:
Court Information (Name, Street address, City, State, County, Zip Code, Country):
Law Enforcement Authority (Name, City, State, County, Zip Code, Country):
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Y/N
This Question is related to your Security Clearance.
2. Other than those offenses already listed, have you EVER had the following happen to you?
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Have you EVER been convicted in any court of the United States of a crime, sentenced to imprisonment
for a term exceeding 1 year for that crime, and incarcerated as a result of that sentence for not less than 1
year? (Include all qualifying convictions in Federal, state, local, or military court, even if previously
listed on this form.)
Have you EVER been charged with any felony offense? (Include those under the Uniform Code of
Military Justice and nonmilitary/civilian felony offenses.)
Have you EVER been convicted of an offense involving domestic violence or a crime of violence (such
as battery or assault) against your child, dependent, cohabitant, spouse, former spouse, or someone with
whom you share a child in common?
Have you EVER been charged with an offense involving firearms or explosives?
Have you EVER been charged with an offense involving alcohol or drugs?
Felony Offense? Y/N:
Date of Offense ( dd-MMM-yyyy ):
Offense Action:
Action Taken:
Amount Fine: $
Name of Parties Involved:
Explanation:
Court Information (Name, Street address, City, State, County, Zip Code, Country):
Law Enforcement Authority (Name, City, State, County, Zip Code, Country):
This Question is related to your Enlistment Eligibility.
3. Other than those offenses already listed, have any of the following happened? (If ""Yes"", you will be asked
to provide details for each offense that pertains to the actions that are identified below.)
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Have you EVER been issued a summons, citation, or ticket to appear in court in a proceeding
against you? (Include all traffic infractions regardless of the fine amount.)
Have you EVER been arrested by any police officer, sheriff, marshal or any other type of law
enforcement official?
Have you EVER been charged, convicted, or sentenced of a crime in any court? (Include all
qualifying charges, convictions or sentences in any Federal, state, local, military, or non-U.S. court,
even if previously listed on this form.)
Have you EVER been or are you currently on probation or parole?
Felony Offense? Y/N:
Date of Offense (dd-MMM-yyyy):
Offense Action:
Action Taken:
Amount Fine: $
Name of Parties Involved:
Explanation:
Court Information (Name, Street address, City, State, County, Zip Code, Country):
Law Enforcement Authority (Name, City, State, County, Zip Code, Country):
4. Is there currently a domestic violence protective order or restraining order issued against you?
12
5. In the last seven (7) years, have you consulted with a health care professional regarding an emotional or
mental health condition or were you hospitalized for such a condition?
Answer 'No' if the counseling was for any of the following reasons and was not court ordered: 1) strictly marital,
family, grief not related to violence by you; or strictly related to adjustments from service in a military combat
environment.
From-To Dates (dd-MMM-yyyy):
Doctor’s Last Name:
Age:
Explanation:
Treatment Facility Information (Name, Street address, City, State, Country, Zip Code):
6. In the last ten (10) years, have you been a party to any public record civil court action not listed elsewhere on
this form?
7. Has your use of alcoholic beverages (such as liquor, beer, wine) resulted in any alcohol-related treatment or
counseling (such as for alcohol abuse or alcoholism)?
8. In the last seven (7) years has your use of alcohol had a negative impact on your work performance, your
professional or personal relationships, your finances, or resulted in intervention by law enforcement/public
safety personnel?
9. Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your use of
alcohol?
10. Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol?
11. Have you EVER received counseling or treatment as a result of your use of alcohol in addition to what you
have already listed on this form?
12. In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of a drug or
controlled substance includes injecting, snorting, inhaling, swallowing, experimenting with or otherwise
consuming any drug or controlled substance.
13. In the last seven (7) years,have you been involved in the illegal purchase, manufacture, cultivation,
trafficking, production, transfer, shipping, receiving, handling or sale of any drug or controlled substance?
14. Have you EVER illegally used or otherwise been involved with a drug or controlled substance while
possessing a security clearance other than previously listed?
15. Have you EVER illegally used or otherwise been involved with a drug or controlled substance while
employed as a law enforcement officer, prosecutor, or courtroom official; or while in a position directly and
immediately affecting the public safety other than previously listed?
16. In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs, regardless of
whether or not the drugs were prescribed for you or someone else?
17. Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of your illegal
use of drugs or controlled substances?
18. Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or controlled
substance?
13
Include question number and continue explanations below for all ‘YES’ answers that may apply:
14
TECHNOLOGY INFORMATION QUESTIONNAIRE
Complete all questions. Additional information is required for ‘YES’ answers given. Refer to the end of
the Technology Information Questionnaire section for additional information.
Y/N
1. In the last seven (7) years have you illegally or without proper authorization accessed or attempted to
access any information technology system?
2. In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or
denied others access to information residing on an information technology system or attempted any of the
above?
3. In the last seven (7) years have you introduced, removed, or used hardware, software, or media in connection
with any information technology system without authorization, when specifically prohibited by rules,
procedures, guidelines, or regulations or attempted any of the above?
Include question number and explain all ‘YES’ answers that apply to include the following information:
Date(s) (dd-MMM-yyyy) of Incident, Street address, City, State, County, Zip Code, Country, Nature of Incident and Action
Taken.
15
GROUP/MEMBER ASSOCIATIONS QUESTIONNAIRE
Complete all questions. Additional information is required for ‘YES’ answers given. Refer to the end of
the Group/Member Associations Questionnaire section for additional information.
1. Have you ever been an officer or a member of, or made a contribution to, an organization dedicated to the
use of violence or force to overthrow the U.S. Government, and which engaged in illegal activities to that
end, either with an awareness of the organization's dedication to that end or with the specific intent to further
such illegal activities?
2. In the last seven (7) years have you illegally or without authorization, modified, destroyed, manipulated, or
denied others access to information residing on an information technology system or attempted any of the
above?
3. In the last seven (7) years have you introduced, removed, or used hardware, software, or media in connection
with any information technology system without authorization, when specifically prohibited by rules,
procedures, guidelines, or regulations or attempted any of the above?
Include question number and explain all ‘YES’ answers that apply to include the following information:
From-To Date(s) (dd-MMM-yyyy), Organization Name and Group/Member Association Information (Street
address, City, State, County, Zip Code, Country).
16
Y/N
CONTACT INFORMATION AND METHOD
List the contact information below along with the best method to contact you. Permanent phone number, current
phone number and an email are required (Permanent and current phone number can be the same).
Country
Best time to contact (Day,
Type
Code
Telephone No.
Ext.
Night or Both)
Permanent
(
)
Home/Current
(
)
Business
(
)
Mobile/Cell
(
)
DSN
(
)
Pager
(
)
Temporary
(
)
EMAIL
Home Email:
School Email:
Work Email:
Which is your primary email? (Home, School or Work)
17
ALIAS
Provide other names used and the time period used (i.e., your maiden name, name(s) by a former marriage,
nickname(s), etc.
Name Type
Other #1 Last
Suffix
(Maiden, Former Marriage,
Name
Other #1 First Name
Other #1 Middle Name
(Jr., II, etc.)
Nickname, Alias, etc.)
From (dd-MMM-yyyy):
Reason(s) why the name changed:
Name Type
Other #2 Last
(Maiden, Former Marriage,
Name
Nickname, Alias, etc.)
From (dd-MMM-yyyy):
Reason(s) why the name changed:
Name Type
Other #3 Last
(Maiden, Former Marriage,
Name
Nickname, Alias, etc.)
From (dd-MMM-yyyy):
Reason(s) why the name changed:
To (dd-MMM-yyyy):
Other #2 First Name
Other #2 Middle Name
Suffix
(Jr., II, etc.)
To (dd-MMM-yyyy):
Other #3 First Name
Other #3 Middle Name
To (dd-MMM-yyyy):
18
Suffix
(Jr., II, etc.)
RESIDENCES
List the places where you lived beginning with your current address (#1) (include temporary school addresses) and
working back 7 years from NOW with NO GAPs in dates (NO P.O. boxes). For all addresses in the last 7 years, list a
reference who knew you at that time period (do not list spouse, former spouses, or other relatives and use each
“person who knew you” only ONCE in the entire application.
Time at Residence:
Reference Information:
From Date ( dd-MMM-yyyy ):
Last Name:
To Date ( dd-MMM-yyyy ):
First Name:
Middle Name:
Suffix:
Residence Information: (Mark ‘X’ to one that applies)
Date of last contact:
Status:
Relationship: (Mark ‘X’ to one that applies)
Military Housing
Business Associate
Owned by you
Friend
Rented or leased by you
Landlord
Other
Explanation:
Neighbor
Other
Explanation:
Address Type: Current
Reference Address:
Street:
Street:
City:
City:
State:
State:
County:
Zip Code:
Zip Code:
Country:
Country:
Reference Daytime Phone Number:
[‘X’ here if unknown
]
Set as Mailing Address? Y/N:
Country Code:
Set as Permanent Address? Y/N:
Telephone No.: (
)
Extension:
Reference Evening Phone Number:
[‘X’ here if unknown
]
Country Code:
Telephone No.: (
)
Reference Cell/Mobile Phone Number:
[‘X’ here if unknown
]
Country Code:
Telephone No.: (
)
Reference Email Address:
[‘X’ here if unknown
]
Email address:
19
RESIDENCES
List the places where you lived beginning with your current address (#1) (include temporary school addresses) and
working back 7 years from NOW with NO GAPs in dates (NO P.O. boxes). For all addresses in the last 7 years, list a
reference who knew you at that time period (do not list spouse, former spouses, or other relatives and use each
“person who knew you” only ONCE in the entire application.
Time at Residence:
Reference Information:
From Date ( dd-MMM-yyyy ):
Last Name:
To Date ( dd-MMM-yyyy ):
First Name:
Middle Name:
Suffix:
Residence Information: (Mark ‘X’ to one that applies)
Date of last contact:
Status:
Relationship: (Mark ‘X’ to one that applies)
Military Housing
Business Associate
Owned by you
Friend
Rented or leased by you
Landlord
Other
Explanation:
Neighbor
Other
Explanation:
Address Type: Previous
Reference Address:
Street:
Street:
City:
City:
State:
State:
County:
Zip Code:
Zip Code:
Country:
Country:
Reference Daytime Phone Number:
[‘X’ here if unknown
]
Set as Mailing Address? Y/N:
Country Code:
Set as Permanent Address? Y/N:
Telephone No.: (
)
Extension:
Reference Evening Phone Number:
[‘X’ here if unknown
]
Country Code:
Telephone No.: (
)
Reference Cell/Mobile Phone Number:
[‘X’ here if unknown
]
Country Code:
Telephone No.: (
)
Reference Email Address:
[‘X’ here if unknown
]
Email address:
20
RESIDENCES
List the places where you lived beginning with your current address (#1) (include temporary school addresses) and
working back 7 years from NOW with NO GAPs in dates (NO P.O. boxes). For all addresses in the last 7 years, list a
reference who knew you at that time period (do not list spouse, former spouses, or other relatives and use each
“person who knew you” only ONCE in the entire application.
Time at Residence:
Reference Information:
From Date ( dd-MMM-yyyy ):
Last Name:
To Date ( dd-MMM-yyyy ):
First Name:
Middle Name:
Suffix:
Residence Information: (Mark ‘X’ to one that applies)
Date of last contact:
Status:
Relationship: (Mark ‘X’ to one that applies)
Military Housing
Business Associate
Owned by you
Friend
Rented or leased by you
Landlord
Other
Explanation:
Neighbor
Other
Explanation:
Address Type: Current
Reference Address:
Street:
Street:
City:
City:
State:
State:
County:
Zip Code:
Zip Code:
Country:
Country:
Reference Daytime Phone Number:
[‘X’ if unknown
]
Set as Mailing Address? Y/N:
Country Code:
Set as Permanent Address? Y/N:
Telephone No.: (
)
Extension:
Reference Evening Phone Number:
[‘X’ here if unknown
]
Country Code:
Telephone No.: (
)
Reference Cell/Mobile Phone Number:
[‘X’ here if unknown
]
Country Code:
Telephone No.: (
)
Reference Email Address:
[‘X’ here if unknown
]
Email address:
PERMANENT ADDRESS
Complete below if you need to add a Permanent Address for a location that is not a former or current address.
Street:
City:
State:
County:
Zip Code:
Country:
Start Date: (DDMMMYYYY):
**More residences need to be added? Continue on blank sheet providing the above information
21
Primary Foreign Language:
Proficiency: [Mark ‘X’ to those that apply]
Read
Speak
Understand
Write
FOREIGN LANGUAGES
Secondary Foreign Language:
Proficiency: [Mark ‘X’ to those that apply]
Read
Speak
Understand
Write
22
EMPLOYMENT SCREENING/MILITARY SERVICE HISTORY
Complete all questions. If additional information is required for ‘YES’ answers given, additional
information will be specified. Refer to the end of the Employment Screening section for additional space if
needed.
1. For this employment, in the last seven (7) years have you received a written warning, been officially
reprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?
Violation:
Date of Violation (dd-MMM-yyyy):
Date of Official Action (dd-MMM-yyyy):
Explanation of Violation:
Employer Name:
Location of Violation (Street address, City, State, County, Zip Code, Country):
2. Do you have former federal civilian employment, excluding military service, NOT indicated previously, to
report?
3. Have any of the following happened to you in the last seven (7) years at employment activities that you have
not previously listed? (If 'Yes', you will be required to add an additional employment in Employment/Military
History.)





Fired from a job?
Quit a job after being told you would be fired?
Have you left a job by mutual agreement following charges or allegations of misconduct?
Left a job by mutual agreement following notice of unsatisfactory performance?
Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the
workplace, such as violation of a security policy?
Include question number and continue explanations below for all ‘YES’ answers that may apply:
23
Y/N
EMPLOYMENT HISTORY DETAIL (Civilian)
ALL Civilian Employment History (paid full time, paid part time and unemployment) must cover the last 7 years.
**Provide ALL medical professional employment (i.e. Nurse, MD, etc.) to back date up to the start of initial
licensing even if beyond the last 7 years. Indicate all periods of unemployment between jobs if applicable. For
periods of unemployment, list reference name, address and phone number. List employment in strict chronological
order beginning with the present employment and working back with no gaps. Do not use reference more than once.
Employer:
Position:
Employer Name
Position Title
Full Time:
Part Time:
Employment Code: (Mark ‘X’ to one that applies)
Federal Contractor (List contractor, not Federal Agency)
Number of hours worked (per week):
Job Responsibilities:
Non-Government Employment (excluding selfemployment)
Self-Employment: (Include business name and name of person
who can verify)
State Government (Non-federal Employment)
Other Federal Employment
Other
Explanation:
Date Range of Employment:
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy): Present
Employer/Verifier Address and Phone No.:
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Applicant work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
-
Supervisor/Verifier Information:
Last Name:
First Name:
Middle Name:
Suffix:
Title:
Email Address:
[‘X’ here if unknown
Supervisor work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Best time to contact:
Reason for leaving:
24
]
EMPLOYMENT HISTORY DETAIL (Civilian)
ALL Civilian Employment History (paid full time, paid part time and unemployment) must cover the last 7 years.
**Provide ALL medical professional employment (i.e. Nurse, MD, etc.) to back date up to the start of initial
licensing even if beyond the last 7 years. Indicate all periods of unemployment between jobs if applicable. For
periods of unemployment, list reference name, address and phone number. List employment in strict chronological
order beginning with the present employment and working back with no gaps. Do not use reference more than once.
Employer:
Position:
Employer Name
Position Title
Full Time:
Part Time:
Employment Code: (Mark ‘X’ to one that applies)
Federal Contractor (List contractor, not Federal Agency)
Number of hours worked (per week):
Job Responsibilities:
Non-Government Employment (excluding selfemployment)
Self-Employment: (Include business name and name of person
who can verify)
State Government (Non-federal Employment)
Other Federal Employment
Other
Explanation:
Date Range of Employment:
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy): Present
Employer/Verifier Address and Phone No.:
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Applicant work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
-
Supervisor/Verifier Information:
Last Name:
First Name:
Middle Name:
Suffix:
Title:
Email Address:
[‘X’ here if unknown
Supervisor work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Best time to contact:
Reason for leaving:
25
]
EMPLOYMENT HISTORY DETAIL (Civilian)
ALL Civilian Employment History (paid full time, paid part time and unemployment) must cover the last 7 years.
**Provide ALL medical professional employment (i.e. Nurse, MD, etc.) to back date up to the start of initial
licensing even if beyond the last 7 years. Indicate all periods of unemployment between jobs if applicable. For
periods of unemployment, list reference name, address and phone number. List employment in strict chronological
order beginning with the present employment and working back with no gaps. Do not use reference more than once.
Employer:
Position:
Employer Name
Position Title
Full Time:
Part Time:
Employment Code: (Mark ‘X’ to one that applies)
Federal Contractor (List contractor, not Federal Agency)
Number of hours worked (per week):
Job Responsibilities:
Non-Government Employment (excluding selfemployment)
Self-Employment: (Include business name and name of person
who can verify)
State Government (Non-federal Employment)
Other Federal Employment
Other
Explanation:
Date Range of Employment:
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy): Present
Employer/Verifier Address and Phone No.:
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Applicant work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
-
Supervisor/Verifier Information:
Last Name:
First Name:
Middle Name:
Suffix:
Title:
Email Address:
[‘X’ here if unknown
Supervisor work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Best time to contact:
Reason for leaving:
26
]
EMPLOYMENT HISTORY DETAIL (Civilian)
ALL Civilian Employment History (paid full time, paid part time and unemployment) must cover the last 7 years.
**Provide ALL medical professional employment (i.e. Nurse, MD, etc.) to back date up to the start of initial
licensing even if beyond the last 7 years. Indicate all periods of unemployment between jobs if applicable. For
periods of unemployment, list reference name, address and phone number. List employment in strict chronological
order beginning with the present employment and working back with no gaps. Do not use reference more than once.
Employer:
Position:
Employer Name
Position Title
Full Time:
Part Time:
Employment Code: (Mark ‘X’ to one that applies)
Federal Contractor (List contractor, not Federal Agency)
Number of hours worked (per week):
Job Responsibilities:
Non-Government Employment (excluding selfemployment)
Self-Employment: (Include business name and name of person
who can verify)
State Government (Non-federal Employment)
Other Federal Employment
Other
Explanation:
Date Range of Employment:
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy): Present
Employer/Verifier Address and Phone No.:
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Applicant work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
-
Supervisor/Verifier Information:
Last Name:
First Name:
Middle Name:
Suffix:
Title:
Email Address:
[‘X’ here if unknown
Supervisor work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Best time to contact:
Reason for leaving:
27
]
EMPLOYMENT HISTORY DETAIL (Civilian)
ALL Civilian Employment History (paid full time, paid part time and unemployment) must cover the last 7 years.
**Provide ALL medical professional employment (i.e. Nurse, MD, etc.) to back date up to the start of initial
licensing even if beyond the last 7 years. Indicate all periods of unemployment between jobs if applicable. For
periods of unemployment, list reference name, address and phone number. List employment in strict chronological
order beginning with the present employment and working back with no gaps. Do not use reference more than once.
Employer:
Position:
Employer Name
Position Title
Full Time:
Part Time:
Employment Code: (Mark ‘X’ to one that applies)
Federal Contractor (List contractor, not Federal Agency)
Number of hours worked (per week):
Job Responsibilities:
Non-Government Employment (excluding selfemployment)
Self-Employment: (Include business name and name of person
who can verify)
State Government (Non-federal Employment)
Other Federal Employment
Other
Explanation:
Date Range of Employment:
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy): Present
Employer/Verifier Address and Phone No.:
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Applicant work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
-
Supervisor/Verifier Information:
Last Name:
First Name:
Middle Name:
Suffix:
Title:
Email Address:
[‘X’ here if unknown
Supervisor work address same as Employer Address?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Best time to contact:
Reason for leaving:
28
]
EMPLOYMENT HISTORY DETAIL (U.S. Military)
United States Military Employment History (Active Duty, National Guard/Reserve, Commissioned Corps) must be
provided for each unit assigned to within the last 7 years.
Unit:
Position:
Unit Name:
Rank:
Employment Code: (Mark ‘X’ to one that applies)
Active Military Duty Stations
National Guard/Reserve
U.S.P.H.S. Commissioned Corps
Date Range of Employment
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy):
Unit Address and Phone No.:
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Best time to Contact?
Applicant work address same as Unit?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Best time to Contact?
Full Time:
Part Time:
Supervisor/Verifier Information
Last Name:
First Name:
Middle Name:
Suffix:
Title:
Email Address:
[‘X’ here if unknown
Supervisor work address same as Unit?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Best time to Contact?
29
]
EMPLOYMENT HISTORY DETAIL (U.S. Military)
United States Military Employment History (Active Duty, National Guard/Reserve, Commissioned Corps) must be
provided for each unit assigned to within the last 7 years.
Unit:
Position:
Unit Name:
Rank:
Full Time:
Part Time:
Employment Code: (Mark ‘X’ to one that applies)
Active Military Duty Stations
National Guard/Reserve
U.S.P.H.S. Commissioned Corps
Date Range of Employment
Supervisor/Verifier Information
From Date (dd-MMM-yyyy):
Last Name:
To Date (dd-MMM-yyyy):
First Name:
Middle Name:
Unit Address and Phone No.:
Street:
Suffix:
City:
Title:
State:
Email Address:
[‘X’ here if unknown
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Best time to Contact?
Applicant work address same as Unit?
Supervisor work address same as Unit?
If No, provide address and phone number.
If No, provide address and phone number.
Street:
Street:
City:
City:
State:
State:
County:
County:
Zip Code:
Zip Code:
Country:
Country:
Country Code:
Country Code:
Telephone No.: (
)
Telephone No.: (
)
Extension:
Extension:
Best time to Contact?
Best time to Contact?
**More employment to be added? Continue on blank sheet providing the above information.
30
]
EMPLOYMENT HISTORY DETAIL (U.S. Military)
United States Military Employment History (Active Duty, National Guard/Reserve, Commissioned Corps) must be
provided for each unit assigned to within the last 7 years.
Unit:
Position:
Unit Name:
Rank:
Employment Code: (Mark ‘X’ to one that applies)
Active Military Duty Stations
National Guard/Reserve
U.S.P.H.S. Commissioned Corps
Date Range of Employment
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy):
Unit Address and Phone No.:
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Best time to Contact?
Applicant work address same as Unit?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Best time to Contact?
Full Time:
Part Time:
Supervisor/Verifier Information
Last Name:
First Name:
Middle Name:
Suffix:
Title:
Email Address:
[‘X’ here if unknown
Supervisor work address same as Unit?
If No, provide address and phone number.
Street:
City:
State:
County:
Zip Code:
Country:
Country Code:
Telephone No.: (
)
Extension:
Best time to Contact?
31
]
EMPLOYMENT HISTORY DETAIL (U.S. Military)
List ALL military service history below, beginning from current and working back to include service in Active Duty,
Reserves (Inactive Reserve/Delayed Entry Program/Unit Member), National Guard, U.S. Merchant Marine and
Foreign Military Service. If there was a break in service, each separate period should be listed. Complete all entries
blocks that may apply. All Non-Commissioned Officer Evaluation Reports and/or all Officer Evaluation Reports
covering service periods will need to be submitted.
Type: (Mark ‘X’ to one that applies)
Enlisted
Officer
Warrant Officer
Service: (Mark ‘X’ to one that applies)
Air Force
Marine Corps
Army
Merchant Marines
Coast Guard
Navy
U.S. Public Health Service
From Date (dd-MMM-yyyy ):
To Date (dd-MMM-yyyy ): Present
SSN/Service #:
Service Status: (Mark ‘X’ to one that applies)
Active
Inactive Reserve
Active Reserve
Unit Member
Rank:
Current/Highest Grade:
Effective Date of Grade (dd-MMM-yyyy ):
Date Active Tour Terminates (dd-MMM-yyyy ):
NG State:
Country:
DISCHARGE INFORMATION
Discharge Type: (Mark ‘X’ to one that applies)
Bad Conduct Discharge
None
Dishonorable
Other Than Honorable
Honorable
Uncharacterized
Honorable Conditions
Narrative Reason:
Separation Code: (From DD 214/NGB 22)
RE Code: (From DD 214/NGB 22)
MILITARY SPECIALITY INFORMATION
Primary Military Occupation (PMOS)
Additional Skill Identifier 1 (ASI1)
Skilled Qualification Identifier 1 (SQI1)
Secondary Military Occupation (SMOS)
Additional Skill Identifier 2 (ASI2)
Skilled Qualification Identifier 2 (SQI2)
Alternate Military Occupation (AMOS)
Additional Skill Identifier (ADI3)
Skilled Qualification Identifier 3 (SQI3)
UNIT INFORMATION
Unit Name:
Unit Street:
Unit Zip Code:
Last Name:
Suffix:
Title/Rank/Grade:
Lost Time (DDMMMYYYY):
Reason:
Unit City:
Unit Country:
SUPERVISOR INFORMATION
First Name:
From Date:
Unit State:
Middle Name:
To Date:
32
EMPLOYMENT HISTORY DETAIL (U.S. Military)
List ALL military service history below, beginning from current and working back to include service in Active Duty,
Reserves (Inactive Reserve/Delayed Entry Program/Unit Member), National Guard, U.S. Merchant Marine and
Foreign Military Service. If there was a break in service, each separate period should be listed. Complete all entries
blocks that may apply. All Non-Commissioned Officer Evaluation Reports and/or all Officer Evaluation Reports
covering service periods will need to be submitted.
Type: (Mark ‘X’ to one that applies)
Enlisted
Officer
Warrant Officer
Service: (Mark ‘X’ to one that applies)
Air Force
Marine Corps
Army
Merchant Marines
Coast Guard
Navy
U.S. Public Health Service
From Date (dd-MMM-yyyy ):
To Date (dd-MMM-yyyy ): Present
SSN/Service #:
Service Status: (Mark ‘X’ to one that applies)
Active
Inactive Reserve
Active Reserve
Unit Member
Rank:
Current/Highest Grade:
Effective Date of Grade (dd-MMM-yyyy ):
Date Active Tour Terminates (dd-MMM-yyyy ):
NG State:
Country:
DISCHARGE INFORMATION
Discharge Type: (Mark ‘X’ to one that applies)
Bad Conduct Discharge
None
Dishonorable
Other Than Honorable
Honorable
Uncharacterized
Honorable Conditions
Narrative Reason:
Separation Code: (From DD 214/NGB 22)
RE Code: (From DD 214/NGB 22)
MILITARY SPECIALITY INFORMATION
Primary Military Occupation (PMOS)
Additional Skill Identifier 1 (ASI1)
Skilled Qualification Identifier 1 (SQI1)
Secondary Military Occupation (SMOS)
Additional Skill Identifier 2 (ASI2)
Skilled Qualification Identifier 2 (SQI2)
Alternate Military Occupation (AMOS)
Additional Skill Identifier (ADI3)
Skilled Qualification Identifier 3 (SQI3)
UNIT INFORMATION
Unit Name:
Unit Street:
Unit Zip Code:
Last Name:
Suffix:
Title/Rank/Grade:
Lost Time (DDMMMYYYY):
Reason:
Unit City:
Unit Country:
SUPERVISOR INFORMATION
First Name:
From Date:
Unit State:
Middle Name:
To Date:
33
EMPLOYMENT HISTORY DETAIL (U.S. Military)
List ALL military service history below, beginning from current and working back to include service in Active Duty,
Reserves (Inactive Reserve/Delayed Entry Program/Unit Member), National Guard, U.S. Merchant Marine and
Foreign Military Service. If there was a break in service, each separate period should be listed. Complete all entries
blocks that may apply. All Non-Commissioned Officer Evaluation Reports and/or all Officer Evaluation Reports
covering service periods will need to be submitted.
Type: (Mark ‘X’ to one that applies)
Enlisted
Officer
Warrant Officer
Service: (Mark ‘X’ to one that applies)
Air Force
Marine Corps
Army
Merchant Marines
Coast Guard
Navy
U.S. Public Health Service
From Date (dd-MMM-yyyy):
To Date ( dd-MMM-yyyy ): Present
SSN/Service #:
Service Status: (Mark ‘X’ to one that applies)
Active
Inactive Reserve
Active Reserve
Unit Member
Rank:
Current/Highest Grade:
Effective Date of Grade (dd-MMM-yyyy ):
Date Active Tour Terminates ( dd-MMM-yyyy ):
NG State:
Country:
DISCHARGE INFORMATION
Discharge Type: (Mark ‘X’ to one that applies)
Bad Conduct Discharge
None
Dishonorable
Other Than Honorable
Honorable
Uncharacterized
Honorable Conditions
Narrative Reason:
Separation Code: (From DD 214/NGB 22)
RE Code: (From DD 214/NGB 22)
MILITARY SPECIALITY INFORMATION
Primary Military Occupation (PMOS)
Additional Skill Identifier 1 (ASI1)
Skilled Qualification Identifier 1 (SQI1)
Secondary Military Occupation (SMOS)
Additional Skill Identifier 2 (ASI2)
Skilled Qualification Identifier 2 (SQI2)
Alternate Military Occupation (AMOS)
Additional Skill Identifier (ADI3)
Skilled Qualification Identifier 3 (SQI3)
UNIT INFORMATION
Unit Name:
Unit Street:
Unit Zip Code:
Last Name:
Suffix:
Title/Rank/Grade:
Lost Time (DDMMMYYYY):
Reason:
Unit City:
Unit Country:
SUPERVISOR INFORMATION
First Name:
From Date:
Unit State:
Middle Name:
To Date:
**More Military History to be added? Continue on blank sheet providing the above information.
34
MILITARY SERVICE SCHOOLS
Enter ALL Military Schools attended.
From Date: (dd-MMM-yyyy)
To Date: (dd-MMM-yyyy)
School Name:
Course Name:
Is this the Highest Level service school attended? Y/N
Completed? Y/N
MILITARY SERVICE SCHOOLS
Enter ALL Military Schools attended.
From Date: (dd-MMM-yyyy)
To Date: (dd-MMM-yyyy)
School Name:
Course Name:
Is this the Highest Level service school attended? Y/N
Completed? Y/N
From Date: (dd-MMM-yyyy)
Installation:
Type: (Mark ‘X’ to one that applies)
Advanced
Basic
ROTC SCHOOL
To Date: (dd-MMM-yyyy)
Ranger
Completed? Y/N
**More Military schools to be added? Continue on blank sheet providing the above information.
35
FOREIGN HISTORY QUESTIONNAIRE
Complete all questions. If additional information is required for ‘YES’ answers given, additional
information will be specified. Refer to the end of the Foreign History section for additional space if
needed.
1. Do you have, or have you had, close and/or continuing contact with a foreign national within the last seven
(7) years with whom you, or your spouse, or cohabitant are bound by affection, influence, common
interests, and/or obligation? Include associates as well as relatives, not previously listed in Family &
Associates.
Name of Person Extending Offer: Last
Countries of Citizenship:
First
Middle
Suffix
Approximate date of first contact:
Approximate date of last contact:
Approximate frequency of contact:
Methods of contact (X all that apply): Telephone
In person
Electronic (Such as email/texting/chat rooms/etc)
Written coorespondence
Other
Nature of relationship with the foreign national: Professional/Business
(X all that apply) Obligation (explain):
Personal
Other
Is this foreign national affiliated with a foreign government, military, security, defense industry, or intelligence
service? Y/N/I don’t know:
Does the foreign national have any other names and/or nicknames? Y/N:
2. Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests (such
as stocks, property, investments, bank accounts, ownership of corporate entities, corporate interests or
businesses) in which you or have direct control or direct ownership? (Exclude financial interests in
companies or diversified mutual funds that are publicly traded on a U.S. exchange.)
Parties involved: Yourself
Spouse
Cohabitant
Dependent children
Date acquired:
Type (Bank Accounts, Financial Business, Other):
Cost at time of acquisition in USD:
Actual or Estimated?
Current Value or Value at the time control or ownership was sold, lost or otherwise disposed of (in USD)?
Actual or Estimated?
Was control or ownership relinquished?
Are there any co-owners of this foreign financial interest?
3. Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial interests that
someone controlled on your behalf?
Parties involved: Yourself
Spouse
Cohabitant
Dependent children
Date acquired:
Type (Bank Accounts, Financial Business, Other):
Cost at time of acquisition in USD:
Actual or Estimated?
Current Value or Value at the time control or ownership was sold, lost or otherwise disposed of (in USD)?
Actual or Estimated?
Was control or ownership relinquished?
Are there any co-owners of this foreign financial interest?
4. Have you, your spouse, cohabitant, or dependent children EVER owned, or do you anticipate owning, or
plan to purchase real estate in a foreign country?
Parties involved: Yourself
Spouse
Cohabitant
Dependent children
Date acquired or to be acquired:
Cost at time of acquisition in USD:
Actual or Estimated?
Type (Business, Land, Rental Property, Vacation Home , Other):
How the real estate was/is to be acquired (such as purchase, gift, etc):
Foreign owned real estate address: Street:
City:
Country:
Was control or ownership relinquished?
Are there any co-owners of this foreign financial interest?
36
Y/N
5. As a U.S. citizen, have you, your spouse, cohabitant, or dependent children received in the past seven (7)
years, or are eligible to receive in the future, any educational, medical, retirement, social welfare, or other
such benefit from a foreign country?
Parties involved: Yourself
Spouse
Cohabitant
Dependent children
Type of benefit (Educational, medical, retirement, social welfare, other):
Frequency of benefit (continuing, future, one-time, other):
Country providing benefit:
Value in USD:
Actual or Estimated?
As a result of this benefit are you, your spouse, your cohabitant, or dependent children obligated in any way to this foreign
country?
6. Have you EVER provided financial support for any foreign national?
Name of Person Extending Offer: Last
First
Middle
Suffix
Amount of all financial support provided:
Actual or estimated:
Frequency of support:
Countries of Citizenship:
Nature of relationship:
Foreign national’s address: Street
City:
State:
Country:
7. Have you in the past seven (7) years provided advice or support to any individual associated with a
foreign business or other foreign organization that you have not previously listed as a former employer?
(Answer 'No' if all your advice or support was authorized pursuant to official U.S. Government business.)
From date (dd-MMM-yyyy):
To date (dd-MMM-yyyy):
Name of Individual to whom Advice or Support was Given:Last
First
Name of Foreign Organization or Business with whom individual is associated:
Country of origin for Organization or Business:
Description of advice or support given:
Was Compensation provided:
8.
Middle
Suffix
Have you, your spouse, cohabitant, or any member of your immediate family in the past seven (7) years
been asked to provide advice or serve as a consultant, even informally, by any foreign government official
or agency? (Answer 'No' if all the advice or support was authorized pursuant to official U.S. Government
business.) For this question, "Immediate Family" means your spouse, parent, step-parents, siblings, half
and step-siblings, children, step-children, and cohabitant.
Name of Foreign Government Official: Last
First
Middle
Date of request:
Name of agency:
Country with which the Government Official or Agency is Affiliated:
Circumstances of request:
Suffix
9. Has any foreign national in the past seven (7) years offered you a job, asked you to work as a consultant,
or consider employment with them?
Name of Person Extending Offer: Last
First
Middle
Position description:
Date Offer Extended:
Offer address: City
State
Zip
Country
Did you accept the offer?
Explanation:
37
Suffix
10. Have you in the past seven (7) years been involved in any other type of business venture with a foreign
national not described above (own, co-own, serve as business consultant, provide financial support, etc.)?
Name of Person Extending Offer: Last
First
Middle
Suffix
Current address of Foreign National: Street
City
State
Zip
Country
Foreign National’s Countries of Citizenship:
Business Venture Description:
Relationship to Foreign National:
From date (dd-MMM-yyyy):
To date (dd-MMM-yyyy):
Nature of Association with Business Venture:
Position Held:
Service Provided:
Financial Support Involved (if none explain why):
Compensation provided:
11. Have you in the past seven (7) years attended or participated in any conferences, trade shows, seminars,
or meetings outside the U.S.? (Do not include those you attended or participated in on official business for
the U.S. government.)
From date (dd-MMM-yyyy):
To date (dd-MMM-yyyy):
Name of Event:
Description of Event:
Name of Sponsoring Organization:
Address of Foreign Conference: Street
City
Country
Purpose of Event:
Was there any subsequent contact with any foreign national as a result of the event?
12. Have you or any member of your immediate family in the past seven (7) years had any contact with a
foreign government, its establishment (such as embassy, consulate, agency, military service, intelligence or
security service, etc.) or its representatives, whether inside or outside the U.S.? (Answer 'No' if the contact
was for routine visa applications and border crossings related to either official U.S. Government travel or
foreign travel on a U.S. passport.) "Immediate Family" means your spouse, parents, step-parents, siblings,
half and step-siblings, children, step-children, and cohabitant.
Individual Involved in Contact: Last
First
Middle
Suffix
Location of Contact: Street
City
Zip
Country
Date of Contact:
Foreign Government(s) Involved:
Type of establishment (such as embassy, consulate, agency, military service, intelligence, or security service, etc)
involved:
Names of foreign representatives involved in contact:
Purpose or circumstances of contact:
Was there any subsequent contact initiated by you, your immediate family member, or a representative of the foreign
organization?
13. Have you in the past seven (7) years sponsored any foreign national to come to the U.S. as a student, for
work, or for permanent residence?
Name of Foreign National: Last
First
Middle
Suffix
Purpose of stay:
From date of stay (dd-MMM-yyyy):
To date of stay (dd-MMM-yyyy):
Purpose of sponsorship:
Countries of Citizenship:
Birth Date (or I don’t know):
Place of Birth: City
State
Zip
Country
Current address of Foreign National: City
State
Zip
Country
Sponsorship Organization: Name
City
State
Zip
Country
Address of Foreign National While Residing in the U.S.: City
State
Zip
Country
14. Have you EVER held political office in a foreign country?
Position Held:
From date (dd-MMM-yyyy):
To date (dd-MMM-yyyy):
Name of Country Involved:
Reasons for these activities:
Current eligibility to hold political office in a foreign country:
38
15. Have you EVER voted in the election of a foreign country?
Date you voted in the foreign election (dd-MMM-yyyy):
Name of country involved:
Reasons for these activities:
Current eligibility to vote in a foreign election:
16. Are you now or have you ever been employed by or acted as a consultant for a foreign government, firm,
or agency?
From date (dd-MMM-yyyy):
Firm:
Government:
Explanation:
To date (dd-MMM-yyyy):
17. Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?
Name in which passport (or identity card) was issued: Last
First
Place issued: City
Country
Passport (or identity card) information: Issuing country
Number
Have you ever used this passport (or identity card) for foreign travel?
Middle
Issue Date
Suffix
Expiration
18. Have you traveled outside the U.S. in the last seven (7) years?
If yes, has your travel in the last seven (7) years been solely for U.S. Government business (i.e., no
personal trips in conjunction with the official U.S. Government business)?
Please fill out one set of questions for each visit out of the country in the last 7 years that was NOT travel under
official U.S. Government business.
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy):
Purpose of Visit: Business/Professional
Conference
Education
Other
Tourism
Visit family or friends
Volunteer Activities
Country Visited:
Number of days involved in the visit:
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for
normal customs requirements) by the local customs or security service officials when entering or leaving this
country?
While traveling to or in this country, were you involved in any encounter with the police?
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected
of being involved or associated with foreign intelligence, terrorist, security, or military organizations?
While traveling to, or in this country, were you involved in any counter intelligence or security issues not
reported?
While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive
knowledge of or undue interest in you or your job?
While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain
classified information or unclassified, sensitive information?
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a
foreign government official or foreign intelligence or security service?
39
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy):
Purpose of Visit: Business/Professional
Conference
Education
Other
Tourism
Visit family or friends
Volunteer Activities
Country Visited:
Number of days involved in the visit:
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for
normal customs requirements) by the local customs or security service officials when entering or leaving this
country?
While traveling to or in this country, were you involved in any encounter with the police?
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected
of being involved or associated with foreign intelligence, terrorist, security, or military organizations?
While traveling to, or in this country, were you involved in any counter intelligence or security issues not
reported?
While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive
knowledge of or undue interest in you or your job?
While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain
classified information or unclassified, sensitive information?
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a
foreign government official or foreign intelligence or security service?
From Date (dd-MMM-yyyy):
To Date (dd-MMM-yyyy):
Purpose of Visit: Business/Professional
Conference
Education
Other
Tourism
Visit family or friends
Volunteer Activities
Country Visited:
Number of days involved in the visit:
While traveling to, or in this country, were you questioned, searched, or otherwise detained (other than for
normal customs requirements) by the local customs or security service officials when entering or leaving this
country?
While traveling to or in this country, were you involved in any encounter with the police?
While traveling to or in this country, were you contacted by, or in contact with any person known or suspected
of being involved or associated with foreign intelligence, terrorist, security, or military organizations?
While traveling to, or in this country, were you involved in any counter intelligence or security issues not
reported?
While traveling to or in this country, were you contacted by, or in contact with anyone exhibiting excessive
knowledge of or undue interest in you or your job?
While traveling to or in this country, were you contacted by, or in contact with anyone attempting to obtain
classified information or unclassified, sensitive information?
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a
foreign government official or foreign intelligence or security service?
Include question number and explain all ‘YES’ answers that apply:
40
AWARD INFORMATION
List military awards received. Do not list theater or service medals.
Award:
Award:
Award:
Award:
Award:
Award:
Award:
Award:
Award:
Award:
GOVERNMENT AND MILITARY
Complete all questions. If additional information is required for ‘YES’ answers given, the question
requiring additional information will be specified. Refer to the end of the Government and Military
section for further information needed for all other ‘YES’ answers provided.
1. Have you EVER served in the U.S. Military?
2. Have you EVER served, as a civilian or military member in a foreign country's military, intelligence,
diplomatic, security forces, militia, other defense force, or government agency?
3. Have you EVER received a discharge that was not honorable?
4. In the last 7 years, have you been subject to court martial or other disciplinary procedure under the Uniform
Code of Military Justice (UCMJ), such as Article 15, Captain's mast, Article 135 Court of Inquiry,
etc?
Date of the court martial or other disciplinary procedure (dd-MMM-yyyy):
Description of the Uniform Code of Military Justice (UCMJ) offenses(s) for which you were charged:
Description of the Uniform Code of Military Justice (UCMJ) offenses(s) for which you were charged:
Court or Convening Authority:
City
State
Country
Description of the final outcome of the disciplinary procedure
5. Are you now or have you ever been a deserter from any branch of the armed forces of the United States?
6. Have you ever been employed by the United States Government?
7. Are you now drawing, or do you have an application pending, or approval for: retired pay, disability
allowance, severance pay, or pension from any agency of the government of the United States?
8. Are you now or have you ever been a conscientious objector? (That is, do you have, or have you ever had, a
firm, fixed, and sincere objection to participation in war in any form or to the bearing of arms because of
religious belief or training?)
9. Is there anything which would preclude you from performing military duties or participating in military
activities whenever necessary (i.e., do you have any personal restrictions or religious practices which
would restrict your availability?)
10. Have you ever been discharged by any branch of the Armed Forces of the United States for reasons
pertaining to being a conscientious objector?
11. Have you ever been an officer or a member or made a contribution to an organization dedicated to the
violent overthrow of the United States Government and which engages in illegal activities to that end, knowing
that the organization engages in such activities with the specific intent to further such activities?
12. Have you ever knowingly engaged in any acts or activities designed to overthrow the United States
Government by force?
13. Have you ever applied and not been selected for appointment in Regular Army as a commissioned officer?
Date (dd-MMM-yyyy):
Explanation:
14. Have you ever applied and not been selected for appointment in Regular Army as a warrant officer?
Date (dd-MMM-yyyy):
Explanation:
15. Have you ever applied and not been selected for appointment in Reserve component (USAR/ARNG) as a
commissioned officer?
Date (dd-MMM-yyyy):
Explanation:
16. Have you ever applied and not been selected for appointment in Reserve component (USAR/ARNG) as a
warrant officer?
Date (dd-MMM-yyyy):
Explanation:
41
Y/N
17. Have you ever applied and not been selected for OCS?
18. Have you ever applied and not been selected for ROTC?
19. Have you ever resigned or been asked to resign in lieu of elimination proceedings; been discharged in lieu
of elimination, furloughed, or placed on inactive status while serving in the US Armed Forces; or, have you
ever resigned or been asked to resign from position while in government or private employment?
Date (dd-MMM-yyyy):
Explanation:
20. Have you been employed by the U.S. Army as a Dietitian, Occupational or Physical Therapist?
From-To Dates (dd-MMM-yyyy):
Explanation:
21. Are you in a promotable status and on a published promotion list?
22. I understand that, if I am selected for appointment, I will be expected to accept such assignments as are in
the best interest of the service regardless of my marital status and/or responsibility for dependents; and it is my
responsibility to make appropriate arrangements for the care of my dependents should I be required to perform
duty in an area where dependents are not permitted.
23. Do you have an ADL Promotion Date?
Date of last ADL Promotion (dd-MMM-yyyy):
24. Have you ever been passed over for a military promotion?
If Yes, how many times?
25. Do you have a current commission? If Yes, give source:
ARNGUS (Direct Appointment, OCS, Other):
USAR (Direct Appointment, OCS, ROTC, ROTC (ECP), ROTC (SMP), Other:
26. Have you EVER had a security clearance eligibility/access authorization denied, suspended, or revoked?
(Note: An administrative downgrade or administrative termination of a security clearance is not a
revocation.)
Date (dd-MMM-yyyy):
Name of the Agency that took the action:
Circumstances:
27. Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted
you a security clearance eligibility/access?
Investigation Completion Date (dd-MMM-yyyy):
Investigating Agency:
Level of Clearance Eligibility/Access Granted:
Date Clearance Eligibility/Access Was Granted:
Agency Issuing Clearance Eligibility/Access:
28. Have you EVER been debarred from government employment?
Debarment Date (dd-MMM-yyyy):
Debarment Agency Name:
Circumstances of the Debarment:
29. Are you a male born after December 31, 1959? If Yes, complete the following information below
(Registration number available at http://www.SSS.gov/)
Registration Number:
Legal Exception Explanation:
Include question number and explain all ‘YES’ answers that apply to include the following information: Explanation.
42
EDUCATION QUESTIONNAIRE
Complete all questions. Additional information is required for ‘YES’ answers given. Refer to the end of
the Education Questionnaire section for additional information.
1. Is your Qualifying Degree from a foreign school?
2. Did you graduate from a High School? (Must list high school information)
3. Are you now or have you ever been enrolled in ROTC or any of the USMAs?
Do you have a guaranteed reserve forces duty service obligation?
Do you have an Active Duty remaining service obligation?
Have you received an ARNG or GRFD-ARNG ROTC scholarship?
Have you received an ARNG or GRFD-ARNG ROTC nonscholarship?
Are you a GRFD-ROTC scholarship cadet?
Are you a GRFD-ROTC nonscholarship cadet?
Are you currently fulfilling a reserve obligation because of receiving an ARNG ROTC scholarship or
nonscholarship?
Are you currently fulfilling a reserve obligation because of receiving an GRFD-ROTC scholarship or
nonscholarship?
4. Have you attended any schools in the last 10 years?
In the next section you will list details of your education,
 you must list your high school
 transcripts from ALL colleges will be required
 list Fellowships, Residencies, and Internships (GME) on an “Advanced Education” section
 you may use the school registrar as a reference for verification, but you must list the school phone number
43
Y/N
EDUCATION
School Information:
Name:
Education Type: (Mark ‘X’ to one that applies)
High School
Graduate
Undergraduate
Doctorate
From Date: (dd-MMM-yyyy)
To Date: ( dd-MMM-yyyy )
Online School?
Website address:
Area of Study:
Degree/Diploma/Other:
Major:
Credit Hours:
Credit Type: (semester, quarter, etc.)
Graduated?: (Y/N)
Graduation Date:
School Location:
Street:
State:
Zip Code:
City:
Country:
Reference Information:
Last Name:
Country Code:
First Name:
Telephone No.: (
)
Middle Name:
Extension:
Suffix:
Street:
State:
Zip Code:
City:
Country:
Questions About School (If answering Yes, provide detailed explanation below).
Have you ever been expelled from school or placed on probation?
Have you ever been the recipient of special educational honors, Dean’s List, awards or scholarships?
For all YES answers that apply, provide a brief explanation:
44
Y/N
EDUCATION
School Information:
Name:
Education Type: (Mark ‘X’ to one that applies)
High School
Graduate
Undergraduate
Doctorate
From Date: (dd-MMM-yyyy)
To Date: ( dd-MMM-yyyy )
Online School?
Website address:
Area of Study:
Degree/Diploma/Other:
Major:
Credit Hours:
Credit Type: (semester, quarter, etc.)
Graduated?: (Y/N)
Graduation Date:
School Location:
Street:
State:
Zip Code:
City:
Country:
Reference Information:
Last Name:
Country Code:
First Name:
Telephone No.: (
)
Middle Name:
Extension:
Suffix:
Street:
State:
Zip Code:
City:
Country:
Questions About School (If answering Yes, provide detailed explanation below).
Have you ever been expelled from school or placed on probation?
Have you ever been the recipient of special educational honors, Dean’s List, awards or scholarships?
For all YES answers that apply, provide a brief explanation:
45
Y/N
EDUCATION
School Information:
Name:
Education Type: (Mark ‘X’ to one that applies)
High School
Graduate
Undergraduate
Doctorate
From Date: (dd-MMM-yyyy)
To Date: ( dd-MMM-yyyy )
Online School?
Website address:
Area of Study:
Degree/Diploma/Other:
Major:
Credit Hours:
Credit Type: (semester, quarter, etc.)
Graduated?: (Y/N)
Graduation Date:
School Location:
Street:
State:
Zip Code:
City:
Country:
Reference Information:
Last Name:
Country Code:
First Name:
Telephone No.: (
)
Middle Name:
Extension:
Suffix:
Street:
State:
Zip Code:
City:
Country:
Questions About School (If answering Yes, provide detailed explanation below).
Have you ever been expelled from school or placed on probation?
Have you ever been the recipient of special educational honors, Dean’s List, awards or scholarships?
For all YES answers that apply, provide a brief explanation:
46
Y/N
EDUCATION
School Information:
Name:
Education Type: (Mark ‘X’ to one that applies)
High School
Graduate
Undergraduate
Doctorate
From Date: (dd-MMM-yyyy)
To Date: ( dd-MMM-yyyy )
Online School?
Website address:
Area of Study:
Degree/Diploma/Other:
Major:
Credit Hours:
Credit Type: (semester, quarter, etc.)
Graduated?: (Y/N)
Graduation Date:
School Location:
Street:
State:
Zip Code:
City:
Country:
Reference Information:
Last Name:
Country Code:
First Name:
Telephone No.: (
)
Middle Name:
Extension:
Suffix:
Street:
State:
Zip Code:
City:
Country:
Questions About School (If answering Yes, provide detailed explanation below).
Have you ever been expelled from school or placed on probation?
Have you ever been the recipient of special educational honors, Dean’s List, awards or scholarships?
For all YES answers that apply, provide a brief explanation:
47
Y/N
ADVANCED EDUCATION
List ALL education/training received to include fellowship, internship, residency and specialty training. Complete all
entries that may apply. All information must match professional certificate(s) and verification letters submitted.
Hospital/School Information: [Mark ‘X’ to one that applies]
Fellowship
Residency
From Date: (dd-MMM-yyyy)
Internship
Specialty Training
To Date: (dd-MMM-yyyy)
Hospital/School Name:
Specialty:
Hospital/School Location Information:
Street:
State:
Zip Code:
City:
Country:
Phone #:
Questions About School (If answering Yes, provide detailed explanation below).
Board Eligible? Y/N:
If Yes, Specialty Board Name:
Board Certified? Y/N:
Certification Date (dd-MMM-yyyy):
ADVANCED EDUCATION
List ALL education/training received to include fellowship, internship, residency and specialty training. Complete all
entries that may apply. All information must match professional certificate(s) and verification letters submitted.
Hospital/School Information: [Mark ‘X’ to one that applies]
Fellowship
Residency
From Date: (dd-MMM-yyyy)
Internship
Specialty Training
To Date: (dd-MMM-yyyy)
Hospital/School Name:
Specialty:
Hospital/School Location Information:
Street:
State:
Zip Code:
City:
Country:
Phone #:
Questions About School (If answering Yes, provide detailed explanation below).
Board Eligible? Y/N:
If Yes, Specialty Board Name:
Board Certified? Y/N:
Certification Date (dd-MMM-yyyy):
ADVANCED EDUCATION
List ALL education/training received to include fellowship, internship, residency and specialty training. Complete all
entries that may apply. All information must match professional certificate(s) and verification letters submitted.
Hospital/School Information: (Mark ‘X’ to one that applies)
Fellowship
Residency
From Date: (dd-MMM-yyyy)
Internship
Specialty Training
To Date: (dd-MMM-yyyy)
Hospital/School Name:
Specialty:
Hospital/School Location Information:
Street:
State:
Zip Code:
City:
Country:
Phone #:
Questions About School (If answering Yes, provide detailed explanation below).
Board Eligible? Y/N:
If Yes, Specialty Board Name:
Board Certified? Y/N:
Certification Date (dd-MMM-yyyy):
**More education to be added? Continue on blank sheet providing the above information
48
FINANCIAL HISTORY QUESTIONNAIRE
Complete all questions. Additional information is required for ‘YES’ answers given. Refer to the end of
the Financial History Questionnaire section for additional information.
1. In the last seven (7) years have you filed a petition under any chapter of the bankruptcy code?
Date Bankruptcy Filed (dd-MMM-yyyy):
Date Bankruptcy Discharged (dd-MMM-yyyy):
Bankruptcy Type (Chapter 7, 11, 13):
Total Amount of Bankruptcy:$
Bankruptcy Court Docket/Account Number:
Name Debt is Recorded Under:
Were you discharged of all debts claimed in this bankruptcy?
Explanation:
Court Name:
Street
City
State
Zip
Country
2. Have you EVER experienced financial problems due to gambling?
Date Financial Problems Began because of Gambling: (dd-MMM-yyyy):
Date Financial Problems Ended: (dd-MMM-yyyy):
Estimate the Amount of Gambling Losses incurred: $
Description of Financial Problems due to Gambling:
If you have taken any actions(s) to rectify your financial problems due to gambling, proved description of your
actions. If you have not taken any action(s), provide explanation:
3. In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when required by
law or ordinance?
Date you failed to file or pay your Federal, State, or other taxes (dd-MMM-yyyy):
Date satisfied (dd-MMM-yyyy):
Amount of taxes:
Did you Fail to File, Pay, or Both?
Type of Taxes:
Federal, State, or Other Agency to which you failed to pay:
Reason for failure to file/pay:
Description of actions taken to satisfy this debt (such as withholdings, frequency and amount of payments, etc.) If
you have not taken any action(s) provide explanation:
4. In the past seven (7) years have you been counseled, warned, or disciplined for violating the terms of
agreement for a travel or credit card provided by your employer?
Date of your counseling, warning, or disciplinary action:
Name of Agency or Company or Employer:
Street
City
State
Zip
Country
Amount of Violation:$
Reason(s) for the counseling, warning, or disciplinary action:
Description of action(s) taken to rectify this situation. If not taken any action(s), provide explanation:
5. Are you currently utilizing, or seeking assistance from, a credit counseling service or other similar
resource to resolve your financial difficulties?
Explanation of Credit Counseling:
Name of the Credit Counseling Organization or Resource:
City
State
Phone #:
Ext:
Best time to contact:
As a result of this counseling, provide a description on any actions(s) you have taken to resolve your financial
difficulties. If you have not taken any action(s), provide explanation
6. Other than previously listed, have any of the following happened to you? (You will be asked to provide
details about each financial obligation that pertains to the items identified below).




In the past seven (7) years, you have been delinquent on alimony or child support payments.
In the past seven (7) years, you had a judgement entered against you. (Include financial obligations
for which you were the sole debtor, as well as those for which you were a cosigner or guarantor.).
In the past seven (7) years, you had a lien placed against your property for failing to pay taxes or
other debts. (Include financial obligations for which you were the sole debtor, as well as those for
which you were a cosigner or guarantor).
You are currently delinquent on any Federal debt. (Include financial obligations for which you are the
sole debtor, as well as those for which you are cosigner or guarantor).
49
Y/N
7. Other than previously listed, have any of the following happened?








In the past seven (7) years, you had any possessions or property voluntarily or involuntarily
repossessed or foreclosed? (Include financial obligations for which you where the sole debtor as well
as those where you were a cosigner or guarantor)
In the past seven (7) years, you defaulted on any type of loan? (Include financial obligations for
which you where the sole debtor as well as those where you were a cosigner or guarantor)
In the past seven (7) years, you had bills or debts turned over to a collection agency? (Include
financial obligations for which you where the sole debtor as well as those where you were a cosigner
or guarantor)
In the past seven (7) years, you had any account or credit card suspended, charged off, or cancelled
for failing to pay as agreed? (Include financial obligations for which you where the sole debtor as
well as those where you were a cosigner or guarantor)
In the past seven (7) years, you were evicted for non-payment?
In the past seven (7) years, you had your wages, benefits, or assets garnished or attached for any
reason?
In the past seven (7) years, you have been over 120 days delinquent on any debt not previously
entered? (Include financial obligations for which you where the sole debtor as well as those where
you were a cosigner or guarantor)
You are currently over 120 days delinquent on any debt? (Include financial obligations for which you
where the sole debtor as well as those where you were a cosigner or guarantor)
Include question number and explain all ‘YES’ answers without prior explanation to include the following
information:
Date (dd-MMM-yyyy) Financial issue began, Type of Action, Amount (USD), Account Number, Name of
Agency/Organization/Individual to whom Debt is/was owed, Name Action Occurred Under, Status of Action, Explanation,
Court/Agency Name and Address.
50
FAMILY & ASSOCIATES
Complete all entries that apply to the best of your knowledge. Mother and Father information is required. If married,
provide Spouse, Mother in Law and Father in Law information. If divorced, Former Spouse information is required.
For any family member that is deceased, provide only name, birth date and place of birth information. SSNs are
required for those you will list as beneficiaries. If anyone was not born in the U.S., but currently reside in the U.S.,
provide citizenship information.
Relationship: (Mark ‘X’ to one that applies)
Adult Living
w/you
Associate
Brother
Cohabitant
Child (custody)
Father
Father in Law
Former Spouse
Foster Parent
Guardian
Half Brother
Half Sister
Mother in
X
Mother
Law
Other Relative
Sister
Stepbrother
Stepchild
Stepfather
Stepmother
Stepsister
Last Name:
Maiden Name:
Deceased? Y/N
First Name:
Dependent? Y/N
Gender:
Middle Name:
Suffix:
Adopted? Y/N
Date of Birth: (dd-MMM-yyyy)
Approximate? Y/N
Has this relative used any other names? Name:
Dates used: From
To
Street:
City:
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
State:
Zip Code:
Country:
Place of Birth:
City:
State:
Country:
Country(ies) of Citizenship:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State:
Court:
Relationship: (Mark ‘X’ to one that applies)
Adult Living
w/you
Associate
Brother
Cohabitant
Child (custody)
X
Father
Father in Law
Former Spouse
Foster Parent
Guardian
Half Brother
Half Sister
Mother in
Mother
Law
Other Relative
Sister
Stepbrother
Stepchild
Stepfather
Stepmother
Stepsister
Last Name:
Maiden Name:
Deceased? Y/N
First Name:
Dependent? Y/N
Gender:
Middle Name:
Suffix:
Adopted? Y/N
Has this relative used any other names? Name:
Dates used: From
To
Date of Birth: (dd-MMM-yyyy)
Approximate? Y/N
Street:
City:
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
State:
Zip Code:
Country:
Place of Birth:
City:
State:
Country:
Country(ies) of Citizenship:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State:
Court:
51
Relationship: (Mark ‘X’ to one that applies)
Adult Living
w/you
Associate
Brother
Cohabitant
Child (custody)
Father
Father in Law
Former Spouse
Foster Parent
Guardian
Half Brother
Half Sister
Mother in
Mother
Law
Other Relative
Sister
Stepbrother
Stepchild
Stepfather
Stepmother
Stepsister
Last Name:
Maiden Name:
Deceased? Y/N
First Name:
Dependent? Y/N
Gender:
Middle Name:
Suffix:
Adopted? Y/N
Has this relative used any other names? Name:
Dates used: From
To
Date of Birth: (dd-MMM-yyyy)
Approximate? Y/N
Social Security No.:
Street:
City:
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
State:
Zip Code:
Country:
Place of Birth:
City:
State:
Country:
Country(ies) of Citizenship:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State:
Court:
Relationship: (Mark ‘X’ to one that applies)
Adult Living
w/you
Associate
Brother
Cohabitant
Child (custody)
Father
Father in Law
Former Spouse
Foster Parent
Guardian
Half Brother
Half Sister
Mother in
Mother
Law
Other Relative
Sister
Stepbrother
Stepchild
Stepfather
Stepmother
Stepsister
Last Name:
Maiden Name:
Deceased? Y/N
First Name:
Dependent? Y/N
Gender:
Middle Name:
Suffix:
Adopted? Y/N
Has this relative used any other names? Name:
Dates used: From
To
Date of Birth: (dd-MMM-yyyy)
Approximate? Y/N
Social Security No.:
Street:
City:
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
State:
Zip Code:
Country:
Place of Birth:
City:
State:
Country:
Country(ies) of Citizenship:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State:
Court:
52
Relationship: (Mark ‘X’ to one that applies)
Adult Living
w/you
Associate
Brother
Cohabitant
Child (custody)
Father
Father in Law
Former Spouse
Foster Parent
Guardian
Half Brother
Half Sister
Mother in
Mother
Law
Other Relative
Sister
Stepbrother
Stepchild
Stepfather
Stepmother
Stepsister
Last Name:
Maiden Name:
Deceased? Y/N
First Name:
Dependent? Y/N
Gender:
Middle Name:
Suffix:
Adopted? Y/N
Has this relative used any other names? Name:
Dates used: From
To
Date of Birth: (dd-MMM-yyyy)
Approximate? Y/N
Social Security No.:
Street:
City:
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
State:
Zip Code:
Country:
Place of Birth:
City:
State:
Country:
Country(ies) of Citizenship:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State:
Court:
Relationship: (Mark ‘X’ to one that applies)
Adult Living
w/you
Associate
Brother
Cohabitant
Child (custody)
Father
Father in Law
Former Spouse
Foster Parent
Guardian
Half Brother
Half Sister
Mother in
Mother
Law
Other Relative
Sister
Stepbrother
Stepchild
Stepfather
Stepmother
Stepsister
Last Name:
Maiden Name:
Deceased? Y/N
First Name:
Dependent? Y/N
Gender:
Middle Name:
Suffix:
Adopted? Y/N
Has this relative used any other names? Name:
Dates used: From
To
Date of Birth: (dd-MMM-yyyy)
Approximate? Y/N
Social Security No.:
Street:
City:
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
State:
Zip Code:
Country:
Place of Birth:
City:
State:
Country:
Country(ies) of Citizenship:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State:
Court:
53
Relationship: (Mark ‘X’ to one that applies)
Adult Living
w/you
Associate
Brother
Cohabitant
Child (custody)
Father
Father in Law
Former Spouse
Foster Parent
Guardian
Half Brother
Half Sister
Mother in
Mother
Law
Other Relative
Sister
Stepbrother
Stepchild
Stepfather
Stepmother
Stepsister
Last Name:
Maiden Name:
Deceased? Y/N
First Name:
Dependent? Y/N
Gender:
Middle Name:
Suffix:
Adopted? Y/N
Has this relative used any other names? Name:
Dates used: From
To
Date of Birth: (dd-MMM-yyyy)
Approximate? Y/N
Social Security No.:
Street:
City:
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
State:
Zip Code:
Country:
Place of Birth:
City:
State:
Country:
Country(ies) of Citizenship:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State:
Court:
Relationship: (Mark ‘X’ to one that applies)
Adult Living
w/you
Associate
Brother
Cohabitant
Child (custody)
Father
Father in Law
Former Spouse
Foster Parent
Guardian
Half Brother
Half Sister
Mother in
Mother
Law
Other Relative
Sister
Stepbrother
Stepchild
Stepfather
Stepmother
Stepsister
Last Name:
Maiden Name:
Deceased? Y/N
First Name:
Dependent? Y/N
Gender:
Middle Name:
Suffix:
Adopted? Y/N
Has this relative used any other names? Name:
Dates used: From
To
Date of Birth: (dd-MMM-yyyy)
Approximate? Y/N
Social Security No.:
Street:
City:
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
State:
Zip Code:
Country:
Place of Birth:
City:
State:
Country:
Country(ies) of Citizenship:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued (dd-MMM-yyyy): City/State:
Court:
**More Family and Associates to be added? Continue on blank sheet providing the above information.
54
Last Name:
First Name:
Middle Name:
Date of Birth: (dd-MMM-yyyy)
Social Security No. (Required):
Use Applicant’s Current Address? Y/N
Use Applicant’s Home of Record? Y/N
Place of Birth:
City of Birth:
State of Birth:
Phone:
Country Code:
SPOUSE INFORMATION
Current Spouse? Y/N
Separated? Y/N
Date separated?
Suffix:
My Spouse is currently serving in the active duty and I
am Requesting joint domicile? Y/N
Approximate DOB?
Street:
State:
Country of Birth:
Country of Citizenship:
Telephone No.:
(
)
-
Place of Marriage:
Date Married: ( dd-MMM-yyyy )
City:
State:
Location of Record:
City:
State:
City:
Country:
Zip Code:
Ext.:
County:
County:
Country:
Zip Code:
Country:
Citizenship Document Information: (i.e. Naturalization Cert., U.S. Passport, Alien Reg., etc.)
Certificate/Registration No.: Date Issued: ( dd-MMM-yyyy ): City/State:
Court:
Alias:
Maiden Name:
Former Married:
Former Name:
Nickname:
Married:
From: (dd-MMM-yyyy )
From: (dd-MMM-yyyy )
From: (dd-MMM-yyyy )
From: (dd-MMM-yyyy )
From: (dd-MMM-yyyy )
55
To: (dd-MMM-yyyy )
To: (dd-MMM-yyyy )
To: (dd-MMM-yyyy )
To: (dd-MMM-yyyy )
To: (dd-MMM-yyyy )
Last Name:
First Name:
Middle Name:
FORMER SPOUSE INFORMATION
Deceased? Y/N
Dependent? Y/N
Suffix:
Former Spouse Status: (Divorced, Widowed,
Annulled)
Approximate DOB?
Date of Birth: ( dd-MMM-yyyy )
Social Security No. (Required):
Last Known Address:
Use Other Family Members/Associates
Address? Y/N
If Yes, provide name used:
Place of Birth:
City of Birth:
State of Birth:
Phone:
Country Code:
Street:
State:
Zip Code:
Country of Birth:
Country of Citizenship:
Telephone No.:
(
)
-
Ext.:
Place of Marriage:
Date Married: ( dd-MMM-yyyy )
City:
State:
County:
Location of Record:
Date Divorced: ( dd-MMM-yyyy )
City:
State:
County:
Alias:
Maiden Name:
Former Married:
Former Name:
Nickname:
Married:
City:
Country:
From: (dd-MMM-yyyy )
From: (dd-MMM-yyyy )
From: (dd-MMM-yyyy )
From: (dd-MMM-yyyy )
From: (dd-MMM-yyyy )
56
Country:
Zip Code:
Country:
To: (dd-MMM-yyyy )
To: (dd-MMM-yyyy )
To: (dd-MMM-yyyy )
To: (dd-MMM-yyyy )
To: (dd-MMM-yyyy )
CITIZENSHIP
Complete all sections that apply. If additional information is required for ‘YES’ answers given, additional information will
be specified.
Do you possess a U.S. passport (current or expired):
U.S. Passport Number :
Date Issued: (dd-MMM-yyyy)
Expiration Date: (dd-MMM-yyyy)
Name in Which Passport Was First Issued:
Citizenship: (Mark ‘X’ to one that applies)
U.S. Citizen at Birth, Native Born
U.S. Citizen Born Abroad of US Parents
U.S. Citizen Naturalized
Immigrant Alien
Do you now hold or have you EVER held dual or multiple citizenships?
Start date:
End date:
Do you have any additional citizenship information to provide?
Explanation:
57
PROFESSIONAL REFERENCES
These are Professional References used to determine your qualifications and ability to perform. Character References
are entered on the Character Reference function.
List a minimum of three people who know your work. They should be supervisors or peers you have worked with during the last year and
who are in a position to know the quality of your work and your work habits and ethics. At least one reference must be in a supervisory
position and you must have reported to that person. The supervisory positions have a Reference Type of Supervisor, Instructor or Dean. If
need be, an individual you use as a Character Reference or the individual(s) you list as your supervisor(s) on the Employment function
can be used as Professional References.
#1 Reference Information:
First Name:
Middle Name:
Last Name:
Suffix:
Reference Address:
Street:
City:
Home Phone:
Available Day or Night? Day
Country Code:
Telephone No.: (
)
Extension:
Email address:
‘X’ if unknown
#2 Reference Information:
First Name:
Middle Name:
Last Name:
Suffix:
Reference Address:
Street:
City:
Home Phone:
Available Day or Night? Day
Country Code:
Telephone No.: (
)
Extension:
Email address:
‘X’ if unknown
#3 Reference Information:
First Name:
Middle Name:
Last Name:
Suffix:
Reference Address:
Street:
City:
Home Phone:
Available Day or Night? Day
Country Code:
Telephone No.: (
)
Extension:
Email address:
‘X’ if unknown
From Date: (yyyymmdd)
To Date: (yyyymmdd)
Reference Type: (Mark ‘X’ to one that applies)
Dean
Instructor
Peer
Supervisor
Unit Commander
Night
State:
Country:
Work Phone:
Available Day or Night?
Country Code:
Telephone No.: (
)
Extension:
Zip Code:
Day
Night
-
From Date: (yyyymmdd)
To Date: (yyyymmdd)
Reference Type: (Mark ‘X’ to one that applies)
Dean
Instructor
Peer
Supervisor
Unit Commander
Night
State:
Country:
Work Phone:
Available Day or Night?
Country Code:
Telephone No.: (
)
Extension:
Zip Code:
Day
Night
-
From Date: (yyyymmdd)
To Date: (yyyymmdd)
Reference Type: (Mark ‘X’ to one that applies)
Dean
Instructor
Peer
Supervisor
Unit Commander
Night
State:
Country:
Work Phone:
Available Day or Night?
Country Code:
Telephone No.: (
)
Extension:
58
Zip Code:
Day
Night
-
CHARACTER REFERENCES
These are Character References used to obtain a security clearance. Professional References are entered on the
Professional Reference function.
Provide three people who know you well and who preferably live in the U.S. They should be friends, peers, colleagues, college
roommates, associates, etc., who are collectively aware of your activities outside of your workplace, school, or neighborhood, and whose
combined association with you covers at least the last seven (7) years. Do not list your spouse, former spouse(s), other relatives, or
anyone listed elsewhere on this form. If need be, an individual you use as a Professional Reference can also be used as a Character
Reference.
#1 Reference Information:
Last Name:
First Name:
Middle Name:
Suffix:
Reference email address:
I don’t know:
Reference Address:
Street:
City:
Home Phone:
Available Day or Night? Day
Night
Country Code:
Telephone No.: (
)
Extension:
From Date: (dd-MMM-yyyy)
To Date: (dd-MMM-yyyy)
Reference Type: (Mark ‘X’ to one that applies)
Friend
Neighbor
Schoolmate
Work Associate
Other:
#2 Reference Information:
Last Name:
First Name:
Middle Name:
Suffix:
Reference email address:
I don’t know:
Reference Address:
Street:
City:
Home Phone:
Available Day or Night? Day
Night
Country Code:
Telephone No.: (
)
Extension:
From Date: (dd-MMM-yyyy)
To Date: (dd-MMM-yyyy)
Reference Type: (Mark ‘X’ to one that applies)
Friend
Neighbor
Schoolmate
Work Associate
Other:
#3 Reference Information:
Last Name:
First Name:
Middle Name:
Suffix:
Reference email address:
I don’t know:
Reference Address:
Street:
City:
Home Phone:
Available Day or Night? Day
Night
Country Code:
Telephone No.: (
)
Extension:
From Date: (dd-MMM-yyyy)
To Date: (dd-MMM-yyyy)
Reference Type: (Mark ‘X’ to one that applies)
Friend
Neighbor
Schoolmate
Work Associate
Other:
State:
Country:
Work Phone:
Available Day or Night?
Country Code:
Telephone No.: (
)
Extension:
State:
Country:
Work Phone:
Available Day or Night?
Country Code:
Telephone No.: (
)
Extension:
State:
Country:
Work Phone:
Available Day or Night?
Country Code:
Telephone No.: (
)
Extension:
59
Zip Code:
Day
Night
-
Zip Code:
Day
Night
-
Zip Code:
Day
Night
-
PROFESSIONAL ORGANIZATION(S)
Organization Name
(i.e. Am. Medical Assoc.)
From Date
(yyyymmdd)
To Date
(yyyymmdd)
Status
(i.e. Current, unrestricted,
suspended, withdrawn…)
PROFESSIONAL LICENSE(S)
List all professional licenses/certifications ever held, even if expired.
State
(i.e. HI)
National
License?
Y/N
License No.
(i.e. 01234)
License Type
(i.e. Registered
Nurse)
Initial Issue Date
(yyyymmdd)
Expiration Date
(yyyymmdd)
PROFESSIONAL PRIVILEGE(S)
All information must match professional privilege(s) verification letter(s) submitted.
Facility Name:
From Date: (yyyymmdd)
To Date: (yyyymmdd)
Status:
Facility Address:
Street:
State:
City:
Country:
Facility Phone No.:
Country Code:
Telephone No.: (
)
-
Zip Code:
Extension:
PROFESSIONAL PRIVILEGE(S)
Facility Name:
From Date: (yyyymmdd)
Status:
Facility Address:
Street:
City:
Facility Phone No.:
Country Code:
From Date: (yyyymmdd)
State:
City:
Telephone No.: (
)
-
60
Zip Code:
Extension:
Status
(i.e. Current,
unrestricted,
suspended,
withdrawn…)
MALPRACTICE INSURANCE PROVIDER
Provide information for Malpractice Insurance Provider(s) within the past 7 years. Information must match
Malpractice Insurance verification letter submitted.
Carrier Name:
Policy No.:
Street Address:
City:
State:
Zip Code:
Telephone No.:(
)
Time of Provider Coverage:
From Date: (yyyymmdd)
To Date: (yyyymmdd)
Carrier Name:
Street Address:
City:
Telephone No.:(
)
Time of Provider Coverage:
From Date: (yyyymmdd)
Case No.:
Suit Filed? Y/N:
MALPRACTICE INSURANCE PROVIDER
Policy No.:
State:
Zip Code:
To Date: (yyyymmdd)
MALPRACTICE CLAIM
Allegation:
Court Date: (yyyymmdd):
Claim Status (Closed, Open, Settled or Suit Withdrawn):
Disposition Favored:
Payment Required? Y/N:
Payment Amount: $
Detailed Medical Facts:
Associated Carrier(s):
Payment Type (Award or Settlement):
MALPRACTICE CLAIM
Case No.:
Allegation:
Suit Filed? Y/N:
Court Date: (yyyymmdd):
Claim Status (Closed, Open, Settled or Suit Withdrawn):
Disposition Favored:
Payment Required? Y/N:
Payment Amount: $
Detailed Medical Facts:
Associated Carrier(s):
Payment Type (Award or Settlement):
ACTIVE DUTY ASSIGNMENT PREFERENCES
Complete the information below regarding active duty preferences.
First Assignment Preference:
Duty Assignment (Location):
Area Assignment (AOC-if applicable):
Second Assignment Preference:
Duty Assignment (Location):
Area Assignment (AOC-if applicable):
Third Assignment Preference:
Duty Assignment (Location):
Area Assignment (AOC-if applicable):
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