Fillable Form 31540 Developed Vetting (DV) Questionnaire

Fill Online, Printable, Fillable, Blank Form 31540 Developed Vetting (DV) Questionnaire Form

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Form 31540 Developed Vetting (DV) Questionnaire

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The Form 31540 Developed Vetting (DV) Questionnaire form is 83 pages long and contains:

  • 4 signatures
  • 49 check-boxes
  • 2060 other fields

Country of origin: UK
File type: PDF

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Page 1
This is an official document. The content and format of
this form remains the property of the Cabinet Office;
the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
Developed Vetting (DV) Questionnaire
2. Security Clearance Required - To be completed by all Sponsors
Sponsors must also complete pages 51 to 53.
1. How to complete this form
The information you provide will be scanned electronically so please ensure you only write inside the white boxed areas. Do not mark
or strike through any other areas of the form. If completing by hand please write in
BLACK INK
using
. Keep each
character within the boxes on the form and leave one space between names/words. If an answer will not fit in the space provided,
please enter your answer on the continuation sheets (pages 48 to 50). If you make a mistake, please do not correct it but delete it by
filling in the relevant box as in the example below. Please do not use correcting fluid.
Ensure you answer
ALL
the questions. You can use the abbreviation
NA
(Not Applicable).
NA
- If a question does not apply to
you,write
NA
in the
first two boxes only
of the relevant question.
Not Known
- If you do not know the answer, or you cannot provide
the information needed, write NOT KNOWN in the first line only of the relevant question. Please provide an explanation why the
information is unknown to you in the appropriate boxes or on the continuation sheets (pages 48 to 50). Unanswered
questions or Not Known replies may cause delay to the processing of this questionnaire.
Surname (now):
Type of Security Clearance Required:
DV
DV (Review)
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* The date entered should be chosen with care and be specific. Expressions like 'ASAP' and 'Soonest' should not be used.
*Date by which clearance is required:
/ /
Day
Month
Year
If the employee requires this clearance to
access classified information from
NATO/EU/Other countries or international
organisations, please tick appropriate box
NATO
EU
Other
(please specify)
3.
Your Details
a. Surname (now):
c. Surname (birth):
d. Sex:
e. Any Other Surname(s) used:
Male
Female
1.
2.
f. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
g. Full forename(s):
h. Have your forenames changed at any time since birth?
Yes
No
If 'Yes', go to Question 3i.
If 'No', go to Question 3k
i. Previous forename(s):
j. Explanation of previous
forenames
Tick here if you are requesting Priority clearance
Tick here if you are requesting Immediate clearance
(Priority and Immediate cases only) I certify that this
application is accompanied by a letter of justification,
signed at the appropriate level.
NSV002 (Revised 04/2010)
Important: Please read the notes on Page 3 before completing the form.
31540
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Page 2
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this form remains the property of the Cabinet Office;
the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
* There is a difference between nationality and citizenship. If you hold or held citizenship rather than nationality, tick here
and advise which countries you held citizenship in, and dates:
*s. Present Nationality:
*t. Dual Nationality
(if any):
*u. Former Nationality
(if any):
r. If you do not have a UK National
Insurance Number (either
temporary or permanent), please
give a brief explanation.
/
Month
Year
Date from:
/
Date from:
/
Date from:
/
Date to:
v. If British naturalised, give number and date of certificate:
Number:
Date:
/ /
Day
Month
Year
If you answered Yes, enter full details, with dates, in date order to cover the whole 10 year period on page 4.
k. Date of Birth:
/ /
Day Month Year
q. National Insurance
Number:
x. Full permanent address: Since
y. Have you within the last 10 years:
Lived at any other addresses in the UK?
Lived outside the UK for more than 12 months at a time?
Yes
No
Yes
No
/
Town:
Street:
House/Flat number:
House name:
Postcode:
Country:
p. Do you have a UK National Insurance Number?
Yes
No
If 'Yes', please give your NI Number at 3q.
If 'No', please give an explanation at 3r
County / Region:
Country:
m. Current Grade /
Rank Position:
o. Staff or Service Number
(if applicable)
:
Is this a
temporary
National Insurance Number?
n. Current Job Title:
District:
l. Town of birth:
No
Yes
County / Region:
Month Year
w. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
Date:
/ /
Day Month Year
31540
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Page 3
This is an official document. The content and format of
this form remains the property of the Cabinet Office;
the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
STATEMENT OF HMG PERSONNEL SECURITY AND NATIONAL SECURITY VETTING POLICY
Minimum Personnel Security Controls
1. It is HM Government's policy that all areas of government and the
national infrastructure should include in their recruitment processes
certain basic checks. These checks include verification of the applicant's
identity, employment history, their right to work in the UK and, if
appropriate, checks of any unspent criminal records. Within government
these controls are described in the Baseline Personnel Security
Standard. In addition, the Centre for the Protection of National
Infrastructure (CPNI) produces a range of relevant guidance on
personnel security and makes similar advice available to the wider
national infrastructure.
National Security Vetting
2. National security vetting comprises a range of additional checks and may
be applied where a risk assessment indicates it is proportionate to do so.
The risk assessment process takes account of the access an individual
may have to sensitive assets (physical, personnel or information) at risk
from a wide range of threats. These threats include: terrorism,
espionage, or other actions that could threaten the United Kingdom. The
requirements of international agreements concerning the protection of
allies' information may also inform such assessments.
3. It is government policy that individuals should not be expected to hold an
existing security clearance in order to apply for posts that require vetting,
except where such posts are short term and need to be filled urgently.
4. There are three different types of national security vetting clearance:
Counter Terrorist Check (CTC), Security Check (SC) and Developed
Vetting (DV). Before any such clearance is undertaken the requirements
of the Baseline Personnel Security Standard must be met. Whilst the
information required and the range and depth of checks undertaken at
each level may vary, they are all intended to allow Government
departments and agencies, the Armed Forces and police forces to
assess whether individuals who are to be employed in sensitive posts or
critical functions might represent a security risk either directly or
indirectly.
Checks
5. Individuals subject to national security vetting (including UK nationals
taking up sensitive posts in international organisations) will be asked to
provide via questionnaire personal information about themselves,
partners, family members and other associates. It may be checked, and
retained for future checks, against:
• Relevant personnel records held by the employing department or
company
• Criminal records (both spent and unspent as defined by the
Rehabilitation of Offenders Act 1974)
• Information held by the Security Service.
• Credit reference agency records
6. The process may also take account of:
• Financial circumstances generally
• Third party character references
• Any medical considerations that could give rise to security concerns
7. Interviews with the vetting subject and referees may be carried out to
establish good character and to verify information that has been
provided.
Decision Making
8. National security vetting decisions may only be taken by Government
departments, agencies, the Armed Forces or police forces. All the
available information is taken into account to reach a reasoned decision
on an individual's suitability to hold a security clearance.
9. Security clearances may be refused or withdrawn where:
• There are security concerns related to an individual's involvement or
connection with activities, organisations or individuals associated with
the threats described in this Statement (or any similar new threats
that emerge);
• Personal circumstances, current or past conduct indicate that an
individual may be susceptible to pressure or improper influence;
• Instances of dishonesty or lack of integrity cast doubt upon an
individual's reliability;
• Other behaviours or circumstances indicate unreliability.
10. Wherever possible existing employees will have an opportunity to
discuss, comment on and challenge any adverse information that
arises. However in certain circumstances it may not be possible to
share such information as this could compromise national security, the
public interest or third party confidentiality.
Avenues of Appeal
11. Existing employees who are subject to national security vetting and
either refused a security clearance or whose clearance is withdrawn
may appeal against such decisions. All departments and agencies that
carry out national security vetting must provide for an internal appeal
process. Where individuals remain dissatisfied they may appeal to
the Security Vetting Appeals Panel, an independent body.
12. The Panel will consider the case, review the information and invite the
appellant and the organisation to make representations. The Panel will
make recommendations to the Head of Department or organisation in
the light of its findings as to whether the decision should stand or be
reviewed. The Panel may also comment on the security vetting
procedures and adequacy of the internal appeal arrangements.
13. There are no national security vetting appeal routes for applicants for
employment who are refused a security clearance. Separate
arrangements exist for applicants, employees and contractors of the
security and intelligence agencies, who may complain to the
Investigatory Powers Tribunal. Any individual may apply to an
Employment Tribunal if they feel that they have been discriminated
against in any part of the recruitment process.
Ongoing Personnel Security Management
14. The national security vetting process provides an assessment of the
vetting subject at the time the process is carried out but active ongoing
personnel security management is required to ensure that a security
clearance maintains its currency. As a minimum this will involve active
consideration of the vetting subject's continuing conduct in respect of
security matters; it will also require checks to be repeated at regular
intervals.
Please note that any information provided will be treated in strict confidence. In cases where a potential risk is identified, and a decision
taken to 'manage the situation' rather than refuse security clearance, those tasked with managing that risk will need the appropriate
information in order to do this effectively.
Failure to disclose relevant circumstances or information is likely in itself to be regarded as evidence of unreliability and will
be taken into account when assessing your suitability for security clearance. It is therefore in your own interests to be honest
and open in the information you provide in this questionnaire.
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Page 4
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
If more than 4 previous addresses in the last 10 years please tick and enter additional address details on the
continuation sheets (pages 48 to 50).
Previous Address
Previous Address
Country:
County / Region:
Postcode:
Town:
District:
Street:
House/Flat number:
House name:
To:
From:
/
Year
Month
/
Year
Month
Previous Address
Previous Address
Country:
County / Region:
Postcode:
Town:
District:
Street:
House/Flat number:
House name:
To:
From:
/
YearMonth
/
YearMonth
Previous Address
Previous Address
Country:
County / Region:
Postcode:
Town:
District:
Street:
House/Flat number:
House name:
To:
From:
/
YearMonth
/
YearMonth
Previous Address
Previous Address
Country:
County / Region:
Postcode:
Town:
District:
Street:
House/Flat number:
House name:
To:
From:
/
Year
Month
/
Year
Month
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Page 5
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
Work
h. Please enter your work address:
5. Marriage and partnerships
a. Are you currently or have you previously been (a) married or (b) registered a civil
partnership under the Civil Partnership Act 2004?
Yes
No
If you answered Yes, please give details below. If you answered No, please go to question 5c.
Date of marriage / registration:
/ /
Day Month Year
If more previous marriages / partnerships please tick here
and enter additional details on the continuation sheets
(pages 47 - 49)
b. Have you ever been divorced, separated or had a civil partnership dissolved?
Yes
No
If you answered Yes, please give details below. If you answered No, please go to question 5c.
Date of Divorce, Separation or Dissolution:
/ /
Day
Month
Year
If divorced, court at which Decree Nisi and Decree Absolute granted. If civil partnership dissolved, court at which
dissolution granted:
If more previous divorces, separations or dissolutions, please tick here
and enter additional details on the
continuation sheets (pages 47 - 49).
c. If living with a partner, from what date?:
If you have not lived with a partner in the last three years go to question 7
/
YearMonth
4. Your Contact Details
f. If we need to contact you, do you wish to be contacted at:
We will try to meet your preference but
this cannot always be guaranteed
e. E-mail:
Please list
all
e-mail addresses that you have, using the continuation pages if necessary.
g. Please provide dates in the next 3 months when you are unavailable for interview:
Home
Ext.
b. Work Telephone:
a. Home Telephone:
c. Military Dialling Code/GTN:
d. Mobile:
(2)
(3)
(1)
Country:
County / Region:
Postcode:
Town:
Address Line 2:
Address Line 1:
Name of Employer:
County / Region:
Country:
Town:
31540
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
Please enter details of any partner with whom you are living as a couple. Please also include ALL former partners who have
died or from whom you have separated (including divorce or the dissolution of a civil partnership) in the last 3 years. If this
includes more than one partner during the last 3 years please tick here
and enter additional details on the continuation
sheets (pages 47 - 49) in the same format as below.
If you have any other information which you feel may be appropriate (e.g. if your partner already holds a security clearance, or
is in government employment) please enter the details on the continuation sheets (pages 47 - 49).
If you do
not
know full details of this individual, please tick here:
Please give explanation:
a. Surname (now):
c. Surname (birth):
d. Sex:
e. Any Other Surname(s) used:
Male
Female
1.
2.
f. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
g. Full forename(s):
h. Have your partner's forenames changed at any time since birth?
Yes
No
i. Previous forename(s):
j. Explanation of previous
forenames
k. Date of Birth:
/ /
Day
Month
Year
l. Town of birth:
County / Region:
Country:
*n. Present Nationality:
*o. Dual Nationality
(if any):
*p. Former Nationality
(if any):
* There is a difference between nationality and citizenship. If they hold or held citizenship rather than nationality, tick here
and advise which countries they held citizenship in, and dates:
/ /
Day
Month
Year
If adopted, date of adoption:
m. If your partner holds a National Security Vetting Clearance (Developed Vetting, Security Check or Counter Terrorist Check),
please tick here
6. Details About Your Partner and/or Former Partner(s)
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Page 7
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If you answered Yes, enter full details, with dates, in date order to cover the whole 5 year period below.
q. If British naturalised,
give number and date of certificate:
Number:
/ /
Day Month Year
Date:
Full permanent address: Since
v. Has your partner or former partner within the last 5 years:
Lived at any other addresses in the UK?
Lived outside the UK for more than 12 months at a time?
Yes
No
Yes
No
/
s. Date of death (if applicable)
/ /
Day
Month
Year
r. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day Month Year
t. Partner's occupation:
u. Please enter your partner's current permanent address below:
Year
Month
Previous Address
Previous Address
Country:
County / Region:
Postcode:
Town:
District:
Street:
House/Flat number:
House name:
To:
From:
/
Year
Month
/
Year
Month
Previous Address
Previous Address
Country:
County / Region:
Postcode:
Town:
District:
Street:
House/Flat number:
House name:
To:
From:
/
YearMonth
/
YearMonth
Country:
County / Region:
Postcode:
Town:
District:
Street:
House/Flat number:
House name:
31540
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Page 8
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b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
Please provide details of all parents and their current and/or former partners in the last 3 years. Even if you are adopted, or
have step-parents, foster parents or legal guardians, we still require details of your natural father and mother below. If you
have any other parents, adoptive parents, step-parents or legal guardians, give details within Questions 9 and 10, using the
continuation sheets (pages 47 - 49) where required.
Yes
No
w. Do you have any other information about your partner which you feel may be relevant?
If so, please give details:
Details About Your Natural Parents, Adoptive Parents, Foster Parents, Step-Parents or Legal Guardians
Please state for each parent / parent's partner, the relationship, e.g. Step-Father/Father's Partner and, if appropriate, their
date of death.
7. Details About Your Natural Father
If you do
not
know full details of your natural father, please tick here:
Please give explanation:
a. Surname (now):
c. Surname (birth):
d. Any Other Surname(s) used:
2.
1.
e. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
f. Full forename(s):
g. Have your father's forenames changed at any time since birth?
Yes
No
h. Previous forename(s):
i. Explanation of previous
forenames
Previous Address
Previous Address
Country:
County / Region:
Postcode:
Town:
District:
Street:
House/Flat number:
House name:
To:
From:
/
YearMonth
/
YearMonth
31540
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Page 9
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
* There is a difference between nationality and citizenship. If your father holds or held citizenship rather than nationality, tick
here and advise which countries he holds/ held citizenship in, and dates:
/ /
Day Month Year
o. If British naturalised,
give number and date of certificate:
Number:
q. Occupation:
j. Date of Birth:
/
YearMonth
r. Please enter your father's current permanent address below: If your father is deceased, please provide the date of death
and enter your father's last known address below.
Full permanent address: Since
House/Flat number:
House name:
Street:
Postcode:
Town:
County / Region:
Country:
s. Date of death (if applicable)
/ /
Day
Month
Year
8. Details About Your Natural Mother
If you do
not
know full details of your natural mother, please tick here:
Please give explanation:
a. Surname (now):
c. Surname (birth):
District:
k. Town of birth:
County / Region:
Country:
*l. Present Nationality:
*m. Dual Nationality
(if any):
*n. Former Nationality (if any):
Date:
/ /
Day
Month
Year
p. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day
Month
Year
Date:
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
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Page 10
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this form remains the property of the Cabinet Office;
the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
* There is a difference between nationality and citizenship. If your mother holds or held citizenship rather than nationality,
tick here and advise which countries she holds/ held citizenship in, and dates:
/ /
Day Month Year
j. Date of Birth:
/
YearMonth
r. Please enter your mother's current permanent address below: If your mother is deceased, please provide the date of death
and enter your mother's last known address below.
Full permanent address: Since
q. Occupation:
Country:
Town:
Street:
House/Flat number:
House name:
o. If British naturalised,
give number and date of certificate:
Number:
/ /
Day Month Year
Date:
p. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day
Month
Year
Date:
*n. Former Nationality
(if any):
*m. Dual Nationality
(if any):
*l. Present Nationality:
Country:
County / Region:
k. Town of birth:
District:
d. Any Other Surname(s) used:
2.
1.
e. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
f. Full forename(s):
g. Have your mother's forenames changed at any time since birth?
Yes
No
h. Previous forename(s):
i. Explanation of previous
forenames
County / Region:
Postcode:
31540
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s. Date of death (if applicable)
/ /
Day Month Year
t. Do you have any other parents, adoptive parents, step-parents or legal guardians? Please
tick 'yes' or 'no'. If 'yes', go to Q9. If 'no', go to Q11.
Yes
No
9. Details of other Parents, Adoptive Parents, Foster Parents, Step-Parents or Legal Guardians
If you do
not
know full details of this individual, please tick here:
Please give explanation:
e. Surname (birth):
d. Surname (now):
f. Any Other Surname(s) used:
2.
1.
g. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
h. Full forename(s):
i. Have this individual's forenames changed at any time since birth?
Yes
No
j. Previous forename(s):
k. Explanation of previous
forenames
/ /
Day Month Year
l. Date of Birth:
m. Town of birth:
County / Region:
*p. Former Nationality
(if any):
*o. Dual Nationality
(if any):
*n. Present Nationality:
Country:
* There is a difference between nationality and citizenship. If the individual holds or held citizenship rather than nationality,
tick here
and advise which countries they hold/ held citizenship in, and dates:
a. Relationship:
/ /
Day
Month
Year
b. Date of adoption (if applicable):
c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
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c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
If you do
not
know full details of this individual, please tick here:
/
YearMonth
t. Please enter the individual's current permanent address below: If the individual is deceased, please provide the date of
death and enter their last known address below.
Full permanent address: Since
House/Flat number:
House name:
Street:
Postcode:
Town:
County / Region:
Country:
q. If British naturalised,
give number and date of certificate:
Number:
/ /
Day
Month
Year
Date:
s. Occupation:
/ /
Day Month Year
u. Date of death (if applicable)
10. Details of other Parents, Adoptive Parents, Foster Parents, Step-Parents or Legal Guardians
Please give explanation:
a. Relationship:
/ /
Day Month Year
d. Surname (now):
b. Date of adoption (if applicable):
f. Any Other Surname(s) used:
2.
1.
g. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
h. Full forename(s):
i. Have this individual's forenames changed at any time since birth?
Yes
No
j. Previous forename(s):
k. Explanation of previous
forenames
e. Surname (birth):
r. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
District:
/ /
Day Month Year
Date:
l. Date of Birth:
/ /
Day Month Year
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c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
If you do
not
know full details of this individual, please tick here:
11. Details About Your First Brother or Sister
Please give explanation:
a. Relationship:
Details About Your Brothers and Sisters
Please provide full details of ALL brothers and sisters aged 18 or over, including those who have died in the last 5 years. In
addition to full brothers and sisters, please include half and step-brothers, half and step-sisters, and adopted brothers or
sisters. Please state for each brother or sister, the relationship e.g. Brother/Step-Brother and, if appropriate, their date of death.
b. Surname (now):
m. Town of birth:
County / Region:
*p. Former Nationality
(if any):
*o. Dual Nationality
(if any):
*n. Present Nationality:
Country:
* There is a difference between nationality and citizenship. If the individual holds or held citizenship rather than nationality,
tick here
and advise which countries they hold/ held citizenship in, and dates:
/
Year
Month
t. Please enter the individual's current permanent address below: If the individual is deceased, please provide the date of
death and enter their last known address below.
Full permanent address: Since
House/Flat number:
House name:
Street:
q. If British naturalised,
give number and date of certificate:
Number:
/ /
Day
Month
Year
Date:
s. Occupation:
r. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
Town:
District:
/ /
Day
Month
Year
u. Date of death (if applicable)
Country:
County / Region:
Postcode:
/ /
Day Month Year
Date:
31540
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e. Any Other Surname(s) used:
2.
1.
f. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
g. Full forename(s):
h. Have this individual's forenames changed at any time since birth?
Yes
No
i. Previous forename(s):
j. Explanation of previous
forenames
/ /
Day
Month
Year
k. Date of Birth:
d. Surname (birth):
* There is a difference between nationality and citizenship. If the individual holds or held citizenship rather than nationality,
tick here
and advise which countries they hold/ held citizenship in, and dates:
p. If British naturalised,
give number and date of certificate:
Number:
/ /
Day
Month
Year
Date:
r. Occupation:
/
Year
Month
Full permanent address: Since
s. Please enter your first brother or sister's current permanent address below: If the individual is deceased, please provide the
date of death and enter their last known address below.
l. Town of birth:
County / Region:
Country:
*m. Present Nationality:
*n. Dual Nationality
(if any):
*o. Former Nationality
(if any):
q. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
House/Flat number: House name:
Street:
Country:
County / Region:
Postcode:
Town:
District:
/ /
Day
Month
Year
Date:
31540
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c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
If you do
not
know full details of this individual, please tick here:
12. Details About Your Second Brother or Sister
Please give explanation:
a. Relationship:
b. Surname (now):
/ /
Day
Month
Year
t. Date of death (if applicable)
e. Any Other Surname(s) used:
2.
1.
f. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
g. Full forename(s):
h. Have this individual's forenames changed at any time since birth?
Yes
No
i. Previous forename(s):
j. Explanation of previous
forenames
/ /
Day
Month
Year
k. Date of Birth:
d. Surname (birth):
l. Town of birth:
County / Region:
Country:
*o. Former Nationality
(if any):
*n. Dual Nationality
(if any):
*m. Present Nationality:
* There is a difference between nationality and citizenship. If the individual holds or held citizenship rather than nationality,
tick here
and advise which countries they hold/ held citizenship in, and dates:
p. If British naturalised,
give number and date of certificate:
Number:
/ /
Day Month Year
Date:
q. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day
Month
Year
Date:
31540
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/
YearMonth
Full permanent address: Since
s. Please enter your second brother or sister's current permanent address below: If the individual is deceased, please provide
the date of death and enter their last known address below.
13. Details About Your Third Brother or Sister
/ /
Day
Month
Year
t. Date of death (if applicable)
r. Occupation:
Street:
County / Region:
Postcode:
Town:
District:
House/Flat number:
House name:
Country:
If you do
not
know full details of this individual, please tick here:
Please give explanation:
a. Relationship:
b. Surname (now):
e. Any Other Surname(s) used:
2.
1.
f. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
g. Full forename(s):
h. Have this individual's forenames changed at any time since birth?
Yes
No
i. Previous forename(s):
j. Explanation of previous
forenames
/ /
Day
Month
Year
k. Date of Birth:
d. Surname (birth):
l. Town of birth:
County / Region:
Country:
c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
31540
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r. Occupation:
/
YearMonth
Full permanent address: Since
s. Please enter your third brother or sister's current permanent address below: If the individual is deceased, please provide
the date of death and enter their last known address below.
If you do
not
know full details of this individual, please tick here:
14. Details About Your Fourth Brother or Sister
Please give explanation:
a. Relationship:
/ /
Day
Month
Year
t. Date of death (if applicable)
b. Surname (now):
d. Surname (birth):
e. Any Other Surname(s) used:
2.
1.
f. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
g. Full forename(s):
House/Flat number:
House name:
Country:
County / Region:
Postcode:
Town:
Street:
District:
*o. Former Nationality
(if any):
*n. Dual Nationality (if any):
*m. Present Nationality:
* There is a difference between nationality and citizenship. If the individual holds or held citizenship rather than nationality,
tick here
and advise which countries they hold/ held citizenship in, and dates:
p. If British naturalised,
give number and date of certificate:
Number:
/ /
Day Month Year
Date:
q. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day
Month
Year
Date:
c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
31540
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If more than 4 siblings please tick here
and enter additional details on the continuation sheets (pages 47 - 49).
i. Previous forename(s):
j. Explanation of previous
forenames
/ /
Day
Month
Year
k. Date of Birth:
l. Town of birth:
County / Region:
Country:
h. Have this individual's forenames changed at any time since birth?
Yes
No
*o. Former Nationality
(if any):
*n. Dual Nationality
(if any):
*m. Present Nationality:
* There is a difference between nationality and citizenship. If the individual holds or held citizenship rather than nationality,
tick here
and advise which countries they hold/ held citizenship in, and dates:
/
Year
Month
Full permanent address: Since
s. Please enter your fourth brother or sister's current permanent address below: If the individual is deceased, please provide
the date of death and enter their last known address below.
/ /
Day Month Year
t. Date of death (if applicable)
p. If British naturalised,
give number and date of certificate:
Number:
/ /
Day
Month
Year
Date:
r. Occupation:
House/Flat number:
House name:
Street:
District:
Country:
Postcode:
County / Region:
Town:
q. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day Month Year
Date:
31540
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Details About Your PARTNER'S Natural Parents, Adoptive Parents, Foster Parents, Step-Parents or
Legal Guardians
Please provide details of ALL your partner's parents and their current and/or former partners in the last 3 years. Even if your
partner is adopted, or has step-parents, foster parents or legal guardians, we still require details of their natural father and
mother below. If your partner has any other parents, adoptive parents, step-parents or legal guardians give details within
Questions 17 and 18, using the continuation sheets (pages 47 - 49) where required.
Please state for each of your partner's parents / parent's partner, the relationship, e.g. Step-Father/Father's Partner and, if
appropriate, their date of death.
If you do
not
know full details of your partner's natural father, please tick here:
15. Details About Your PARTNER'S Natural Father
Please give explanation:
a. Surname (now):
c. Surname (birth):
d. Any Other Surname(s) used:
2.
1.
e. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
f. Full forename(s):
h. Previous forename(s):
i. Explanation of previous
forenames
j. Date of Birth:
g. Have your partner's father's forenames changed at any time since birth?
Yes
No
/ /
Day
Month
Year
k. Town of birth:
County / Region:
Country:
*n. Former Nationality (if any):
*m. Dual Nationality
(if any):
*l. Present Nationality:
* There is a difference between nationality and citizenship. If your partner's father holds or held citizenship rather than
nationality, tick here
and advise which countries he holds/ held citizenship in, and dates:
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
31540
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/
YearMonth
Full permanent address: Since
r. Please enter your partner's father's current permanent address below: If your partner's father is deceased, please provide
the date of death and enter your partner's father's last known address below.
/ /
Day
Month
Year
s. Date of death (if applicable)
o. If British naturalised,
give number and date of certificate:
Number:
/ /
Day Month Year
Date:
q. Occupation:
If you do
not
know full details of your partner's natural mother, please tick here:
16. Details About Your PARTNER'S Natural Mother
Please give explanation:
d. Any Other Surname(s) used:
2.
1.
e. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
f. Full forename(s):
h. Previous forename(s):
i. Explanation of previous
forenames
/ /
Day Month Year
j. Date of Birth:
g. Have your partner's mother's forenames changed at any time since birth?
Yes
No
a. Surname (now):
c. Surname (birth):
House/Flat number: House name:
Street:
District:
Town:
County / Region:
Postcode:
Country:
p. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day
Month
Year
Date:
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
31540
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t. Does your partner have any other parents, adoptive parents, step-parents or legal guardians?
Please
tick 'yes' or 'no'. If 'yes', go to Q17. If 'no', go to Q19.
Yes
No
k. Town of birth:
County / Region:
Country:
*n. Former Nationality
(if any):
*m. Dual Nationality
(if any):
*l. Present Nationality:
* There is a difference between nationality and citizenship. If your partner's mother holds or held citizenship rather than
nationality, tick here
and advise which countries she holds/ held citizenship in, and dates:
o. If British naturalised,
give number and date of certificate:
Number:
/ /
Day
Month
Year
Date:
q. Occupation:
/
Year
Month
Full permanent address: Since
r. Please enter your partner's mother's current permanent address below: If your partner's mother is deceased, please provide
the date of death and enter your partner's mother's last known address below.
/ /
Day
Month
Year
s. Date of death (if applicable)
If you do
not
know full details of this individual, please tick here:
17. Details About Your PARTNER'S other Parents, Adoptive Parents, Foster Parents, Step-Parents or
Legal Guardians
Please give explanation:
House/Flat number:
House name:
Street:
District:
Town:
County / Region:
Postcode:
Country:
p. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day
Month
Year
Date:
31540
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a. Relationship:
/ /
Day
Month
Year
b. Date of adoption (if applicable):
f. Any Other Surname(s) used:
2.
1.
g. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
h. Full forename(s):
j. Previous forename(s):
i. Have this individual's forenames changed at any time since birth?
Yes
No
d. Surname (now):
e. Surname (birth):
k. Explanation of previous
forenames
l. Date of Birth:
m. Town of birth:
County / Region:
Country:
*p. Former Nationality
(if any):
*o. Dual Nationality
(if any):
*n. Present Nationality:
* There is a difference between nationality and citizenship. If the individual holds or held citizenship rather than
nationality, tick here
and advise which countries they hold/ held citizenship in, and dates:
q. If British naturalised,
give number and date of certificate:
Number:
/ /
Day Month Year
Date:
s. Occupation:
/ /
Day
Month
Year
r. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day
Month
Year
Date:
c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
31540
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If you do
not
know full details of this individual, please tick here:
18. Details of PARTNER'S other Parents, Adoptive Parents, Foster Parents, Step-Parents or Legal
Guardians
Please give explanation:
g. Explanation of different surnames
(e.g. marriage, deed poll, etc.)
h. Full forename(s):
j. Previous forename(s):
k. Explanation of previous
forenames
/ /
Day
Month
Year
l. Date of Birth:
i. Have this individual's forenames changed at any time since birth?
Yes
No
/
Year
Month
Full permanent address: Since
House/Flat number:
House name:
Street:
Postcode:
Town:
County / Region:
Country:
t. Please enter the individuals current permanent address below: If the individual is deceased, please provide the date of
death and enter their last known address below.
/ /
Day Month Year
u. Date of death (if applicable)
a. Relationship:
/ /
Day Month Year
b. Date of adoption (if applicable):
f. Any Other Surname(s) used:
2.
1.
d. Surname (now):
e. Surname (birth):
District:
c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
31540
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m. Town of birth:
County / Region:
Country:
*p. Former Nationality
(if any):
*o. Dual Nationality
(if any):
*n. Present Nationality:
* There is a difference between nationality and citizenship. If the individual holds or held citizenship rather than
nationality, tick here
and advise which countries they hold/ held citizenship in, and dates:
q. If British naturalised,
give number and date of certificate:
Number:
/ /
Day Month Year
Date:
s. Occupation:
/
Year
Month
Full permanent address: Since
House/Flat number:
House name:
Street:
Postcode:
Town:
County / Region:
Country:
t. Please enter the individuals current permanent address below: If the individual is deceased, please provide the date of
death and enter their last known address below.
/ /
Day
Month
Year
u. Date of death (if applicable)
District:
r. If non-UK National, date of taking up permanent residence in UK:
(This is not necessarily the same as the date of the permission to stay in the UK)
/ /
Day Month Year
Date:
31540
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If more than 4 co-residents please tick here
and enter additional co-residents' details on the continuation sheets
(pages 47 - 49).
19. Details About Your Co-Residents
Please give details of anyone aged 18 or over living with you in shared accommodation (e.g. lodgers, au-pairs, flat-mates,
etc).You need not enter details of your partner or of anyone you have already included in this questionnaire. Do not enter
details of those who live in the same hostel or shared Service accommodation.
If not applicable please go to question 20.
a. Surname (now):
/ /
Day Month Year
c. Forename(s):
*f. Present
Nationality:
e. Town of Birth:
d. Date of Birth:
OR Approximate Age (in Years):
*If applicable, please differentiate between citizenship and nationality
g. Occupation:
a. Surname (now):
/ /
Day
Month
Year
c. Forename(s):
*f. Present
Nationality:
e. Town of Birth:
d. Date of Birth:
OR Approximate Age (in Years):
*If applicable, please differentiate between citizenship and nationality
g. Occupation:
a. Surname (now):
/ /
Day Month Year
c. Forename(s):
*f. Present
Nationality:
e. Town of Birth:
d. Date of Birth:
OR Approximate Age (in Years):
*If applicable, please differentiate between citizenship and nationality
g. Occupation:
a. Surname (now):
/ /
Day Month Year
c. Forename(s):
*f. Present
Nationality:
e. Town of Birth:
d. Date of Birth:
OR Approximate Age (in Years):
*If applicable, please differentiate between citizenship and nationality
g. Occupation:
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
31540
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20. Employment in HM Forces
a. Are you now, or have you ever been a member of HM Forces or Reserve?
22. Your Present Employment
21. Employment in HM Government Service, the Civil Nuclear Industry, Police Forces
and the Devolved Administrations*
/
Year
Month
a. Are you employed now, or have you ever been employed, by any of the above?
If you answered 'no' please go to Question 22. If you answered 'yes' please give details below.
b. Present or most recent
organisation:
c. Dates of Service:
From:
To:
d. Grade now or on leaving:
Yes
No
/
YearMonth
/
YearMonth
b. Are you currently serving?
c. Dates of Service:
From:
To:
d. Rank now or on discharge:
e. Service (RN/RM, Army or RAF):
f. Service Number:
Yes
No
/
Year
Month
a. Are you presently employed?
Yes
No
To be completed if you are NOT currently employed in HM Forces or HM Government Service.
This includes employment in the UK government departments and agencies, British Energy, Canberra UK, Centronic, Civil Nuclear
Constabulary, Direct Rail Services Ltd, Dounreay Site Restoration Ltd, Enrichment Technology UK (Marlow, Capenhurst), GE
Healthcare, Geodis, Imperial College Reactor Centre, International Nuclear Services (Warrington), James Fisher (Crewing Services)
Ltd, Magnox, Nuclear Decommissioning Authority, National Nuclear Laboratory, NUVIA, Sellafield Ltd, RSRL (Harwell and Winfrith),
Springfield Fuels Ltd, Studsvik (Gateshead), UKAEA, Urenco, VT Nuclear Services, WH Bowker, Inutec, EDF Nuclear, Horizon Nuclear
Power, the Civil Aviation Authority, the BT Group of companies and the Post Office.
If you answered 'yes' please give present employment details below. If you answered 'no' please go to question 23.
b. Name of employer:
c. Address of employer:
Address Line 1:
Address Line 2:
Town:
County/Region:
d. Telephone:
Postcode:
e. Surname of Immediate Supervisor:
f. Forenames of Immediate Supervisor:
If you answered 'no' please go to Question 21. If you answered 'yes' please give details below.
Yes
No
Country:
31540
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g. Immediate Supervisor's job title:
h. Immediate Supervisor's e-mail
address (if known):
i. How long have you been supervised by this individual:
Months
Years
If your answer is less than one year, and you have worked for your present employer for at least that length of time, please use the
continuation page to give full details of all other supervisors you have had in the last 12 months.
j. Your current job title:
k. Date of joining:
/
Year
Month
23. Your Previous Employment
Please enter details of any other full or part-time employment you have held within the last 10 years giving the most recent
employment first. Please include any periods of unemployment of 3 months or more giving the address of the relevant Benefit
Office. Where work was obtained through an employment agency, details of the agency and dates only need be given (use the
continuation sheets on pages 47 - 49. Self-employed contractors or consultants who have not obtained work through an
employment agency should provide details of 3 firms worked for.
If you have no previous employment go to question 25.
a. Name of employer:
b. Address of employer:
Address Line 1:
Address Line 2:
Town:
County/Region:
c. Telephone:
Postcode:
d. Surname of Immediate Supervisor:
e. Forenames of Immediate Supervisor:
g. Supervisor's job title:
h. Supervisor's e-mail
address (if known):
j. Your job title:
k. Dates:
/
Year
Month
f. Supervisor's Grade/Rank:
i. Your Grade/Rank:
/
Year
Month
From:
To:
Country:
a. Name of employer:
b. Address of employer:
Address Line 1:
Address Line 2:
Town:
County/Region: Postcode:
31540
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c. Telephone:
d. Surname of Immediate Supervisor:
e. Forenames of Immediate Supervisor:
g. Supervisor's job title:
h. Supervisor's e-mail
address (if known):
j. Your job title:
k. Dates:
/
YearMonth
f. Supervisor's Grade/Rank:
i. Your Grade/Rank:
/
YearMonth
From:
To:
Country:
a. Name of employer:
b. Address of employer:
Address Line 1:
Address Line 2:
Town:
County/Region:
c. Telephone:
Postcode:
d. Surname of Immediate Supervisor:
e. Forenames of Immediate Supervisor:
g. Supervisor's job title:
h. Supervisor's e-mail
address (if known):
j. Your job title:
k. Dates:
/
Year
Month
f. Supervisor's Grade/Rank:
i. Your Grade/Rank:
/
Year
Month
From:
To:
Country:
a. Name of employer:
b. Address of employer:
Address Line 1:
Address Line 2:
Town:
County/Region:
c. Telephone:
Postcode:
d. Surname of Immediate Supervisor:
e. Forenames of Immediate Supervisor:
Country:
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If more than 4 previous employers please tick here
and enter additional employment details on the continuation
sheets (pages 47 - 49).
g. Supervisor's job title:
h. Supervisor's e-mail
address (if known):
j. Your job title:
k. Dates:
/
Year
Month
f. Supervisor's Grade/Rank:
i. Your Grade/Rank:
/
Year
Month
From:
To:
24. Your Supervisors
To be completed only if you are currently serving in HM Forces, Reserve or HM Government or have done so in the last 5
years. If not please go to question 25.
Please give details of your immediate supervisor/line manager in each posting in HM Forces/Reserve/Government service in
the last 5 years, giving the most recent first. The immediate supervisor/line manager is the person who directly supervised you
and saw you most frequently in each posting; for service personnel it must be someone of Petty Officer/SNCO rank or above.
a. Dates you were supervised:
b. Section, Branch, Unit or Establishment:
/
Year
Month
/
Year
Month
From:
To:
g. Post Title:
f. Grade/Rank:
e. Forename(s)
c. Surname
k. Email Address (If known):
i. Military Telephone Number:
j. Civilian Telephone Number:
Country:
Postcode:
County/Region:
Town:
Address Line 2:
Address Line 1:
h. Please enter the present work/daytime address and telephone number of this supervisor below:
a. Dates you were supervised:
b. Section, Branch, Unit or Establishment:
/
YearMonth
/
YearMonth
From:
To:
f. Grade/Rank:
e. Forename(s)
c. Surname
g. Post Title:
d. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
d. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
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d. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
d. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
k. Email Address (If known):
i. Military Telephone Number:
j. Civilian Telephone Number:
Country:
Postcode:
County/Region:
Town:
Address Line 2:
Address Line 1:
h. Please enter the present work/daytime address and telephone number of this supervisor below:
a. Dates you were supervised:
b. Section, Branch, Unit or Establishment:
/
Year
Month
/
Year
Month
From:
To:
g. Post Title:
f. Grade/Rank:
e. Forename(s)
c. Surname
k. Email Address (If known):
i. Military Telephone Number:
j. Civilian Telephone Number:
Country:
Postcode:
County/Region:
Town:
Address Line 2:
Address Line 1:
h. Please enter the present work/daytime address and telephone number of this supervisor below:
a. Dates you were supervised:
b. Section, Branch, Unit or Establishment:
/
Year
Month
/
Year
Month
From:
To:
g. Post Title:
f. Grade/Rank:
e. Forename(s)
c. Surname
Town:
Address Line 2:
Address Line 1:
h. Please enter the present work/daytime address and telephone number of this supervisor below:
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c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
k. Email Address (If known):
i. Military Telephone Number:
j. Civilian Telephone Number:
Country:
Postcode:
County/Region:
25. Your Full Time Education
Yes
No
If you answered Yes, please give full details below of all courses, although there is no need to go back further than age 14.
If you answered No, please go to question 26.
Have you received full time education during the last 5 years?
If more than 4 supervisors please tick here
and enter the details for each supervisor on the continuation sheets
(pages 47 - 49).
a. School/College/University:
b. Surname
d. Forename(s)
e. Official Address:
Address Line 1:
Address Line 2:
Town:
County/Region:
f. Telephone:
Postcode:
Country:
g. Email Address (If known):
h. Dates Attended:
From:
/
Year
Month
To:
/
Year
Month
Details of your Head/Principal/Tutor who knew you best at School/College/University:
If more than 2 full time educational courses please tick here and enter the details for each additional educational course
on the continuation sheets (pages 47 - 49).
a. School/College/University:
b. Surname
d. Forename(s)
e. Official Address:
Address Line 1:
Address Line 2:
Town:
County/Region:
f. Telephone:
Postcode:
Country:
g. Email Address (If known):
h. Dates Attended:
From:
/
YearMonth
To:
/
YearMonth
Details of your Head/Principal/Tutor who knew you best at School/College/University:
c. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
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26. Your Character Referees
Please give details of a minimum of three referees (NOT RELATIVES OR PARTNERS AND PREFERABLY NOT SUPERVISORS
OR EMPLOYERS) who, collectively, must have known you well over the past 10 years. At least one of the referees should be
someone in your own age group. They should preferably be British citizens (but this is not obligatory) and, since it may be
necessary for them to be interviewed, they must be able to make themselves available for that purpose in the UK or in a major
military base overseas. YOU SHOULD TELL YOUR REFEREES THAT YOU WISH TO PUT THEIR NAMES FORWARD.
Referees should between them cover each specific area in which you have lived during this period: thus additional referees
should be named if you have moved frequently during the last 10 years. It is not sufficient to nominate someone you know
officially or professionally, such as a doctor, unless you know them socially as well. Similarly, staff members of a school,
college or university should not be chosen unless they are close personal friends. Referees should include a person (not a
partner), who knows you well in your home environment and ideally someone (other than a supervisor or employer) who
knows you well in the work environment.
First Character Referee
a. Surname
c. Forename(s)
d. Date of Birth:
e. Occupation:
f. Home Address of Referee:
House/Flat Number:
Street:
District:
Town:
Country:
Postcode:
County/Region:
g. Home Telephone:
/
Year
Month
OR Approximate Age (in Years):
Postcode:
Country:
County/Region:
Town:
Address Line 2:
Address Line 1:
k. Alternative Address for Interview (if applicable):
House Name:
h. Work Telephone:
i. Mobile Telephone:
Ext.
j. Email Address:
l. How long have you known the Referee? Years:
m. When did you last see the Referee?
n. Frequency of contact:
Once a Year:
Once a Week:
Once a Month:
/ /
Day Month Year
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
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Second Character Referee
a. Surname
c. Forename(s)
d. Date of Birth:
e. Occupation:
f. Home Address of Referee:
House/Flat Number:
Street:
District:
Town:
Country:
Postcode:
County/Region:
g. Home Telephone:
/
YearMonth
OR Approximate Age (in Years):
Postcode:
Country:
County/Region:
Town:
Address Line 2:
Address Line 1:
k. Alternative Address for Interview (if applicable):
House Name:
h. Work Telephone:
i. Mobile Telephone:
Ext.
j. Email Address:
l. How long have you known the Referee? Years:
m. When did you last see the Referee?
n. Frequency of contact:
Once a Year:
Once a Week:
Once a Month:
/ /
Day
Month
Year
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
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If more than 3 character referees please tick here
and enter the details for each additional character referee on the
continuation sheets (pages 47 - 49).
Third Character Referee
a. Surname
c. Forename(s)
d. Date of Birth:
e. Occupation:
f. Home Address of Referee:
House/Flat Number:
Street:
District:
Town:
Country:
Postcode:County/Region:
g. Home Telephone:
/
Year
Month
OR Approximate Age (in Years):
Postcode:
Country:
County/Region:
Town:
Address Line 2:
Address Line 1:
k. Alternative Address for Interview (if applicable):
House Name:
h. Work Telephone:
i. Mobile Telephone:
Ext.
j. Email Address:
l. How long have you known the Referee? Years:
m. When did you last see the Referee?
n. Frequency of contact:
Once a Year:
Once a Week:
Once a Month:
/ /
Day Month Year
b. Title (Mr/Mrs/Ms/Miss/Dr/Prof/Rev):
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27. Health Declaration
Please read the following BEFORE answering the questions below and overleaf about your health.
In some cases it may be necessary to consult your doctor and you may be asked to attend a medical examination. Any enquiries
will be conducted by the Defence Vetting Agency's Vetting Medical Adviser (VMA), an approved Occupational Health Organisation
(OHO) or Medical Officer (MO), such as BMI Health Services,or approved Medical officer (MO). In all but the most exceptional
circumstances, these reports will not be made available to Departmental Security Officers, Personnel Officers or to line management.
Exceptionally, a medical report may need to be seen by an appropriate senior person in your vetting authority in order to help reach a
proper assessment of your suitability to hold a security clearance. This may or may not include access to your full medical records. In
such cases, you will be asked to give your consent for this to be done.
If you answer 'yes' to Question 27b, c, d or e below, you will be asked to sign the declaration on page 36. By doing so,you will
be giving your consent, under the terms of the Access to Medical Reports Act 1988, for the VMA/OHO/MO to obtain a medical
report from your doctor or other specialist, if this is considered necessary. Under the terms of the Act, you have the right to
withhold your consent at any stage in the process, but you should be aware that this may mean it is not possible to grant or
renew your security clearance.
Once you have given your consent, you have the right to see the medical report before it is supplied to the VMA/OHO/MO. The
VMA/OHO/MO will write to tell you that they have requested a report, and you will have 21 days from the date of their letter in which to
ask your doctor or other specialist to let you see the report before it is forwarded to them. Your doctor or other specialist will tell you if
you cannot see any part of the report for professional medical reasons. If you are given access to your report, it will not be forwarded to
the VMA/OHO/MO until you give your consent.
If you think any information in the medical report is incorrect or misleading, you can ask in writing for it to be amended. You should note
that if your doctor or other specialist does not accept the information as incorrect or misleading, they do not have to make any
amendment. They will however invite you to prepare a written statement on the disputed information, which will be attached to the
medical report when it is sent to the VMA/OHO/MO. Subject to the provisions of the Act, you have a right to see the medical report for
up to six months after it has been sent to the VMA/OHO/MO. If your doctor or other specialist gives you a copy of the medical report at
your request, they may charge you a reasonable fee to cover the cost of supplying it.
Now please answer the following questions about your health. Although it may be taken into account, information
provided will not necessarily prevent you having a security clearance.
Yes
No
Certain psychological and medical conditions may have security implications.
a. Are you currently taking any medication?
b. Have you suffered at any time from clinical depression, mental illness,nervous
breakdown/nervous debility, serious medical or psychological problems?
c. Do you suffer, or have you ever suffered from any condition that may cause occasional
and momentary loss of consciousness, for example epilepsy, insulin-dependent diabetes
and certain heart conditions?
d. Are you currently or have you ever been a habitual user of addictive substances (e.g.
drugs or alcohol)?
e. Are you aware of any health matters not already covered by your previous answers
which might affect your suitability for access to sensitive information or assets?
If you have answered 'No' to all the above questions, go to Question 28. You need not sign the next page.
Yes
No
Yes
No
Yes
No
Yes
No
If you have answered 'Yes' to Question 27a only, please give details of your medication below, then go to Question 28.
You need not sign the next page.
If you have answered 'Yes' to Question 27b, c, d or e, please give full details below. Complete Questions 27f - 27m, and
sign and date the next page where indicated.
Details:
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f. Your Surname
i. Title (Dr/Prof etc):
g. Your Forename(s)
h. Surname of Your Current General
Practitioner/Medical Officer:
j. Surgery Name:
Address Line 1:
Address Line 2:
Town:
Country:
Postcode:
County/Region:
k. If appropriate, please give details of your hospital specialist below:
Postcode:
Country:
County/Region:
Town:
Address Line 2:
Address Line 1:
Hospital Name:
m. Hospital Registration Number:
(if appropriate)
Surname of Your Hospital
Specialist
l. Title (Dr/Prof etc):
PLEASE READ THIS BEFORE SIGNING
You are only required to sign here IF you have answered 'Yes' to any question from 27b to 27e, inclusive.
By signing this page, you will be giving your consent, under the terms of the Access to Medical Reports Act 1988,for the
VMA/OHO/MO to obtain a medical report from your doctor or other specialist, if this is considered necessary.
Under the terms
of the Act, you have the right to withhold your consent at any stage in the process, but you should be aware that this may mean it is
not possible to grant or renew your security clearance.
/ /
Day Month Year
Date:
Signed:
31540
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28. Criminal Convictions & Related Matters
In line with HM Government's policy on vetting on page 3, you must declare any matter
which may be relevant.
This includes:
any criminal convictions which you may have, including those which are 'spent'. In line with the Rehabilitation of
Offenders Act 1974 (Exceptions) Order 1975, the Rehabilitation of Offenders (Exclusions and Exceptions)(Scotland) Order 2003, and
the Rehabilitation of Offenders (Exceptions) Order (Northern Ireland) 1979, spent convictions may be taken into account where national
security is concerned. In Northern Ireland, spent convictions may also be taken into account where protecting public safety or public
order is involved.
You must reveal all convictions, whether or not spent, under the legislation.
The relevant department or agency will decide if a criminal conviction affects your security clearance. Although it may be taken into
account, this information will not necessarily prevent you from being awarded a security clearance.
Please answer the three questions on the next page and
sign and date the section.
You have the option to detach the Criminal Declaration (page 38) should you wish the Vetting Authorities alone to see your
response on these matters. You should remove the section and place in an envelope, then seal the envelope, sign your name
across the flap and attach it to the front of the questionnaire before sending to your sponsor.
Failure to disclose relevant circumstances or information is likely in itself to be regarded as evidence of unreliability and will
be taken into account when assessing your suitability for security clearance.
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You are reminded that your answers will be checked against national criminal records.
Yes
No
Have you ever been:
a. convicted or found guilty by a Court (including juvenile courts) of ANY offence in ANY
country (excluding parking and speeding, but including all other motoring offences
even where a spot fine has been administered by the police)?
b. on probation, or received a formal caution, or been absolutely/conditionally
discharged,or had a fixed penalty notice or penalty notice for disorder issued to you, or
accepted a fiscal fine from the Procurator Fiscal in Scotland, or been bound over after
being charged with any offence, or is there any action pending against you?
c. convicted by a Court Martial, or sentenced to detention or dismissal or fined while
serving in the armed forces of the UK or any Commonwealth or foreign country?
If you answered Yes to any of the questions on this page, please give full details, (including dates) below.
Yes
No
Yes
No
/ /
Day
Month
Year
Date:Signed:
Surname:
Full
Forename(s):
Please enter your full name and sign and date below.
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30. Other Information
You are required to state if there are any other matters which might be relevant to the granting of
a security clearance.
If you answered Yes to any of the questions on this page, please give full details below.
31. Previous Security Clearances
29. Security Information
You are reminded that your answers will be checked against national security records.
Type of
Questionnaire:
Department,
agency or firm:
Have you completed any previous government security questionnaires or held a
security clearance before?
If you answered Yes, please provide information on the most recent questionnaire/security clearance, the department,
agency or firm you applied to or were working for, and the date completed.
Yes
No
/
YearMonth
Date Completed:
Have you ever had a security clearance withdrawn or withheld?
Yes
No
If so, please state what level of clearance, which department, agency or firm you were working for or had applied to, and
the date when your clearance was withdrawn.
Have you ever been involved in:
b. terrorism?
Yes
No
c. sabotage?
Yes
No
e. Have you ever been a member of, or supported a group or groups involved in any of the
above activities?
Yes
No
a. espionage?
Yes
No
f. Have you ever had a close association with anyone, including any member of your
family, who, to your knowledge, has been a member of or given active support to any
such group or activities?
Yes
No
d. Actions intended to overthrow or undermine Parliamentary democracy by political,
industrial or violent means?
Yes No
Yes
No
a. Do you currently have, or have you ever had, significant financial difficulties?
b. Are you now, or have you ever been, involved in conduct liable to lead to susceptibility
to pressure or improper influence?
Yes
No
Yes
No
c. Are you aware of any other circumstances or characteristics not covered by your
previous answers which might affect your suitability for access to sensitive information
or assets?
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Date of withdrawal:
Please give the reason
for this:
Level of clearance (e.g DV, SC, CTC):
Department, Agency or Firm:
Is there any other information
that you wish to provide in
support of your clearance
application?
/ /
Day
Month
Year
Financial Information
In the following questions you are being asked to provide a clear, complete and accurate picture of your current and
recent financial situation. This must reflect the situation of
anyone
who shares financial responsibility with you.
32. Your Properties
a. How many properties do you own, or partly own, in the UK or overseas?
b. Details of your properties:
Date of Purchase
/ /
Day Month Year
Purchase price
£
Property 1
What type of mortgage?
£
Current market valuation
Mortgaged?
Address Line 1:
Address Line 2:
Town:
Postcode:
Country:
County/Region:
If you own more than 2 properties, please provide details on the continuation pages.
c. Total of property market valuations, including those on continuation pages (if any)
£
Date of Purchase
/ /
Day
Month
Year
Purchase price
£
Property 2
What type of mortgage?
£
Current market valuation
Mortgaged?
Address Line 1:
Address Line 2:
Town:
Postcode:
Country:
County/Region:
Yes
No
Yes
No
Repayment
Interest Only
Flexible
Other
Repayment
Interest Only
Flexible
Other
Term of mortgage (in months):
Term of mortgage (in months):
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a. How much do you (and your partner) have in savings accounts, premium bonds and
invested in shares, funds, etc.?
33. Savings and Other Assets
Description of
savings/investments:
c. What is the valuation of your (and your partner's) vehicles?
£
£
Description of
vehicles:
d. What is the valuation of your (and your partner's) other assets, e.g. jewellery, antiques,
timeshares?
£
Description of
other assets:
e. Have you ever received a lump sum worth more than £5,000? (e.g. redundancy, pension
commutation, inheritance, gift, winnings)
Yes No
Details:
a. How many mortgages and secured loans are linked to your properties?
34. Mortgages
d. Do you have any other mortgages or secured loans in addition to those declared above?
If 'yes', please give details on the continuation pages.
Yes No
g. Have you ever adjusted the payment terms of your mortgages, e.g. payment holiday?
Yes
No
h. Have you ever remortgaged to consolidate your personal debts?
Yes
No
If you answer 'yes' to Question 34f, g or h, please give details on the continuation pages.
e. Total of mortgage / loan balances outstanding (including any listed on the continuation
pages):
£
f. Have you ever taken a further mortgage advance(s) for any purpose?
Yes
No
TOTAL OF ALL ASSETS (add Total from Section 32 and amounts given in this section)
£
2
nd
.
1
st
.
b. Mortgage / loan lenders of property 1:
Date of 1st mortgage / loan:
/
YearMonth
Initial amount:
£
Balance outstanding:
£
2
nd
.
1
st
.
c. Mortgage / loan lenders of property 2:
Date of 1st mortgage / loan:
/
YearMonth
Initial amount:
£
Balance outstanding:
£
Date of 2nd mortgage:
Initial amount:
£
Balance outstanding:
£
/
Year
Month
Date of 2nd mortgage / loan:
/
Year
Month
Initial amount:
£
Balance outstanding:
£
b. Do you save:
Regularly?
Occasionally?
Hardly ever?
Date of 2nd mortgage / loan:
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Issuer:
Credit limit:
Issuer:
Credit limit:
Issuer:
Credit limit:
Issuer:
Credit limit:
a. How many credit, store and charge card accounts do you (and your partner) have?
36. Credit Cards
b. Please give details below.
c. Total of balances outstanding (including any listed on the continuation page)
£
d. Do you transfer balances between credit cards, e.g. 0% interest deals?
Yes
No
£
Balance outstanding now:
c. Total of loan balances outstanding (including any listed on the continuation pages)
£
a. How many loan agreements (including student loans but not secured loans listed at Q34) are outstanding?
35. Loans
b. Please give details below. Use the continuation pages if necessary.
Lender 1:
Purpose:
/
Year
Month
Date taken out:
£
Amount:
a. How many current accounts were
overdrawn
in the previous month?
b. Please give details below. Use the continuation pages if necessary.
37. Current Accounts - Overdrafts
c. Total of overdrafts (including any listed on the continuation page)
£
d. In the last 5 years, how many times have you exceeded your overdraft limit(s)?
TOTAL OF ALL LIABILITIES (add 34e, 35c, 36c, 37c)
£
Repayment:
£
Type:
£££
Avg monthly payment:
Balance outstanding:
Type:
£££
Avg monthly payment:
Balance outstanding:
Type:
£
£
£
Avg monthly payment: Balance outstanding:
£
£
Branch:
Bank:
Max. O/D last month:
Overdraft limit:
£
Balance outstanding now:
Lender 2:
Purpose:
/
Year
Month
Date taken out:
£
Amount
:
Repayment:
£
Type:
£
Avg monthly payment:
Balance outstanding:
£
£
£
£
Branch:Bank:
Max. O/D last month:
Overdraft limit:
Expiry Date:
/
Year
Month
Expiry Date:
/
Year
Month
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Page 43
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
39. Household Monthly Income
To enable us to assess the household income - please provide
a clear picture of all sources of earned and unearned income.
a.
SELF
OTHER PERSON
£ £
b.
c.
d.
e.
f.
g.
h.
i.
j. Total individual
monthly
incomes
k. Total joint
monthly
income
£
If a fuller explanation of your income would be helpful to us, please provide the details below.
Details:
l. Has all income been declared for tax purposes (e.g. rental income)?
Yes
No
38. General Circumstances
a. Are you living with someone?
b. If you are living with someone, do they share a financial responsibility with you or make a
contribution to your financial situation?
If you answered 'yes', it will be necessary to explore the impact
of this person's contribution on your financial situation. Please include the requested information in the
relevant sections of this form.
Yes
No
Yes
No
Details:
c. For whom do you have a financial responsibility, other than yourself (e.g. partner, children, parent)?
Details:
d. What major financial changes to your budget do you anticipate in the next 12 months? (e.g. salary increase, partner returning
to work, endowment policy maturing or reduction in hours, partner ceasing work, moving house and increasing mortgage etc)
e. Have you been the victim of "identity theft" or credit card fraud? If 'yes', please give details.
Yes
No
Details:
£ £
£ £
£ £
£ £
£ £
£ £
£ £
£ £
£ £
Current
annual
salary (gross)
Usual
annual
bonus (gross)
Annual
car allowance (gross)
Monthly
net salary (including average bonus and
any allowances)
Monthly
income from state benefits (e.g. Child Benefit,
Family Credit)
Monthly
net income from pensions and annuities
Monthly
net income from savings and investments
averaged)
Monthly income from rented properties
Monthly maintenance received
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Page 44
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
41. Household Monthly Outgoings
a. Mortgage / Rent / Board / Lodging
£
To enable us to assess the household outgoings, please provide an accurate account of all
household expenditure.
MONTHLY COST
£
£
£
£
£
£
£
£
£
£
£
£
£
£
b. Service charge / ground rent / management fees
c. Council Tax
d. Housekeeping (i.e. food and household necessities)
e. Motoring costs (including tax, insurance, petrol & maintenance) / commuting and travel costs
f. Utility bills (gas, electricity, oil, water bills, telephones and mobile phones)
g. Loan repayments
h. Sky / Cable / TV licence / Internet access
i. Maintenance payment for children
j. Nursery fees / school fees / parental contribution to student costs
k.Pensions / insurance (all - excluding car insurance)
l. Holidays (average per month of annual costs)
m. Entertainment (including sports and gym club memberships, trips out, etc.)
n. Other regular commitments (please detail below)
Details:
Total of outgoings:
40. Accommodation Charges
b. If 'yes', how much (per month)?
£
c. What other costs are you liable for (e.g. service charge, agent's fees, etc.)?
a. Do you pay rent for any property?
Yes
No
d. Do you share rent and utility costs with other tenants?
Yes
No
e. Do you receive accommodation free of charge? If 'yes', please give details below.
Yes
No
Details:
Details:
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Had a credit or store card withdrawn?
Sought a reduction in monthly repayments with a lender?
Ever consolidated debt onto a new financial arrangement?
Had a default or termination notice issued to you by a bank or creditor?
Consulted a debt management company or advisory service, e.g. CAB?
Arranged a debt management plan (formal or informal)?
Been subject to a county court judgement?
Been subject to an attachment of earnings order?
Had repossession proceedings commenced against you?
Been investigated by HMRC or DWP?
b. Have you and/or your partner ever applied for an Individual Voluntary
Arrangement (IVA), or (in Scotland only) a Protected Trust Deed, or a
Debt relief Order?
c. Have you and/or your partner ever been declared bankrupt?
d. Do you have any financial interests that may conflict with your duties
as a Civil Servant, member of HM Forces, or as a Government
contractor? (e.g. your partner runs a company, which tenders for
contracts that you are responsible for placing)
e. Are there any details or explanations that would help us to
understand your financial position better?
If you answered 'yes' to any question, please provide full details on the continuation pages.
42. Financial History / Arrangements
a. Have you and/or your partner in the last 10 years:
Had a credit or store card application declined?
Had a personal loan application declined?
Number of
Times
Most Recent
Year
43. Financial Obligations
a. Do you have any form of financial obligation in excess of £1000 that has not been disclosed
elsewhere on this form?
If 'yes', please advise details on the continuation pages.
Yes
No
Yes No
b. Have you ever lent or given anyone (including family members) more than £1000 ?
If 'yes', please
advise details on the continuation pages, including any plans for repayment.
c. If you answered 'yes' to Questions 38a and 38b - does the other person have debts in their sole
name in excess of £5000, to your knowledge?
If 'yes', please provide details below.
Yes
No
Details:
Yes
No
Yes No
Yes
No
Yes
No
Yes No
Yes No
Yes
No
Yes No
Yes
No
Yes No
Yes
No
Yes No
Yes
No
Yes
No
Yes
No
Yes No
If you are a self-employed contractor, please go to Section 44. Otherwise, please go to the Declaration on Page 50.
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Page 46
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from Cabinet Office Government Security Secretariat
44. SELF-EMPLOYED CONTRACTORS - ADDITIONAL INFORMATION SHEET
a. Are you being employed through an agency for the contracted work?
b. Are you self employed and submit invoices in your personal/trading name?
c. Are your invoices submitted by a company, of which you are the primary director or shareholder?
d. If 'Yes', please provide the following information:
Company Name:
e. Are your annual returns to Companies House up to date?
f. Are your annual accounts registered at Companies House up to date?
g. Are payments of VAT, tax and social security paid up to date, by their due date?
If you have answered 'No' to
Q44e, f or g, please provide
an explanation here
k. Have you ever been involved with a company that has undertaken a voluntary liquidation or
creditors winding up?
Yes
No
Yes
No
Yes
No
Yes No
Yes No
Yes No
Yes
No
Yes
No
Full Name:
Yes No
l. Have you ever been disqualified from being a company director?
m. Has the company been investigated by HMRC or DWP?
Company Number:
Accounting Date:
/ /
Day Month Year
j. Has the company been subject to a county court judgement?
Yes
No
If you have answered 'Yes' to
Q44h, i or j, please provide
an explanation here
DETAILS OF INCOME
n. Please provide details of your personal (and your partner's) income from the company, including the amount of any
dividends received and frequency of payments, for the previous and current accounting periods.
If you have answered 'Yes' to
Q44k, l or m, please provide
an explanation here
Details:
N.B. Copies of company accounts may be requested to support your description or provide clarity.
i. Have the directors been fined for non-filing of documents at any time?
Yes No
h. Has a late filing penalty been imposed on the company at any time?
Yes No
Now please complete the declaration on Page 50
31540
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Continuation of Answers
Question
Number
IMPORTANT: When providing additional information please write the Question Number against each answer and provide all
the information requested in the original question.
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Page 48
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
IMPORTANT: When providing additional information please write the Question Number against each answer and provide all
the information requested in the original question.
Continuation of Answers
Question
Number
31540
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Page 49
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
IMPORTANT: When providing additional information please write the Question Number against each answer and provide all
the information requested in the original question.
Question
Number
Continuation of Answers
31540
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Page 50
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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
Declaration
I declare that I have read and understood the statement of HM Government's policy on vetting on page 3 of this questionnaire.
I understand that in accordance with this policy the personal information that I have provided on this form about myself, my partner
(if applicable) and my family will be submitted for checking against national criminal and security records.
I understand that, a check against credit reference agency records and investigations into my financial circumstances will also be
carried out. I understand, too, that the information provided may be subject to ongoing checks where they are necessary and
proportionate.
I declare that the information I have given is true and complete to the best of my knowledge and belief, and I understand that any
false statement or deliberate omission in the information I have given in this questionnaire may disqualify me from employment
(including employment in connection with Crown contracts if applicable) or make me liable to disciplinary action, which may include
dismissal.
I undertake to notify any material changes in the information I have given above (e.g. change of partner, address or financial
circumstances), including any future criminal convictions, to the Personnel or Security branch concerned.
Important: Data Protection Act 1998.
This questionnaire asks you to supply "personal" and "sensitive personal"data as defined by
the Data Protection Act 1998. You will be supplying this data to the appropriate vetting authority where it will be processed
exclusively for the purpose of security vetting, in accordance with HM Government's vetting policy, save that, in the highly unlikely
event that data supplied by you discloses or suggests that:
i. a criminal offence has occurred or is likely to occur or,
ii. staff may be at risk of danger e.g. if you have been diagnosed with a serious mental condition as potentially endangering
yourself or others
then the vetting authority may pass on that information alone to the appropriate person(s). Subject to this, the vetting authority will
protect the information which you provide and will ensure that it is not passed to anyone who is not authorised to see it.
By signing the declaration on this page, you are explicitly consenting for the data you provide in this questionnaire to be
processed in the manner described above.
If you have any concerns about any of the questions we ask, or what we will do with the information you provide, which are not
answered by the guidance notes please contact the person who issued this form for further information.
Note:
Please review the form
BEFORE SIGNING
to ensure that all questions have been fully answered. Please check that you
have signed the Criminal Convictions Declaration on page 38 and (if you answered 'yes' to any question from 27b to 27e inclusive)
the Health Declaration on page 36.
When completed, this application form must be returned to your Sponsor. Contractors, please note at page 38 that you may detach
and place in a sealed envelope the Criminal Convictions & Related Matters page before returning the form to the Sponsor.
Date:
Signed:
/ /
Day Month Year
31540
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Page 51
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from Cabinet Office Government Security Secretariat
For Official Use Only
/
Routine
Priority
Immediate
Developed Vetting (DV) Questionnaire
(Revised 04/2010)
To be completed by all Sponsors (Including HM Forces, Government Agencies and Firms)
How to complete this form
The information you provide will be scanned electronically so please ensure you only write inside the white boxed areas. Do not mark
or strike through any other areas of the form. If completing by hand please write in
BLACK INK
using
. Keep each
character within the boxes on the form and leave one space between names/words. If an answer will not fit in the space provided,
please enter your answer on the continuation sheets (pages 48 to 50). If you make a mistake, please do not correct it but delete it by
filling in the relevant box as the example below. Please do not use correcting fluid.
Ensure you answer
ALL
the questions. You can use the abbreviation
NA
(Not Applicable).
NA
- If a question does not apply to
you,write
NA
in the
first two boxes only
of the relevant question.
Not Known
- If you do not know the answer, or you cannot provide
the information needed, write
NOT KNOWN
in the
first line only
of the relevant question.
Please provide an explanation why the
information is unknown to you in the appropriate boxes or on the continuation sheets (pages 48 to 50). Unanswered
questions or Not Known replies may cause delay to the processing of this questionnaire.
Please
ensure
you have completed section 2
(Security Clearance Required) on page 1
, before submitting this request.
Please specify the following employment details for the post which DV clearance is required:
Employment Type:
RN
Army
RAF
MOD Civilian
Other Civil
Servant
Other
Contractor
Police Officer /
Civilian Staff
Other
Civil Nuclear
Employee
Civil Nuclear
Contractor
If a contractor, is the applicant:
List X?
Non-List X?
Job Title:
Establishment /
Location
Is the post for which security clearance is required:
Is this clearance being requested on initial recruitment?
Tick here if the post for which clearance is required is within, or closely associated with, the DVA.
I CERTIFY THAT THE FOLLOWING CHECKS HAVE BEEN COMPLETED:
a. Full Baseline Personnel Security Standard (BPSS), comprising verification of the applicant's:
* Identity
* Employment / academic history for (as a minimum) the past 12 months
* Nationality / immigration status (including the right to work in the UK)
Yes
No
Yes No
b. Where the full BPSS has NOT yet been completed, the applicant's identity and
immigration status have been verified.
c. Departmental Record Check (for Service personnel, Civil Servants and employees of
the civil nuclear industry only).
d. Company Record Check (for Contractors only). This entails a check of all available
records held for the applicant (If the applicant is a new recruit, this includes any
documentation provided as part of the recruitment process)
Yes
No
Not Applicable
Yes No
Not Applicable
Yes
No
Not Applicable
Non Reserved
Reserved
Surname (now):
31540
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Page 52
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from Cabinet Office Government Security Secretariat
I certify that
the relevant records held for the applicant have been checked for items of security interest and that: (tick one box):
No items of security interest were found Some items of security interest were found
(please give details below)
Details of any items of security interest:
/ /
Day
Month
Year
Applicant's Date of Birth:
I confirm that the applicant's identity has been verified.
If the Subject is an existing employee and has been employed for 3 years or more, please tick.
How did you confirm the applicant's identity?
Please include relevant dates and details. If full passport not produced, two other
forms of identity must be checked. However, if you have confirmed above that the Subject has been employed for at least 3 years, only
a company records check is required, together with the date on which it was carried out.
Applicant's Forename(s):
Applicant's Surname:
/ /
Day
Month
Year
Date:
Signed:
If Other, please give details below.
Form of identification
Full EU Passport
Full non-EU Passport
Driving Licence
Birth Certificate
Company Records
Other
/ /
/ /
/ /
/ /
/ /
/ /
Number
Date of issue (Day/Month/Year)
Position within
organisation:
Email Address:
Telephone:
Name:
Ext.
31540
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For Contractors Only
(Including List X, Consultants and Subcontractors working on government and civil nuclear sites)
Length of employee's time with the firm:
Is the Subject a Sub Contractor working for either List X Companies or Government
Departments/HM Forces, e.g. Consultants, builders, maintenance staff?
Months
Years
Will the employee be on your company's payroll?
Is clearance required for access to a site only?
Name of firm/
organisation:
Postcode:
Country:
County/Region:
Town:
Address Line 2:
Address Line 1:
No
Yes
No
Yes
Contract Number:
To whose information will the employee have access ?
Site where the
employee works or is
to work:
Title and type of work:
No
Yes
Notification of clearance. To be completed by all Sponsors. (Including HM Forces, Government
Agencies and Firms)
The outcome of this application will be notified to the Sponsor in writing to the address given below. If an electronic
notification is required please provide an e-mail address in addition.
Sponsor's Address (if different from Notification Address)
Postcode:
Email:
Country:
County/Region:
Town:
Address Line 2:
Address Line 1:
Name of firm/
organisation:
Sponsor's Reference:
Sponsor's ID:
Name of firm/
organisation:
Postcode:
Country:
County/Region:
Town:
Address Line 2:
Address Line 1:
31540
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Form 31540 Developed Vetting (DV) Questionnaire

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