Standard Form 85 |
Form approved: |
Revised December 2013 |
OMB No. 3206-0261 |
U.S. Office of Personnel Management |
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5 CFR Parts 731 and 736 |
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Questionnaire for Non-Sensitive Positions
Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 5 and the release on Page 6. If you have any questions, call the office that gave you the form.
Purpose of this Form
The U.S. Government conducts background investigations to establish that applicants or incumbents either employed by the Government or working for the Government under contract, are suitable for the job. Information from this form is used primarily as the basis for this investigation. Complete this form only after a conditional offer of employment has been made.
Giving us the information we ask for is voluntary. However, we may not be able to complete your investigation, or complete it in a timely manner, if you don’t give us each item of information we request. This may affect your placement or employment prospects.
Authority to Request this Information
The U.S. Government is authorized to ask for this information under Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code; and parts 5, 731, and 736 of Title 5, Code of Federal Regulations.
Your Social Security Number is needed to keep records accurate, because other people may have the same name and birth date. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.
The Investigative Process
Background investigations are conducted using your responses on this form and on your Declaration for Federal Employment (OF 306) to develop information to show whether you are reliable, trustworthy, and of good conduct and character. Your current employer must be contacted as part of the investigation, even if you have previously indicated on applications or other forms that you do not want this.
Instructions for Completing this Form
1.Follow the instructions given to you by the person who gave you the form and any other clarifying instructions furnished by that person to assist you in completion of the form. Find out how many copies of the form you are to turn in. You must sign and date, in black ink, the original and each copy you submit.
2.Type or legibly print your answers in black ink (if your form is not legible, it will not be accepted). You may also be asked to submit your form in an approved electronic format.
3.All questions on this form must be answered. If no response is necessary or applicable, indicate this on the form (for example, enter "None" or "N/A"). If you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking "APPROX." or "EST."
4.Any changes that you make to this form after you sign it must be initialed and dated by you. Under certain limited circumstances, agencies may modify the form consistent with your intent.
5.You must use the State codes (abbreviations) listed on the back of this page when you fill out this form. Do not abbreviate the names of cities or foreign countries.
6.The 5-digit postal ZIP codes are needed to speed the processing of your investigation. The office that provided the form will assist you in completing the ZIP codes.
7.All telephone numbers must include area codes.
8.All dates provided on this form must be in Month/Day/Year or Month/Year format. Use numbers (1-12) to indicate months. For example, June 10, 1978, should be shown as 6/10/78.
9.Whenever "City (Country)" is shown in an address block, also provide in that block the name of the country when the address is outside the United States.
10.If you need additional space to list your residences or employments/self-employments/unemployment or education, you should use a continuation sheet, SF 86A. If additional space is needed to answer other items, use a blank piece of paper. Each blank piece of paper you use must contain your name and Social Security Number at the top of the page.
Final Determination on Your Eligibility
Final determination on your eligibility for a position is the responsibility of the Office of Personnel Management or the Federal agency that requested your investigation. You may be provided the opportunity personally to explain, refute, or clarify any information before a final decision is made.
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 of up to $10,000, and/or 5 years imprisonment, or both. 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 trustworthiness is a very important consideration in deciding your suitability. Your prospects of placement are better if you answer
all questions truthfully and completely. You will have adequate opportunity to explain any information you give us on the form and to make your comments part of the record.
Disclosure of Information
The information you give us is for the purpose of determining your suitability for Federal employment; we will protect it from unauthorized disclosure. The collection, maintenance, and disclosure of background investigative information is governed by the Privacy Act. The agency which requested the investigation and the agency which conducted the investigation have published notices in the Federal Register describing the systems of records in which your records will be maintained. You may obtain copies of the relevant notices from the person who gave you this form. The information on this form, and information we collect during an investigation may be disclosed without your consent as permitted by the Privacy Act (5 USC 552a(b)) and as follows:
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 Question 14, 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 USC 2904 and 2906.
11. To the Office of Management and Budget when necessary to the review of private relief legislation.
STATE CODES (ABBREVIATIONS)
Alabama |
AL |
Hawaii |
HI |
Massachusetts |
MA |
New Mexico |
NM |
South Dakota |
SD |
Alaska |
AK |
Idaho |
ID |
Michigan |
MI |
New York |
NY |
Tennessee |
TN |
Arizona |
AZ |
Illinois |
IL |
Minnesota |
MN |
North Carolina |
NC |
Texas |
TX |
Arkansas |
AR |
Indiana |
IN |
Mississippi |
MS |
North Dakota |
ND |
Utah |
UT |
California |
CA |
Iowa |
IA |
Missouri |
MO |
Ohio |
OH |
Vermont |
VT |
Colorado |
CO |
Kansas |
KS |
Montana |
MT |
Oklahoma |
OK |
Virginia |
VA |
Connecticut |
CT |
Kentucky |
KY |
Nebraska |
NE |
Oregon |
OR |
Washington |
WA |
Delaware |
DE |
Louisiana |
LA |
Nevada |
NV |
Pennsylvania |
PA |
West Virginia |
WV |
Florida |
FL |
Maine |
ME |
New Hampshire |
NH |
Rhode Island |
RI |
Wisconsin |
WI |
Georgia |
GA |
Maryland |
MD |
New Jersey |
NJ |
South Carolina |
SC |
Wyoming |
WY |
American Samoa |
AS |
District of Columbia |
DC |
Guam |
GU |
Northern Marianas |
CM |
Puerto Rico |
PR |
Trust Territory |
TT |
Virgin Islands |
VI |
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PUBLIC BURDEN INFORMATION
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to Reports and Forms Management Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Room CHP-500, Washington, D.C. 20415. Do not send your completed form to this address.
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Standard Form 85 |
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Revised December 2013 |
QUESTIONNAIRE FOR |
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U.S. Office of Personnel Management |
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NON-SENSITIVE POSITIONS |
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5 CFR Parts 731 and 736 |
Form approved: OMB No. 3206-0261
OPM |
Codes |
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Agency Use Only (Complete items A through K using instructions provided by USOPM)
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C Nature of |
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E Geographic |
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Agency Case Number |
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K Requesting |
Name and Title |
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Signature |
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Official |
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Persons completing this form should begin with the questions below.
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FULL |
If you have only initials in your name, use them and state (IO). |
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NAME |
If you have no middle name, enter "NMN". |
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Last Name |
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First Name |
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-If you are a "Jr.," "Sr.," "II," etc., enter this in the box after your middle name.
Middle Name |
Jr., II, etc. |
2DATE OF BIRTH
Month Day Year
3PLACE OF BIRTH - Use the two letter code for the State.
Country (if not in the United States)
5OTHER NAMES USED
Give other names you used and the period of time you used them (for example: your maiden name, name(s) by a former marriage, former name(s), alias(es), or nickname(s)). If the other name is your maiden name, put "nee" in front of it.
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#1 |
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Month/Year |
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#3 |
Name |
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#2 |
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#4 |
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6 |
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SEX (Mark one box) |
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Female |
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Male |
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7 |
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CITIZENSHIP |
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I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. (Answer |
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Your Mother’s Maiden Name |
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items b and d) |
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a |
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Mark the box at the right that |
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I am a U.S. citizen, but I was NOT born in the U.S. (Answer items b , c and d) |
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reflects your current citizenship |
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status, and follow its instructions. |
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I am not a U.S. citizen. (Answer items b and e) |
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UNITED STATES CITIZENSHIP |
If you are a U.S. citizen, but were not born in the U.S., provide information about one or more of the following proofs of your citizenship. |
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Naturalization Certificate (Where were you naturalized?) |
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Court |
City |
Citizenship Certificate (Where was the certificate issued?) City
State Department Form 240 - Report of Birth Abroad of a Citizen of the United States
Give the date the form was Month/Day/Year Explanation prepared and give an explanation
if needed
U.S. Passport
Passport Number |
Month/Day/Year Issued |
This may be either a current or previous U.S. Passport.
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d |
DUAL CITIZENSHIP |
If you are (or were) a dual citizen of the United States and |
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another country, provide the name of that country in the space to |
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the right. |
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ALIEN If you are an alien, provide the following information: |
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e |
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Place You |
City |
State |
Date You Entered U.S. |
Alien Registration Number |
Country(ies) of Citizenship |
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Entered the |
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United States: |
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8WHERE YOU HAVE LIVED
List the places where you have lived, beginning with the most recent (#1) and working back 5 years. All periods must be accounted for in your list. Be sure to indicate the actual physical location of your residence: do not use a post office box as an address, do not list a permanent address when you were actually living at a school address, etc. Be sure to specify your location as closely as possible: for example, do not list only your base or ship, list your barracks number or home port. You may omit temporary military duty locations under 90 days (list your permanent address instead), and you should use your APO/FPO address if you lived overseas.
For any address in the last 3 years, list a person who knew you at that address, and who preferably still lives in that area (do not list people for residences completely outside this 3-year period, and do not list your spouse, former spouses, or other relatives).
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Month/Year |
Month/Year |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
#1 |
To |
Present |
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Name of Person Who Knows You |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
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Month/Year |
Month/Year |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
#2 |
To |
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Name of Person Who Knew You |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
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Month/Year |
Month/Year |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
#3 |
To |
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Name of Person Who Knew You |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
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Month/Year |
Month/Year |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
#4 |
To |
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Name of Person Who Knew You |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
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Month/Year |
Month/Year |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
#5 |
To |
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Name of Person Who Knew You |
Street Address |
Apt. # |
City (Country) |
State |
ZIP Code |
9WHERE YOU WENT TO SCHOOL
List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 5 years. List all College or University degrees and the dates they were received. If all of your education occurred more than 5 years ago, list your most recent education beyond high school, no matter when that education occurred.
- Use one of the following codes in the "Code" block:
1 - High School |
2 - College/University/Military College |
3 - Vocational/Technical/Trade School |
- For correspondence schools and extension classes, provide the address where the records are maintained.
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Month/Year Month/Year |
Code |
#1 |
To |
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Street Address and City (Country) of School |
Degree/Diploma/Other
State
Month/Year Awarded
ZIP Code
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Month/Year Month/Year |
Code |
#2 |
To |
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Street Address and City (Country) of School |
Degree/Diploma/Other
State
Month/Year Awarded
ZIP Code
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Month/Year Month/Year |
Code |
#3 |
To |
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Street Address and City (Country) of School |
Degree/Diploma/Other
State
Month/Year Awarded
ZIP Code
Enter your Social Security Number before going to the next page
10YOUR EMPLOYMENT ACTIVITIES
List your employment activities, beginning with the present (#1) and working back 5 years. You should list all full-time work, part-time work, military service, temporary military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment. The entire 5-year period must be accounted for without breaks, but you need not list employments before your 16th birthday.
Code. Use one of the codes listed below to identify the type of employment:
1 |
- Active military duty stations |
5 |
- State Government (Non-Federal |
7 |
- Unemployment (Include name of |
9 - Other |
2 |
- National Guard/Reserve |
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employment) |
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person who can verify) |
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3 |
- U.S.P.H.S. Commissioned Corps |
6 |
- Self-employment (Include business name |
8 |
- Federal Contractor (List Contractor, |
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4 |
- Other Federal employment |
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and/or name of person who can verify) |
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not Federal agency) |
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Employer/Verifier Name. List the business name of your employer or the name of the person who can verify your self-employment or unemployment in this block. If military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to reflect changes in your military duty locations or home ports.
Previous Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same location. After entering the most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information.
Month/Year |
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Employer/Verifier Name/Military Duty Location |
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Your Position Title/Military Rank |
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To |
Present |
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Employer’s/Verifier’s Street Address |
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City (Country) |
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State |
ZIP Code |
Telephone Number |
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Street Address of Job Location (if different than Employer’s Address) |
City (Country) |
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State |
ZIP Code |
Telephone Number |
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Supervisor’s Name & Street Address (if different than Job Location) |
City (Country) |
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Enter your Social Security Number before going to the next page
YOUR EMPLOYMENT ACTIVITIES (CONTINUED) |
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Month/Year Month/Year |
Code Employer/Verifier Name/Military Duty Location |
Your Position Title/Military Rank |
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Supervisor |
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PERIODS |
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Supervisor |
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ACTIVITY |
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Supervisor |
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To |
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Month/Year |
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Code |
Employer/Verifier Name/Military Duty Location |
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Your Position Title/Military Rank |
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Street Address of Job Location (if different than Employer’s Address) |
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Supervisor’s Name & Street Address (if different than Job Location) |
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State |
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Telephone Number |
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Supervisor |
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PERIODS |
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Supervisor |
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ACTIVITY |
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(Block #6) |
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Supervisor |
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11PEOPLE WHO KNOW YOU WELL
List three people who know you well and live in the United States. They should be good friends, peers, colleagues, college roommates, etc., whose combined association with you covers as well as possible the last 5 years. Do not list your spouse, former spouses, or other relatives, and try not to list anyone who is listed elsewhere on this form.
Name |
Dates Known |
Telephone Number |
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#1 |
Month/Year |
Month/Year |
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Day |
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To |
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Night |
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Home or Work Address |
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ZIP Code |
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Name |
Dates Known |
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Telephone Number |
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#2 |
Month/Year |
Month/Year |
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Day |
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To |
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Night |
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Home or Work Address |
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State |
ZIP Code |
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Name |
Dates Known |
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Telephone Number |
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#3 |
Month/Year |
Month/Year |
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Day |
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To |
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Night |
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Home or Work Address |
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City (Country) |
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State |
ZIP Code |
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Enter your Social Security Number before going to the next page
Page 4
12 YOUR SELECTIVE SERVICE RECORD |
Yes |
No |
aAre you a male born after December 31, 1959? If "No," go to 13. If "Yes," go to b.
bHave you registered with the Selective Service System? If "Yes," provide your registration number. If "No," show the reason for your legal exemption below.
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Registration Number |
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Legal Exemption Explanation |
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YOUR MILITARY HISTORY |
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Yes |
No |
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13 |
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aHave you served in the United States military?
bHave you served in the United States Merchant Marine?
List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of service (#1) and work backward. If you had a break in service, each separate period should be listed.
Code. Use one of the codes listed below to identify your branch of service:
1 - Air Force |
2 - Army |
3 - Navy |
4 - Marine Corps |
5 - Coast Guard |
6 - Merchant Marine |
7 - National Guard |
O/E. Mark "O" block for Officer or "E" block for Enlisted.
Status. "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use an "X"; use the two-letter code for the state to mark the block.
Country. If your service was with other than the U.S. Armed Forces, identify the country for which you served.
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Month/Year Month/Year |
Code |
Service/Certificate # |
O |
E |
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Status |
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Active |
Inactive |
National |
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Active |
Guard |
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Reserve |
Reserve |
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14 |
ILLEGAL DRUGS |
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Yes |
No |
In the last year, have you used, possessed, supplied, or manufactured illegal drugs? When used without a prescription, illegal drugs include marijuana, cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), stimulants (cocaine, amphetamines, etc.), depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.). (NOTE: Neither your truthful response nor information derived from your response will be used as evidence against you in any subsequent criminal proceeding.)
If you answered "Yes," provide information relating to the types of substance(s), the nature of the activity, and any other details relating to your involvement with illegal drugs. Include any treatment or counseling received.
Month/Year Month/Year
To
To
To
Continuation Space
Use the continuation sheet(s) (SF86A) for additional answers to items 8, 9, and 10. Use the space below to continue answers to all other items and any information you would like to add. If more space is needed than is provided below, use a blank sheet(s) of paper. Start each sheet with your name and Social Security number. Before each answer, identify the number of the item.
After completing this form you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the following certification and sign and date the release on Page 6.
Certification That My Answers Are True
My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both. (See section 1001 of title 18, United States Code).
Enter your Social Security Number before going to the next page
Page 5
Standard Form 85 |
Form Approved |
Revised December 2013 |
OMB No. 3206-0261 |
U.S. Office of Personnel Management |
|
5 CFR Parts 731 and 736 |
|
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 it in ink.
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 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 to include publically available electronic information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, and criminal history record information.
I understand that, for some sources of information, a separate specific release will be needed, and I may be contacted for such a release at a later date.
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 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.
Photocopies of this authorization with my signature are valid. This authorization is valid for two (2) years from the date signed.
Signature (Sign in ink) |
Full name (Type or print legibly) |
Date signed (mm/dd/yyyy) |
Other names used |
|
Social Security Number |
Current street address Apt. # |
City (Country) State ZIP Code |
Home telephone number |