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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
BLOCK LETTERS
. 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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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
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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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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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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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Page 6
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the form must not be modified without prior permission
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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:
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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
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Page 9
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the form must not be modified without prior permission
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* 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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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:
31540
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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):
31540
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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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the form must not be modified without prior permission
from Cabinet Office Government Security Secretariat
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