Form SF 85 Content Guid SF 85 Content Guid SF 85

Questionnaire for Non-Sensitive Positions
OMB No. 3206–0261
Form: SF 85

Interactive/Branching
Electronic Questionnaire

Questionnaire Content Guide

FOR REFERENCE ONLY
NOT A FORM FOR COMPLETION

General Electronic Form Notes/Notices (all Sections)
The questions/content captured in this document are intended to display what data will be captured from the subject and the additional questions
to be presented based on the subject’s responses to previous questions during data capture.
Question numbering and “electronic form navigation notes” have been made throughout this form to help facilitate review and navigation. These
items are subject to change based on the data collection or processing systems this form may be implemented in. Additionally numbering and
electronic form notes are not to be considered part of the content of the form. Only the section numbers are applicable as the official numbering
for this form.
Screens may vary based on html style formatting, java scripting, data capture formatting, system functionality, validation, and navigation.
Systems that are used for the collection of the “Questionnaire for Non-Sensitive Positions (SF 85)” data for investigative purposes are subject to
OMB review and approval.
Dropdown lists throughout this form (such as listings of countries, document types, etc.) are subject to change based on changes or requirements
of federal information processing standards and other updates/changes to pertinent information collection, consistent with approved content.

OFFICE OF PERSONNEL MANAGEMENT
Questionnaire for Non-Sensitive Positions, SF 85
Questionnaire for Non-Sensitive 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 17 and 20, 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 and reinvestigations of persons under consideration for, or retention of, nonsensitive low risk positions as defined in 5 CFR 731. It is also used for determining fitness of individuals under consideration for, or retention in positions in the excepted service when
the duties to be performed are equivalent to a low risk position. This form may also be used by agencies in determining whether a subject should be issued a Federal credential for access
to federally controlled facilities and information systems . For applicants, this form is to be used only after a conditional offer of employment has been made, unless OPM has provided
for an exception. This form is not to be used for National Security sensitive positions.
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 position or your ability to obtain or retain Federal or contract employment, 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 positions, physical and /or logical access required to perform
duties, 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, or prosecution.
This form may become a permanent document that may be used as the basis for future investigations, determinations of 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 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 Orders13764, 13741, 10577, 13467, and 13488, as
amended; sections 3301, 3302, 7301, and 9101 of title 5, United States Code (U.S.C.); parts 2, 5, 6, 731, and 736 of title 5, Code of Federal Regulations (CFR), Homeland Security
Presidential Directive (HSPD) 12, and Federal information processing standards.
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 may prevent or
delay the processing of your background investigation. The authority for soliciting and verifying your SSN is Executive Order 9397, as amended by EO 13478.
The Investigative Process
Background investigations for non-sensitive positions are conducted to gather information to determine whether you are reliable, trustworthy, of good conduct and character, and will
not present an unacceptable risk,. The information that you provide on this form and your Declaration for Federal Employment (OF 306) 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.
In addition to the questions on this form, inquiry also is made about your adherence to security requirements, your honesty and integrity, falsification, misrepresentation, and any other
behavior, activities, or associations that tend to demonstrate a person is not reliable or trustworthy, or poses an unacceptable risk to the life, safety, or health of employees, contractors,
vendors or visitors to a Federal facility; the Government’s physical assets or information systems; personal property; records, or, the privacy of the individuals whose data the
Government holds in its systems. After an eligibility determination is made, you may also be subject to reinvestigations to ensure your continuing suitability for employment.
The information you provide on this form may be confirmed during the investigation, and may be used for identification purposes throughout the investigation process.
Your Personal Interview
Some investigations may include an interview with you as needed as 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. If contacted, it
is imperative that the interview be conducted as soon as possible after contact is made by the investigator. 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.
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. 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.
6. For telephone numbers in the U.S., ensure that the area code is included.
7. All dates provided in this form must be in Month/Day/Year or Month/Year format. The month and day should be entered as a two character numbers (i.e., 01 for January and 29 for
29th day of the month). The year should be entered as a four character number (i.e., 1978 or 2001). 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 "Estimated." box.
Final Determination on Your Eligibility
Final determination on your eligibility for a position and/or physical or logical access to federal facilities and information is the responsibility of the Office of Personnel Management or
the Federal agency that requested your investigation. You may 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 prohibited categories, including but not limited to race, color, religion, sex
(including pregnancy and gender identity), national origin, disability, and sexual orientation, when making determinations of eligibility for non-sensitive positions, physical and/or
logical access required to perform duties.
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, 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 are 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 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. You will not receive prior notice of such disclosures under a routine use.
The Defense Counterintelligence and Security Agency, the Government’s primary investigative service provider, has published its routine uses in the Federal Register at the
following address: https://www.federalregister.gov/documents/2018/10/17/2018-22508/privacy-act-of-1974-system-of-records. If another agency is conducting your investigation, it
will inform you of its routine uses.
Public Burden Information
The public reporting burden to complete this information collection is estimated at 120 minute per response, including time for reviewing instructions, searching data sources, gathering
and maintaining the data needed, and the completing and reviewing the collected information. An agency may not conduct or sponsor, and a person is not required to respond to a
collection of information unless it displays a currently valid OMB control number and expiration date. Send comments regarding this burden estimate or any other aspect of this collection
information, including suggestions for reducing this burden to the Office of Personnel Management, ATTN: Suitability Executive Agent Programs. Current information regarding this
collection of information – including all background materials -- can be found at https:/www.reginfo.gov/public/do/PRAMain by using the search function to enter either the title of the
collection (Suitability Executive Agent Programs) or the OMB Control Number (3206-0261).
--------------------END OF INSTRUCTION PAGES -------------------

f.

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), or removal and debarment from Federal
YES NO
Service.

Agency Use Block “AUB”
Investigating agency user only
Codes:
(FIPC CODES)
Case Number:
FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: AS A REMINDER, AGENCIES ARE RESPONSIBLE FOR REVIEWING
INFORMATION PROVIDED ON THE OF 306, RESUME, AND OTHER DOCUMENTATION PROVIDED AS PART OF THE HIRING
PROCESS TO IDENTIFY POSSIBLE DISCREPANCIES WITH INFORMATION PROVIDED ON THE STANDARD FORM
QUESTIONNAIRE. AGENCIES MUST NOTIFY THEIR INVESTIGATIVE SERVICE PROVIDER OF ANY DISCREPANCIES THAT MAY
EXIST BETWEEN THE FORMS, AND REQUEST RESOLUTION OF THE CONFLICT THROUGH THE INVESTIGATION PROCESS. IN
THIS SITUATION THE DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.
A – Type of Investigation
B – Extra coverage / advanced results
C –Risk level
D – Nature of action code
E – Date of action
F – Geographic location
G – Position code
H – Position title
I – SON (Submitting Office Number )
J – Location of Official Personnel Folder _ None _ NPRC _ At SON _e-OPF _ Other
Other address / web address of e-OPF
Zip Code
K – SOI (Security Office Identifier)
L – Location of Security Folder _ None _ NPI _ At SOI __ Other
Other address
Zip Code
M – IPAC
N – TAS
O – Obligating document number
P - BETC
Q – Accounting data and /or Agency case number
R – Investigative requirement _Initial _Reinvestigation
S – Requesting Official: Name, Title, Signature, Email Address, Telephone, Date
T – Secondary Requesting Official: Name, Title, Email Address, Telephone Number
U – Applicant Affiliation _ FED CIV _ CON _ MIL _ Other
V – Deployment/PCS (if Imminent):
From Est.-To Dates, Est., Permanent Relocation, Reason(s) for temporary duty assignment or PCS, point of contact at location, Telephone number
(Include Ext.), Address/Unit/Duty location (Include City or Post Name)
Agency Special Instructions for the Investigative Service Provider:
Cage Code
Contracting Number

Beginning of Questionnaire

FOR REFERENCE ONLY, NOT A FORM FOR COMPLETION
Section 1 – Full Name
Provide your full name. If you have only initials in your name, provide them and indicate “Initial only”. If you
do not have a middle name, indicate “No Middle Name”. If you are a "Jr.," "Sr.," etc. enter this under Suffix.

Last

First

Middle

Suffix

Section 2 – Date of Birth
Provide your date of birth.

Date _ _-_ _-_ _ _ _ Est. □

Section 3 – Place of Birth
Provide your Place of birth.

City

County

State

Country

Section 4 – SSN
Provide your U.S. Social Security Number.

□ Not applicable _ _ _-_ _-_ _ _ _

Section 5 – Other Names Used
Provide your other names used and the period of time you used them (for example: your maiden name, name(s) by a former marriage (s), former name(s),
alias (es), or nickname(s)).
Have you used any other names?
YES
NO
Provide your other name used and the period of time you used it [for example: your maiden name, name by a former marriage, former
Branch
If Yes to
name, alias, or nickname]. If you have only initials in your name, provide them and indicate “Initial only.” If you do not have a middle
“Other
name, indicate “No Middle Name” (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Names”
Provide other name used.
Last
First
Middle
Suffix
Maiden name?
Yes
No
Provide dates used.
From Date (Estimated)
To Date (Estimated/Present)
(Multiple
Provide the reason(s) why the name changed.
Reason: (Free Text)
Entries
Do you have additional names to enter?
Yes (Yes adds another entry)
No (Required to pass validation)
Allowed)

Section 6 – Your Identifying Information
Provide your Identifying Information

Height

(feet)

(inches)

Weight (in pounds)

Hair Color

Eye Color

Sex (M/F)

Section 7 – Your Contact Information
Provide three contact numbers. At least one telephone number is required. Additional numbers provided may assist in the completion of your background
investigation.
Provide your contact information.
Home email address
Email (Free Text)
Work email address
Email (Free Text)
Email addresses may be used as a
contact method, and identify subject
in records.
Home telephone number
Work telephone number
Mobile/Cell telephone number
Extension Time Day Night Both
Extension Time Day Night Both
Extension Time Day Night Both
__Check box if International or DSN __Check box if International or DSN
__Check box if International or DSN
phone number
phone number
phone number

Section 8 – U.S. Passport Information
Do you possess a U.S. passport (current or expired)?
YES
NO
Provide the following information for the most recent U.S. passport you currently possess:
Provide your U.S. passport number
Passport (Free Text)
Branch
Click HERE for U.S. State Department passport help. http://travel.state.gov/passport
If Yes to
Provide the issue date of passport.
Date (Estimated)
Provide the expiration date of passport.
Date (Estimated)
“passport”
Provide the name in which passport was first issued.
Last
First name:
Middle name:
Suffix
name:

Section 9 – Citizenship
Select the box that reflects your current citizenship status and click Save.
Provide your current citizenship status:
□ I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
□ I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country. □ I am a naturalized U.S. citizen. □ I am a derived U.S. citizen. □ I
am not a U.S. citizen.
Provide your Mother’s Maiden Name Last Name/First Name/ Middle Name/Suffix
You answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.
Provide type of documentation of U.S. citizen born abroad.
Explanation
Branch
FS 240, DS 1350, FS 545, Other (Provide explanation)
Provide document number for U.S. citizen born abroad:
Document Number (Free Text)
Foreign Born
Date __-__-____ Estimated □
to U.S. Parents Provide the date the document was issued.
Provide the place of issuance.
City
State
Country
in a Foreign
Provide the name in which document was issued.
Last name:
First
Middle
Suffix
Country
name:
name:
Provide your Certificate of Citizenship number.
Certificate Number (Free Text)
Provide the date the certificate was issued.
Date __-__-____ Estimated □
Provide the name in which the certificate was issued.
Last name:
First
Middle
Suffix
name:
name:
Were you born on a U.S. military installation?
YES
NO
You answered that you were born on a U.S. military installation.
Branch If Yes
Provide the name of the base.

Name (Free Text)

Branch
Citizenship
Naturalization
U.S Citizen

Branch
Citizenship
Derived

Branch
Citizenship
Not a U.S.
citizen

You answered that you are a naturalized U.S. citizen.
Provide the date of entry into the U.S.
Provide the location of entry into the U.S.
Provide country(ies) of prior citizenship.
Do/did you have a U.S. alien registration number?
Branch If Yes
Provide your U.S. alien registration number on
Certificate of Naturalization-utilize USCIS,
CIS, or INS registration number, I-551, I-766.
Provide your Certificate of Naturalization number (N550 or N570).
Provide the name of the court that issued the Certificate of Naturalization
Provide the address of the court that issued the
Certificate of Naturalization
Street
City
Provide the date the Certificate of Naturalization was issued.
Provide the name in which the Certificate of Naturalization was issued.

Date __-__-____ Estimated □
City
State
Country (Allows for Multiples)
YES
Alien Registration Number (Free Text)

NO

Certificate of Naturalization Number (Free Text)
Court (Free Text)

State
Zip
Date __ -__-____ Estimated □
Last
First
Middle
name:
name: name:

Suffix

Provide the basis of naturalization. - Based on my own individual naturalization application,
Explanation
- Other (Provide explanation)
You answered that you are a derived U.S. citizen.
Provide your alien registration number (on Certificate of Citizenship — utilize USCIS, CIS or INS registration number)
Alien
Registration Number (Free Text)
Provide your Permanent Resident Card number (I-551)
Permanent Resident Card number (I-551) (Free Text)
Provide your Certificate of Citizenship number (N560 or N561)
Certificate of Citizenship number (N560 or N561) (Free Text)
Provide the name in which the document was issued.
Last name:
First name:
Middle name:
Suffix:
Provide the date document was issued Date __-__-___ Estimated __
Provide the basis of derived citizenship. -By operation of law through my U.S. citizen parent .-Other (Provide explanation)
Explanation
Not a U.S. Citizen
Provide your residence status.
Status (Free
Provide your date of entry into the
Date __ -__-____ Estimated □
Text)
U.S.
Provide your country (ies) of citizenship. Allow
Provide your place of entry in the U.S.
City (Free Text) State
multiple
Provide your alien registration number. (I-1551, I-766)
Registration Number (Free Text)
Provide document expiration date (I-766 ONLY).
Date__-__-____ Estimated □
Provide type of document issued. (I-94, U.S. Visa-red
I-94, U.S. Visa (red foil number), I-20, DS-2019,
Explanation
foil number, I-20, DS-2019, etc.)
Other (Provide explanation)
Provide document number:
Document Number (Free Text)
Provide the name in which the document was issued.
Last name:
First
Middle
Suffix
name:
name:
Provide the date document was issued.
Date_-__-____
Provide document expiration
Date_-__-____
Estimated □
date.
Estimated □

Section 10 – Dual/Multiple Citizenship
Do you now or have you EVER held dual/multiple citizenships?
YES NO
You answered “Yes” to having EVER held dual/multiple citizenship
Provide country of citizenship
During what period of time did you hold citizenship with this country?
Provide the date range that you held this citizenship; beginning with the date it was
From Date
To Date (Estimated/Present)
Branch
acquired through its termination or “Present,” whichever is appropriate.
(Estimated)
How did you acquire this non-U.S. citizenship you now have or previously had?
How (Free Text)
Dual/Multiple
Citizenship
(Multiple
Entries
Allowed)

Do you currently hold citizenship with this country?
Branch
If Present/Current
Provide explanation:
Summary of dual/multiple citizenships you have listed: Allow multiple
Select Country Value
Dates of Citizenship
Do you have an additional citizenship to provide?
YES (Yes adds another entry)

YES

NO

Actions
NO (Required to validate)

Section 11 – Where You Have Lived
List the places where you have lived beginning with your present residence and working back 5 years. Residences for the entire period must be accounted
for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you
were not physically located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list
residence before your 18th birthday unless to provide a minimum of 2 years residence history.
You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.
For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew
you for residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives as the verifier for periods of residence.
Enter residence information. (Multiple Entries Allowed)
Provide dates of residence.
From Date (Estimated )
To Date
(Estimated /Present)
Is/was this residence: □ Owned by you □ Rented or leased by you □ Military housing □ Other (Provide explanation)
Explanation (Free Text)

Provide the street address.
Street address and City
Provide the country if outside the United States; otherwise provide
State
Zip Code
Country
State and Zip Code
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and country
Branch
Physical
location or home port/fleet headquarter. Provide physical location data:
Location
Street Address/Unit/Duty Location:
City or Post Name
Provide State for ports in United States, or Country location.
State and Zip Code or Country
You have indicated an address outside of the United States.
Branch
APO/FPO
Do/did you have an APO/FPO address while at this location?
Yes
No
Address
Branch You have indicated that you have or had and APO/FPO while at this location.
Provide APO/FPO address:
Address
APO or FPO
APO/FPO State Code Zip Code
Provide the name of a neighbor, landlord (if rental), or other person who knows you at this address.
Last
First
Middle
Suffix Provide date of last contact:
Date MM-YYYY_ Estimated
Provide the full name:
name: name: name:
□
Provide your relationship to this person (select all that apply)
□ Neighbor □ Friend □ Landlord □ Business associate
□ Other (Provide explanation) Explanation (Free Text)
Provide the following contact information for this person :
Provide evening phone number for this
Number/Extensio Provide daytime phone number for this person: Number/Extension
person:
n __Check box
__Check box if
if International or
International or
DSN phone
DSN phone number
number
_I don’t
Branch
_I don’t
know
know
Person Who
Provide cell/mobile phone number for this person:
Number/Extension Time Day Night Both
Knew you
__Check box if International or DSN phone number
_I don’t know
(if address
Provide e-mail address for this person:
Email (Free Text) _I don’t know
dates within
last 3 years)
Provide street address for this person (including apartment
Street address
City
number).
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
You have indicated an APO/FPO address; provide physical location data with street address, base, post, embassy, unit, and
Branch
country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name
Location
Provide State for ports in United States, or Country location.
State and Zip Code or Country
You have indicated an address outside of the U.S.
Branch
APO/FPO
Does the person who knew you have an APO/FPO address?
YES NO
Address
Branch If Yes Provide APO/FPO address:
Address
APO or FPO
APO/FPO State Code
Zip Code
Do you have an additional residence to report?
YES (Yes adds another entry)
NO (Required to validate)

Section 12 – Where You Went to School
Do not list education before your 18th birthday, unless to provide a minimum of two years education history. (Multiple Entries Allowed)
Have you attended any schools in the last 5 years?
YES NO
Have you received a degree or diploma more than 5 years ago?
YES NO
Provide the dates of attendance.
From Date (Estimated)
To Date (Estimated/Present)
Select the most appropriate box to describe your school. □ High School □ College/University/Military College
□ Vocational/Technical/Trade School □ Correspondence/Distance/Extension/Online School
Provide the name of the school:
Name (Free Text)
Provide the street address of the school. For correspondence/distance/
Street address
City
extension/online schools, provide the address where the records are maintained.
For assistance determining the school address, refer to
http://ope.ed.gov/accreditation/search.aspx
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list
people for education periods completed more than 3 years ago. For correspondence/distance/extension/ online schools, list
someone who knew you while you received this education
Branch
Branch
Provide the name of person who knows/knew you at school: □ I don’t know
Last
First
Initial Only □
name:
name:
No First Name □
If Yes to
If Yes to
Attending
Provide current address for this person (including apartment number).
Street
City
Receiving
Schools
Provide Country if outside the United States; otherwise, provide State and Zip
State
Zip Code Country
Degree
Code
Provide telephone number for this person.
Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
___ I don’t know
Provide email address for this person: □ I don’t know
Email (Free Text)
Did you receive a degree/diploma?
YES NO
Provide type of degrees(s)/diploma(s) received and date(s) awarded:
Degree/diploma
• High School Diploma
Other degree/diploma
Branch
• Associate’s • Bachelor’s • Master’s • Doctorate
If Yes to
Other Degree (Free Text)
• Professional Degree (e.g. MD, DVM, JD) • Other
Receiving Degree
Month / Year
Date __-__-____
Estimated □

Do you have additional education to enter (include education within the last 5
years, as well as degrees or diplomas more than 5 years ago)?

YES (Yes adds
another entry)

NO (Required to
validate)

Section 13a – Employment Activities – Employment & Unemployment Record
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 5 years. The entire
period must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of
military duty station. Provide separate entries for employment activities with the same employer but having different physical
addresses. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.
(Multiple Entries Allowed)
Select your employment activity: □ Active military duty station □ National Guard/Reserve □ USPHS Commissioned Corps
□ Other Federal employment
□ State Government (Non-Federal employment)
□ Self-employment □ Unemployment
□ Federal Contractor
□ Non-government employment (excluding self-employment)
□ Other (Provide explanation)
Other Type Explanation (Free Text)
Provide dates of employment.
From Date (Estimated)
To Date (Estimated/Present)
Active Duty, National Guard/Reserve, or USPHS Commissioned Corps
Select the employment status for this position: □ Full-time □ Part-time
Provide your assigned duty
Duty station (Free Text)
Provide your most recent
Rank/position (Free Text)
station during this period.
rank/position title.
Provide address of duty station.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code.
Telephone number
Number/Extension Time Day Night Both
__Check box if International or DSN phone number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
unit, and country location or home port/fleet headquarter.
Provide physical location data:
Branch
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip
Country
Branch
Code
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
If Employment
address while at this location?
APO/FPO
Type is Active
Address
Branch If Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Duty, National
Guard/Reserve,
Provide the name of your supervisor.
Supervisor name (Free Text)
or USPHS
Provide the rank/position title of your supervisor.
Supervisor rank/position (Free Text)
Commissioned
Provide the email address of your supervisor. □ I don’t know
Supervisor email (Free Text)
Corps
Provide the physical work location of your supervisor.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide supervisor telephone number
Number/Extension Time Day Night Both
__Check box if International or DSN phone number
You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address,
base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your
Branch
supervisor:
Physical
Location
Street Address/Unit/Duty Location:
City or Post Name:
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Did/does your supervisor have an
YES NO
Branch
APO/FPO address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Other Federal employment, State Government, Federal Contractor, Non-government employment, or Other
Provide most recent position title.
Position (Free Text)
Select the employment status for this position: □ Full-time □ Part-time
Provide the name of your employer
Employer name (Free Text)
Provide the address of employer
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide telephone number
Number/Extension Time Day Night
Both
Branch
__Check box if International or DSN
phone number
If Employment
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than
Type is Other
one occasion at the same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of
Federal
time, you would enter information concerning the most recent period of employment above, and provide dates, position titles, and
employment,
supervisors for the two previous periods of employment as entries below). Not Applicable □ (Multiple Entries Allowed)
State
Dates of employment
From Date (Estimated)
To Date (Estimated/Present)
Government,
Federal
Position title
Position (Free Text)
Supervisor
Supervisor (Free Text)
Contractor, NonIs/was your physical work address different than your employer’s address?
YES NO
government
Provide the work address where you are/were physically located.
Street Address
City
employment, or
Provide Country if outside the United States; otherwise
State
Zip Code
Country
Branch
Other
Physical
provide State and Zip Code
Location
Provide the telephone number
Number/Extension Time Day Night Both
__Check box if International or DSN phone number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
Branch
unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code
Country
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
APO/FPO
address while at this location?

Address
Branch if Yes
Provide APO/FPO address:
Provide the name of your supervisor.
Provide the position title of your supervisor.
Provide the email address of your supervisor. □ I don’t know
Provide the physical work location of your supervisor.
Provide Country if outside the United States; otherwise,
provide State and Zip Code
Provide the telephone number for this supervisor.

Branch
If Employment
Type is SelfEmployment

Branch
If Employment
Type is
Unemployment

Address

Street address
State

APO/FPO

APO/FPO State
Zip Code
Supervisor name (Free Text)
Supervisor position (Free Text)
Supervisor email (Free Text)
City
Zip Code
Country

Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
You have indicated an APO/FPO address for your supervisor; provide physical location data with either street address,
base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location data of your
Branch
supervisor:
Physical
Location
Street Address/Unit/Duty Location:
City or Post Name:
Provide state for ports in the United States, or country location.
State and Zip Code or Country
You have indicated an address outside of the United States. Did/does your supervisor have an
YES NO
Branch
APO/FPO address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Self-Employment
Provide most recent position title.
Position (Free Text)
Select the employment status for this position:
□ Full-time □ Part-time
Provide the name of your employment
Employment name (Free Text)
Provide the address of employment
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide telephone number
Number/Extension Time Day Night
Both
__Check box if International or DSN
phone number
Is your physical work address different than your employment address?
YES NO
Provide the work address where you are/were physically
Street address
City
located.
Provide Country if outside the United States; otherwise, provide State and Zip State
Zip
Country
Branch
Code
Code
Physical
Provide telephone number
Number/Extension Time Day Night
Location
Both
__Check box if International or DSN
phone number
You have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy,
Branch
unit, and country location or home port/fleet headquarter. Provide physical location data:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code Country
You have indicated an address outside of the United States. Do you or did you have an APO/FPO YES NO
Branch
address while at this location?
APO/FPO
Address
Branch if Yes
Provide APO/FPO address: Address
APO/FPO
APO/FPO State
Zip Code
Provide the name of someone that can verify your self-employment.
Last
First
Provide the address of this verifier.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide the telephone number for this person
Number/Extension Time Day Night Both
__Check box if International or DSN phone number
You have indicated an APO/FPO address for your self-employment verifier; provide physical location data with either
Branch
street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location
Verifier
data for this person
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code Country
You have indicated an address outside of the United States. Does your self-employment verifier
YES NO
Branch
have an APO/FPO address?
Verifier
APO/FPO
Provide APO/FPO address for this person:
Address
APO/FPO
Branch if Yes
Address
APO/FPO State
Zip Code
Unemployment
Provide the name of someone who can verify your unemployment activities and means of support
Last
First name:
name:
Provide the address of this verifier.
Street address
City
Provide Country if outside the United States; otherwise,
State
Zip Code
Country
provide State and Zip Code
Provide the telephone number for this person
Number/Extension Time Day Night Both _Check box if
International or DSN phone number
You have indicated an APO/FPO address for your unemployment verifier; provide physical location data with either
Branch
street address, base, post, embassy, unit, and country location or home port/fleet headquarter. Provide physical location
Verifier
data for this person:
Physical
Street Address/Unit/Duty Location:
City or Post Name:
Location
Provide state for ports in the United States, or country location.
State
Zip Code Country
You have indicated an address outside of the United States. Does your unemployment verifier
YES NO
Branch

Verifier
have an APO/FPO address?
APO/FPO
Provide APO/FPO address for this person:
Address
APO/FPO
Branch if Yes
Address
APO/FPO State
Zip Code
Provide the reason for leaving the employment activity.
Reason (Free Text)
For this employment have any of the following happened to you in the last five (5) years?
YES NO
• Fired • Quit after being told you would be fired • Left by mutual agreement following charges or
allegations of misconduct • Left by mutual agreement following notice of unsatisfactory performance
Branch

Select the type of incident: • Fired • Quit after being told you would be fired
• Left by mutual agreement following charges or allegations of misconduct
If Employment
Branch
• Left by mutual agreement following notice of unsatisfactory performance
Type is Active
Provide the reason for being fired.
Reason (Free Text)
Branch
Duty, National
If Fired, Quit,
If Fired
Provide the date you were fired.
Date (Estimated)
Guard/Reserve,
Left by Mutual
Provide the reason for quitting.
Reason (Free Text)
Branch
USPHS
Agreement, or
Provide the date you quit after being told you would be
Date (Estimated)
If Quit
Commissioned
Left After
fired.
Corps, Other
Unsatisfactory
Provide the charges or allegations of misconduct.
Charges (Free Text)
Federal
Performance
Branch
Provide
the
date
you
left
following
charges
or
allegations
Date (Estimated)
employment,
If Left after Charges
of misconduct.
State
(Multiple
Provide the reason(s) for unsatisfactory performance.
Reason (Free Text)
Branch
Government,
Entries
If Left Unsatisfactory Provide the date you left by mutual agreement following a Date (Estimated)
Federal
Allowed)
performance
notice of unsatisfactory performance.
Contractor, NonIn the last five (5) years do you have another reason for leaving to
YES (Yes adds
NO (Required to
government
report for this employment?
another entry)
validate)
employment,
For this employment, in the last five (5) years have you received a written warning, been officially
YES NO
Selfreprimanded, suspended, or disciplined for misconduct in the workplace, such as a violation of security policy?
Employment,
Officially reprimanded, suspended, or disciplined for misconduct.
Branch
Unemployment,
If Disciplined,
Provide the month and year you were warned, reprimanded, suspended or
Date/ Estimated □
or Other
Warned,
disciplined.
Reprimanded, or
Provide the reason(s) for being warned, reprimanded, suspended or disciplined
Reason (Free Text)
Suspended
Do you have another instance of discipline or a warning to
YES (Yes adds
NO (Required to
(Multiple Entries
provide?
another entry)
validate)
Allowed)
Do you have an additional employment activity to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 13b – Employment Record
Have any of the following happened to you in the last five (5) years at employment activities that you have not previously listed? (If Yes, you will be
required to add an additional employment in Section 13a)
• 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?
YES NO

Section 14 – Selective Service Record
Were you born a male after December 31, 1959?
YES
NO
Selective Service Registration
Have you registered with the Selective Service System (SSS)?
I don’t know
YES
NO
The Selective Service website, www.sss.gov, can help provide the registration number for persons who have
Branch
Branch
registered. Note: Selective Service Number is not your Social Security Number
If Yes
Provide registration number:
Registration number (Free Text)
If Yes to Born
You responded 'No' to having registered with the Selective Service System (SSS)
Branch
Male After
If No
Provide explanation
Explanation (Free Text)
12/31/1959
You responded 'I don't know' to having registered with the Selective Service System (SSS)
Branch
If I Don’t Know
Provide explanation
Explanation (Free Text)

Section 15 – Military History
Have you EVER served in the U.S. Military?
YES NO
You responded ‘Yes’ to having served in the U.S. Military:
Provide the branch of service you served in:
State of service, if National
Officer or enlisted: Provide your service number
□ Army □ Army National Guard
Guard
□ Not Applicable
(Free Text)
□ Navy □ Air Force □ Air National Guard
□ Officer
Provide your status
□ Marine Corps □ Coast Guard
□ Enlisted
□ Active Duty □ Active Reserve
Number (Free Text)
Branch
□ Inactive Reserve
Provide your dates of service
From Date (Estimated)
To Date (Estimated/Present)
If Yes to
Were you discharged from this instance of U.S. military service, to include Reserves, or National Guard?
YES NO
Serving in
You responded ‘Yes’ to being discharged from U.S. military service, to include Reserves
the U.S.
or National Guard.
Branch
Military
Provide the type of discharge you received: □ Honorable □ Dishonorable □ Under Other than Honorable Conditions □
General □ Bad Conduct □ Other (provide type)
If Yes to
(Multiple
Discharged
Provide other discharge type:
Discharge explanation (Free Text)
Entries
Provide
the
date
of
discharge
listed
above
Date (Estimated)
Allowed)
Branch If Discharge Not Honorable
Provide the reason(s) for the discharge.
Reason(s) (Free Text)
Do you have additional military service to report?
YES (Yes adds
NO (Required to
another entry)
validate)
In the last 5 years, have you been subject to court martial or other disciplinary procedure
YES
NO
under the Uniform Code of Military Justice (UCMJ), such as Article 15, Captain’s mast,

Article 135 Court of Inquiry, etc?
You responded ‘Yes’ to having 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 in the last 5 years.
Provide the date of the court martial or other disciplinary procedure.
Date (Estimated)
Provide a description of the Uniform Code of Military Justice (UCMJ) offense(s) for which you
Description (Free
were charged.
Text)
Branch
Provide the name of the disciplinary procedure, such as Court Martial, Article 15, Captain’s mast,
Name
If Yes to
Article 135 Court of Inquiry, etc.
(Free Text)
Military
Provide the description of the military court or other authority in which you were charged (title of
Description
Discipline
court or convening authority, address, to include city and state or country if overseas).
(Free Text)
Provide the description of the final outcome of the disciplinary procedure, such as found guilty,
Description
found not guilty, fine, reduction in rank, imprisonment, etc.
(Free Text)
In the last 5 years do you have an additional
YES (Yes adds another entry)
NO (Required to validate)
instance of military discipline to report?
Have you EVER served as a civilian or military member in a foreign country’s military, intelligence, diplomatic, security forces,
YES NO
militia, other defense force, or government agency?
You responded ‘Yes’ to having 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.
Branch
During your foreign service, which organization were you serving under: □ Military (Army, Navy, Air Force, Marines, etc.), Specify
□ Intelligence Service □ Diplomatic Service □ Security Forces □ Militia □Other Defense Forces, Specify □ Other Government Agency,
If Yes to
Specify
Serving in a Provide the name of the foreign organization.
Name (Free Text)
Foreign
Provide your period of service
From Date (Estimated)
To Date (Estimated/Present)
Military
Provide the name of the country
Provide your highest position/rank
Position held (Free Text)
held
(Multiple
Provide the division/department/office in which you served.
Division (Free Text)
Entries
Provide a description of the circumstances of your association with this organization.
Description (Free Text)
Allowed)
Provide a description of the reason for leaving this service.
Description (Free Text)
Do you have an additional foreign military service to report?
YES (Yes adds
NO (Required to
another entry)
validate)

Section 16 – Police Record
For this section 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.
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 last five (5) 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 last five (5) years have you been arrested by any police officer, sheriff, marshal or any other type of law enforcement official?
• In the last 7 five (5) years have you been charged with, convicted of, or sentenced for 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).
• In the last 7 five (5) years have you been or are you currently on probation or parole?
• Are you currently on trial or awaiting a trial on criminal charges?
YES NO
Provide the date of offense.

Branch
If Yes to the
Above
Happening
(Multiple
Entries
Allowed)

Date (Estimated)

Provide a description of the
specific nature of the offense.

Description (Free Text)

Provide the location where the offense occurred.
Street address and city
State and Zip Code or Country
Were you arrested, summoned, cited, or did you receive a ticket to appear as a result of this offense by any police
YES NO
officer, sheriff, marshal or any other type of law enforcement official?
Arresting/citing/summoning agency
Branch
If Yes to Being
Provide the name of the law enforcement agency that arrested/cited/summoned you.
Name (free Text)
Arrested/Cited/
Provide the location of the law
Street address and city, County
State and Zip Code or Country
Summoned
enforcement agency.
As a result of this offense were you charged, convicted, currently awaiting trial, and/or ordered to appear in court
YES NO
in a criminal proceeding against you?
Branch - If No
You responded ‘No’ to “As a result of this offense were you charged, convicted, currently awaiting trial, and/or
to Charged or
ordered to appear in court in a criminal proceeding against you?”
Convicted
Provide Explanation
Explanation (Free Text)
Court information
Provide the name of the court.
Name of court (Free Text)
Provide the location of the court.
Street address and city
State and Zip Code or Country
Provide all the charges brought against you for this offense, and the outcome of each charged offense (such as found
guilty, found not-guilty, charge dropped or “nolle pros,” etc). If you were found guilty of or pleaded guilty to a lesser
offense, list separately both the original charge and the lesser offense.
Branch
Felony/Misdemeanor
Felony, Misdemeanor, Other
Charge
Charge (Free Text)
Outcome
Outcome (Free Text)
Date (Month/Year)
Date
If Yes to
(Est.)
Charged or
Convicted
Were you sentenced as a result of this offense?
YES NO
Conviction detail
Branch
Provide a description of the sentence.
If Yes to
If the conviction resulted in imprisonment, provide the dates
From Date (Estimated)
Being
that you actually were incarcerated. (Not Applicable □ )
To Date (Estimated/Present)
Sentenced
If conviction resulted in probation or parole, provide the
From Date (Estimated)

dates of probation or parole. (Not Applicable □ )
To Date (Estimated/Present)
Trial detail
Branch
If No to
Are you currently on trial, awaiting a trial, or awaiting sentencing on criminal
YES NO
Being
charges for this offense?
Sentenced
Provide Explanation
Explanation (Free Text)
Do you have any other offenses where any of the following has happened to you?
YES
NO
• In the last five (5) years have you been issued a summons, citation, or ticket to appear in
(Yes adds
(Required to validate)
court in a criminal proceeding against you? (Do not include citations involving traffic
another entry)
infractions where the fine was less than $300 and did not include alcohol or drugs)
• In the last five (5) years have you been arrested by any police officer, sheriff, marshal or
any other type of law enforcement official?
• In the last five (5) years have you been charged with, convicted of, or sentenced for a crime
in any court? (Include all qualifying charges, convictions, or sentences in a Federal, state,
local, military, or non-U.S. court even if previously listed on this form.)
• In the last five (5) years have you been or are you currently on probation or parole?
• Are you currently on trial or awaiting a trial on criminal charges?
Is there currently a domestic violence protective order or restraining order issued against you?
YES NO
You responded ‘Yes’ to currently having a domestic violence protective order or restraining order issued against you.
Branch
If Yes to
Provide explanation:
Explanation (Free Text)
Domestic
Provide the date the order was issued.
Date (Estimated)
Violence
Provide the name of the court or agency that issued the order.
Name of court (Free Text)
(Multiple
Provide the location of the court or agency that issued the order.
Street address and city
State and Zip Code or Country
Entries
Do you have another domestic violence protective order or
YES
NO
Allowed)
restraining order currently issued against you to report?
(Yes adds another entry)
(Required to validate)

Section 17 – Illegal Use of Drugs and Drug Activity
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. This particular section 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 not in accordance
with Federal laws, even if permissible under state laws.
In the last year have you illegally used any drugs or controlled substances? Use of a drug or controlled substance includes injecting, YES NO
snorting, inhaling, swallowing, experimenting with or otherwise consuming any drug or controlled substance.
You answered ‘Yes’ to in the last year having illegally used a drug or controlled substance.
Branch
Provide the type of drug or controlled substance.
Explanation if other (Free Text)
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
If Yes to
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Illegally Using
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
Drugs or
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Controlled
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation):
Substances
Provide an estimate of the
Date (Estimated)
Provide an estimate of the month Date (Estimated)
month and year of first use.
and year of most recent use.
(Multiple
Provide
nature
of
use,
frequency,
and
number
of
times
used.
Nature of use (Free Text)
Entries
Do you have an additional instance(s) of illegal use of a drug or controlled
YES
NO
Allowed)
substance to enter?
(Yes adds another entry)
(Required to validate)
In the last year, have you been involved in the illegal purchase, manufacture, cultivation, trafficking, production, transfer, shipping,
YES NO
receiving, handling or sale of any drug or controlled substance?
You answered ‘Yes’ to in the last year having been involved in the illegal purchase, manufacture, cultivation, trafficking, production,
transfer, shipping, receiving, handling or sale of a drug or controlled substance.
Provide the type of drug or controlled substance.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Branch
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation free text):
If Yes to
Provide an estimate of the month Date
Provide an estimate of the month and
Date (Estimated)
Illegal Drug
and year of first involvement.
(Estimated)
year of most recent involvement.
Activity
Provide nature of and frequency of activity.
Nature of activity (Free Text)
Provide the reason(s) why you engaged in the activity.
Reason(s) (Free Text)
(Multiple
Do you have an additional instance(s) of having been involved in the illegal purchase,
YES
NO
Entries
manufacture, cultivation, trafficking, production, transfer, shipping, receiving, handling or sale (Yes adds
(Required to
Allowed)
of a drug or controlled substance to enter?
another entry)
validate)
In the last year have you intentionally engaged in the misuse of prescription drugs, regardless of whether or not the drugs were
YES NO
prescribed for you or someone else?
You responded ‘Yes’ to in the last year having intentionally engaged in the misuse of prescription drugs, regardless of whether the drugs
Branch
If Yes to
were prescribed for you or someone else.
Misuse of
Provide the name of the prescription drug that you misused.
Drug names (Free Text)
Prescription
Provide the dates of involvement in the above.
From Date (Estimated)
To Date (Estimated/Present)
Drugs
Provide the reason(s) for and circumstances of the misuse of the prescription drug.
Reasons (Free Text)
Do you have an additional instance(s) of intentionally engaging in the misuse
YES
NO
(Multiple
of prescription drugs in the last year to enter?
(Yes adds another entry) (Required to validate)
Entries
Allowed)
In the last year have you been ordered, advised, or asked to seek counseling or treatment as a result of your illegal use of drugs or
YES NO
controlled substances?

You responded ‘Yes’ to having in the last year, been ordered, advised, or asked to seek counseling or treatment as a result of your illegal
use of drugs or controlled substances
If Yes to
Have any of the following ordered, advised, or asked you to seek counseling or treatment as a result of your illegal use of drugs or
Being Ordered
controlled substances? (Select all that apply)
Treatment for
□ An employer, military commander, or employee assistance program
□ A medical professional
the Misuse of
□ A mental health professional
□ A court official / judge
Drugs
□ I have not been ordered, advised, or asked to seek counseling or treatment by any of the above.
Provide explanation
Explanation (Free Text)
Did you take action to receive counseling or treatment?
YES NO
(Multiple
Branch If No
You have indicated that you did not receive treatment. Provide explanation.
Explanation (Free Text)
Entries
to Action Taken
Allowed)
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.)
□ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.)
□ Steroids (Such as the clear, juice, etc.)
Branch
If Yes to Action □ Inhalants (Such as toluene, amyl nitrate, etc.)
Taken
□ Other (Provide explanation):
Explanation (Free Text)
Provide the name of the treatment
Name (Last name, First name)
provider. (Last name, First name)
Provide the address for this treatment provider. Street address and city
State and Zip Code or Country
Provide a telephone number for the treatment provider.
Number/Ext. Extension Time Day
Night Both _Check box if
International
Provide the dates of treatment.
Date From (Estimated)
Date To (Estimated/Present)
Did you successfully complete the treatment?
YES NO
Branch If No
You have indicated that you did not successfully
Explanation (Free Text)
to Successful
complete the treatment. Provide explanation.
Treatment
Do you have another instance of having been ordered, advised, or asked to
YES
NO
seek drug or controlled substance counseling or treatment to enter?
(Yes adds another entry) (Required to validate)
In the last year have you voluntarily sought counseling or treatment as a result of your use of a drug or controlled substance?
YES NO
Voluntary treatment detail
Provide the type of drug or controlled substance for which you were treated.
□ Cocaine or crack cocaine (Such as rock, freebase, etc.) □ Stimulants (Such as amphetamines, speed, crystal meth, ecstasy, etc.)
□ THC (Such as marijuana, weed, pot, hashish, etc.)
□ Depressants (Such as barbiturates, methaqualone, tranquilizers, etc.)
Branch
□ Ketamine (Such as special K, jet, etc.)
□ Narcotics (Such as opium, morphine, codeine, heroin, etc.)
If Yes to
□ Hallucinogenic (Such as LSD, PCP, mushrooms, etc.) □ Steroids (Such as the clear, juice, etc.)
Voluntarily
□ Inhalants (Such as toluene, amyl nitrate, etc.)
□ Other (Provide explanation free text)
Seeking
Provide the name of the treatment provider. (Last name, First name)
Name (Free Text)
Treatment for
Provide the address for this treatment provider.
Street address and city
State and Zip Code or Country
the Misuse of
Provide a telephone number for the treatment provider.
Number/Extension Time Day Night
Drugs
Both _Check box if International
Provide the dates of treatment.
Date From (Estimated)
Date To (Estimated/Present)
(Multiple
Did
you
successfully
complete
the
treatment?
YES NO
Entries
Branch If No to
You have indicated that you did not successfully complete the
Explanation (Free Text)
Allowed)
Successful Treatment treatment. Provide explanation.
Do you have another instance of voluntarily seeking counseling or
YES
NO
treatment as a result of your use of a drug or controlled substance in the
(Yes adds another entry)
(Required to validate)
last year?
Branch

Section 18 – Investigations and Clearance Record
Has the U.S. Government (or a foreign government) EVER investigated your background and/or granted you a security clearance
YES NO
eligibility/access?
You responded ‘Yes’ to the U.S. Government (or a foreign government) having investigated your background and/or having granted
you a security clearance eligibility/access.
Provide the investigating agency:
□ U.S. Department of Defense
□ U.S. Department of State
□ U.S. Office of Personnel Management
□ Federal Bureau of Investigation
□ U.S. Department of Treasury (Provide name of bureau)
□ U.S. Department of Homeland Security
Explanation or name of government or
□ Foreign government (Provide name of government) □ I don’t know
bureau. (Free Text)
Branch
□ Other (Provide explanation)
If Yes to Having
Date the investigation was completed.
□ I don’t know
Date (Estimated)
Ever Been
Was a clearance eligibility/access granted? Yes
No
Investigated
(Multiple Entries
Allowed)

If yes, to having
clearance
eligibility/access
granted
(Multiple Entries
Allowed)

Provide the name of agency that issued the clearance eligibility/access if
different from the investigating agency.

Name (Free Text)

Provide the date clearance eligibility/access was granted. □ I don’t
know

Date (Estimated)

Provide the level
□ None
□ Confidential
□ Secret
□ Top Secret
of clearance
□ Sensitive Compartmented Information (SCI) □ Q
□L
□ I don’t
eligibility/access
know
granted.
□ Issued by foreign country
□ Other (Provide explanation)
Explanation
(Free Text)
Do you have another investigation to enter?
YES (Yes adds another entry)
NO (Required to validate)
In the last five (5) years have you had a security clearance eligibility/access authorization denied, suspended, or revoked? (Note: An
YES NO
administrative downgrade or administrative termination of a security clearance is not a revocation.)
You responded ‘Yes’ to having a security clearance eligibility/access authorization denied, suspended, or revoked within the last five
(5) years.
Branch
Provide the date security clearance eligibility/access authorization was denied, suspended or revoked.
Date (Estimated)
If Yes to Denied
Provide the name of the agency that took the action.
Name (Free Text)
(Multiple Entries
Provide an explanation of the circumstances of the denial, suspension or revocation action.
Explanation (Free Text)
Allowed)
Do you have another denied, revoked or suspended security
YES
NO
clearance eligibility/access authorization to enter?
(Yes adds another entry) (Required to validate)
In the last five (5) years have you been debarred from government employment?
YES
NO
You responded ‘Yes’ to in the last 5 years having been debarred from government employment.
Branch
Provide the name of the government agency taking debarment action.
Agency name
If Yes to
Debarment
Provide the date the debarment occurred.
Date (Estimated)
(Multiple Entries
Provide an explanation of the circumstances of the debarment
Circumstances (Free text)
Allowed)
Do you have another Government debarment to enter?
YES (Yes adds another entry)
NO (Required to validate)

Section 19 – Financial Record
In the last five (5) years have you failed to file or pay Federal, state, or other taxes when required by law or ordinance?
YES
NO
You responded ‘Yes’ to having failed to file or pay Federal, state, or other taxes when required by law or ordinance.
Did you fail to file, pay as required, or both? □ File □ Pay □ Both
Branch
Provide the year you failed to file or pay your Federal, state or other taxes.
Est.
Provide the reason(s) for your failure to file or pay required taxes.
Reasons (Free Text)
If Yes to
Provide the Federal, state or other agency to which you failed to file or pay taxes.
Agency (Free Text)
Failing to
Provide the type of taxes you failed to file or pay (such as property, income, sales, etc.).
Tax Type (Free Text)
File/Pay Taxes
Provide the amount (in U.S. dollars) of the taxes. □ Estimated
Amount (Free Text)
Provide date satisfied. □ Not applicable
Date (Estimated)
(Multiple
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
Entries
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.
Allowed)
Are there any other instances in the last five (5) years where you failed to
YES
NO
file or pay Federal, state or other taxes when required by law or ordinance?
(Yes adds another entry) (Required to validate)
Other than previously listed, has the following happened to you? (You will be asked to provide details about each financial obligation that pertains to the
items identified below).
• 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 a
cosigner or guarantor).
YES

NO

Provide the associated loan / account number(s) involved
Loan / account number (Free Text)
Identify/describe the type of property involved (if any).
Property type (Free Text)
Provide the amount (in U.S. dollars) of the financial issue. □ Estimated
Amount (Free Text)
Provide the reason(s) for the financial issue.
Reasons (Free Text)
Provide the current status of the financial issue.
Status (Free Text)
Provide the date the financial issue began.
Date (Estimated)
Provide date the financial issue was resolved. □ Not resolved
Date (Estimated)
Provide the name of the court involved.
Court name (Free Text)
Provide the address of the court involved.
Street address and City
State and Zip Code or Country
Provide a description of any action(s) you have taken to satisfy this debt (such as withholdings,
Description (Free Text)
frequency and amount of payments, etc.). If you have not taken any action(s) provide explanation.
Other than previously listed, are there any other instances of the following occurrence?
• 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 a cosigner or guarantor).

YES (Yes adds another entry)

NO (Required to validate)

1E a

Section 20 – Association Record
The following pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an
adverse employment or credentialing decision. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or are
dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or
coercion or to affect the conduct of a government by mass destruction, assassination or kidnapping.
Are you now or have you EVER been a member of an organization dedicated to terrorism, either with an awareness of the
YES NO
organization’s dedication to that end, or with the specific intent to further such activities?
You responded ‘Yes’ to being or EVER having been a member of an organization dedicated to terrorism, either with an awareness of
Branch
the organization’s dedication to that end, or with the specific intent to further such activities.
If Yes to Being a
Provide the full name of the organization.
Organization name (Free Text)

Member of a
Terrorist
Organization

Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
Provide the dates of your involvement with the organization.
From Date (Estimated)
To Date (Estimated/Present)
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Provide all contributions made to the organization, if any. □ No contributions made
Contributions (Free Text)
(Multiple Entries
Provide a description of the nature of and reasons for your involvement with the organization.
Involvement (Free Text)
Allowed)
Do you have any other instances of being a member of an organization dedicated to
YES
NO
terrorism, either with an awareness of the organization’s dedication to that end, or with the
(Yes adds
(Required to
specific intent to further such activities to report?
another entry)
validate)
Have you EVER knowingly engaged in any acts of terrorism?
YES NO
Branch If Yes
You responded ‘Yes’ to EVER having knowingly engaged in any acts of terrorism.
Engaging in
Describe the nature and reasons for the activity.
Nature and reasons (Free Text)
Terrorism
Provide the dates for any such activities
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of knowingly engaging in acts of
YES
NO
Allowed)
terrorism to report?
(Yes adds another entry)
(Required to validate)
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force?
YES
NO
You responded ‘Yes’ to having EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by
Branch
force.
If Yes to
Provide the reason(s) for advocating acts of terrorism.
Reasons (Free Text)
Advocating
Provide the dates of advocating acts of terrorism
From Date (Estimated)
To Date (Estimated/Present)
(Multiple Entries
Do you have any other instances of advocating acts of terrorism or activities
YES (Yes adds
NO (Required to
Allowed)
designed to overthrow the U.S. Government by force to report?
another entry)
validate)
Have you EVER been a member of an organization dedicated to the use of violence or force to overthrow the United States
YES NO
Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or with the
specific intent to further such activities?
You responded ‘Yes’ to having EVER been a member of an organization dedicated to the use of violence or force to overthrow the
United States Government, and which engaged in activities to that end with an awareness of the organization’s dedication to that end or
Branch
with the specific intent to further such activities.
Provide the full name of the organization.
Organization name (Free Text)
If Yes to being
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
Member of
Provide the dates of your involvement with the organization
From Date (Estimated)
To Date (Estimated/Present)
Organization
Using Violence
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
to Overthrow the
Provide all contributions made to the organization, if any. □ No contributions made
Contributions (Free Text)
U.S. Govt.
Provide a description of the nature of and reasons for your involvement with the organization.
Description (Free Text)
Do you have any other instances of being a member of an organization dedicated to the use
YES
NO
(Multiple Entries
of violence or force to overthrow the United States Government, which engaged in
(Yes adds
(Required to
Allowed)
activities to that end with an awareness of the organization’s dedication to that end or with
another entry)
validate)
the specific intent to further such activities to report?
Have you EVER been a member of an organization that advocates or practices commission of acts of force or violence to
YES NO
discourage others from exercising their rights under the U.S. Constitution or any state of the United States with the specific intent to
further such action?
You responded ‘Yes’ to being or EVER having been a member of an organization that advocates or practices commission of acts of
force or violence to discourage others from exercising their rights under the U.S. Constitution or that of any state of the U.S. with the
specific intent to further such action.
Provide the full name of the organization.
Organization Name (Free Text)
Branch
Provide the address/location of the organization.
Street address and City
State and Zip Code or Country
If Yes to Being a
Provide the dates of your involvement with the organization
From Date (Estimated)
To Date (Estimated/Present)
Member of
Organization
Provide all positions held in the organization, if any.
□ No positions held
Positions (Free Text)
Using Violence
Provide all contributions (in U.S. dollars) made to the organization, if any. □ No contributions
Contributions (Free Text)
made
(Multiple Entries
Provide a description of the nature of and reasons for your involvement with the organization.
Involvement (Free Text)
Allowed)
Do you have any other instances of being a member of an organization that advocates or
YES
NO
practices commission of acts of force or violence to discourage others from exercising
(Yes adds
(Required to validate)
their rights under the U.S. Constitution or any state of the United States with the specific
another entry)
intent to further such action to report?
Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by force?
YES
NO
Branch If Yes to You responded ‘Yes’ to having EVER knowingly engaged in activities designed to overthrow the U.S. Government by force.
Describe the nature and reasons for the activity.
Reasons (Free Text)
Activities to
Overthrow
Provide the dates of such activities.
From Date (Estimated)
To Date Estimated/Present)
(Multiple Entries
Do you have any other instances of having knowingly engaged in activities YES
NO
Allowed)
designed to overthrow the U.S. Government by force to report?
(Yes adds another entry) (Required to validate)
Have you EVER associated with anyone involved in activities to further terrorism?
YES
NO
Branch If Yes to
Terrorism Association Detail
Having
Provide Explanation
Explanation (Free Text)
Terrorism
Association
Additional Comments
After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate,
and then sign and date the following certification and the attached release(s).
Certification
My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in
good faith. I have carefully read the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this
form can be punished by fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or
falsifying information may have a negative effect on my employment prospects, or job status, or my removal and debarment from Federal
service.

Draft version 9
Signature (Sign in ink)

Date (mm/dd/yyyy)

Standard Form 85
Revised
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
OMB No. 3206-0261

QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation or reinvestigation to obtain any information relating to my activities,
conduct, and character from individuals, schools, residential management agents, employers, criminal justice
agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other
sources of information. This information may include, but is not limited to current and historic academic,
residential, achievement, performance, attendance, disciplinary, employment, criminal, financial, and credit
information, and publicly available social media information. I authorize the Federal agency conducting my
investigation to disclose the record of investigation or ongoing evaluation to the requesting agency for the purpose
of making a determination of suitability or eligibility for a non-sensitive position and/or for physical or logical
access to federal facilities and information systems.
I Understand that, for these purposes, publicly available social media information includes any electronic social
media information that has been published or broadcast for public consumption, is available on request to the public,
is accessible on-line to the public, is available to the public by subscription or purchase, or is otherwise lawfully
accessible to the public. I further understand that this authorization does not require me to provide passwords; log
into a private account; or take any action that would disclose non-publicly available social media information.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name,
Social Security Number, and date of birth with information in SSA records and provide the results of the match) to
the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my
investigation for the purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the
other Federal agency requesting or conducting my investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and
other sources of information, separate specific release may be needed, and I may be contacted for such releases at a
later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau
of Investigation, the Department of Defense, the Department of Homeland Security, the Office of the Director of
National Intelligence, Department of State, and any other authorized Federal agency, to request criminal record
information about me from criminal justice agencies for the purpose of determining my suitability or eligibility for
appointment to, or retention in, a non-sensitive position, in accordance with 5 U.S.C. 9101 or my eligibility for
logical or physical access. I understand that I may request a copy of such records as may be available to me under
the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information
upon request of the investigator, special agent, or other duly accredited representative of any Federal agency
authorized above regardless of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by
the Federal Government only for the purposes provided in this Standard Form 85, and that it may be disclosed by the
Government only as authorized by law.
I Authorize the information to be used to conduct officially sanctioned and approved suitability-related studies and
analyses, which will be maintained in accordance with the Privacy Act.

Draft version 9
Photocopies of this authorization with my signature are valid. This authorization is valid for five (5) years from the
date signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink)

Full name (Type or print legibly)

Other names used
Current street address Apt. #

City (Country)

State

Date signed (mm/dd/yyyy)

Date of birth

Social Security Number

ZIP Code

Telephone number

Standard Form 85
Revised
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
OMB No. 3206-0261

SF 85 QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS
UNITED STATES OF AMERICA
FAIR CREDIT REPORTING DISCLOSURE AND AUTHORIZATION
Disclosure
One or more reports from consumer reporting agencies may be obtained for employment
purposes pursuant to the Fair Credit Reporting Act, codified at 15 U.S.C. § 1681 et seq.
Purpose
Depending on circumstances within your background, the Federal government may require
information from one or more consumer reporting agencies in order to obtain information in
connection with a background investigation, reinvestigation, or ongoing evaluation (i.e.
continuous evaluation) for positions designated as low risk, non-sensitive, and for physical and
logical access. The information obtained may be disclosed to other Federal agencies for the
above purposes in fulfillment of official responsibilities to the extent that such disclosure is
permitted by law. Information from the consumer report will not be used in violation of any
applicable Federal or state equal employment opportunity law or regulation.
Authorization
I hereby authorize any investigator, special agent, or other duly accredited representative of the
authorized Federal agency conducting my initial background investigation, reinvestigation, or
ongoing evaluation (i.e. continuous evaluation) for positions designated as low risk, nonsensitive, and for physical and logical access to request, and any consumer reporting agency to
provide, such reports for the purposes described above.

Photocopies of this authorization with my signature are valid. This authorization shall remain in
effect so long as I occupy a non-sensitive position.

Print name

Social Security Number

Draft version 9

Signature (Sign in ink)

Date (mm/dd/yyyy)