Fillable Orientation 16 Questionnaire National Security Positions (Jacksonville University)

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Orientation 16 Questionnaire National Security Positions (Jacksonville University)

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Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
Questionnaire for National Security Positions
Follow instructions fully or we cannot process your form. If you have any questions, contact the office that gave you the form.
The United States (U.S.) Government conducts background investigations
and reinvestigations of persons under consideration for or retention in national
security positions as defined in 5 CFR 732 and for positions requiring access
to classified information under Executive Order 12968.
Withholding, misrepresenting, or falsifying information will have an impact on a
security clearance, employment prospects, or job status, up to and including
denial or revocation of your security clearance, or your removal and
debarment from Federal Service.
This form is a permanent document that may be used as the basis for future
investigations, security clearance determinations, and determinations of your
suitability for employment. Your responses to this form may be compared with
previous security questionnaires. It is imperative that the information provided
be true and accurate to the best of your knowledge.
Giving us this information is voluntary. If you do not provide each item of
requested information, however, we will not be able to complete your
investigation, which will adversely affect your eligibility for a national security
position. Any information that you provide is evaluated on the basis of its
recency, seriousness, relevance to the position and duties, and consistency
with all other information about you.
Purpose of this Form
Special Instructions for Completing this Form
Instructions for Completing this Form
Authority to Request this Information
Depending upon the purpose of your investigation, the U.S. Government is
authorized to ask for this information under Executive Orders 10450, 10865,
12333, and 12968; sections 3301, 3302, and 9101 of title 5, U.S. Code
(U.S.C.); sections 2165 and 2201 of title 42, U.S.C.; chapter 23 of title 50,
U.S.C.; and parts 2, 5, 731, 732, and 736 of title 5, Code of Federal
Regulations.
Your Social Security Number (SSN) is needed to identify your unique records.
Although disclosure of your SSN is not mandatory, failure to disclose your
SSN may prevent or delay the processing of your background investigation.
The authority for soliciting and verifying your SSN is Executive Order 9397.
The Investigative Process
Background investigations for national security positions are conducted to
gather information to show whether you are reliable, trustworthy, of good
conduct and character, and loyal to the U.S. The information that you provide
on this form may be confirmed during the investigation. The investigation may
extend beyond the time covered by this form when necessary to resolve
issues. Your current employer may be contacted as part of the investigation,
even if you have previously indicated on applications or other forms that you
do not want your current employer to be contacted.
In addition to the questions on this form, inquiry also is made about your
adherence to security requirements, honesty and integrity, vulnerability to
exploitation or coercion, falsification, misrepresentation, and any other
behavior, activities, or associations that tend to show the person is not
reliable, trustworthy, or loyal. Checks of Federal agency records may be
made about your spouse or other cohabitant.
Your Personal Interview
Some investigations will include an interview with you as a routine part of the
investigative process. The investigator may ask you to explain your answers
to any question on this form. This provides you the opportunity to update,
clarify, and explain information on your form more completely, which often
helps to complete your investigation faster. It is important that the interview
be conducted as soon as possible after you are contacted. Postponements
will delay the processing of your investigation, and declining to be interviewed
may result in your investigation being delayed or canceled.
For the interview, you will be asked to bring identification with your picture on
it, such as a valid state driver's license. There are other documents you may
be asked to bring to verify your identity as well. These may include
documentation of any legal name change, Social Security card, passport, and/
or your birth certificate.
Questions on this form related to residence, employment, and education will
require 7 years of information except that Single-Scope Background
Investigations (SSBI) will require 10 years of information.
Provide 7 years of information unless you have been instructed to provide 10
years to satisfy SSBI requirements. If you are unsure as to the amount of
information to provide, contact the office that gave you this form.
The instructions for these questions specify a 10-year time frame when an
SSBI is required. If you have any questions about this investigative request
or whether the 7-year time frame or the 10-year time frame applies to your
responses to these questions, contact the office that gave you this form.
You may also be asked to bring documents about information you provided on
the form or about other matters requiring specific attention. These matters
include (a) alien registration or naturalization documentation; (b) delinquent
loans or taxes, bankruptcies, judgments, liens, or other financial obligations;
(c) agreements involving child custody or support, alimony, or property
settlements; (d) arrests, convictions, probation, and/or parole; or (e) other
matters described in court records.
Final determination on your eligibility for a national security position is the
responsibility of the Federal agency that requested your investigation. You
will be provided the opportunity personally to explain, refute, or clarify any
information before a final decision is made.
Final Determination on Your Eligibility
1. Follow the instructions given to you by the office that gave you this form
and any other clarifying instructions furnished by that office to assist you in
completion of this form. You must sign and date, in ink, the original and each
copy you submit. You should retain a copy of the completed form for
your records.
10. If you need additional space for explanation or to list your residences,
employment/self-employment/unemployment, or education, you should use a
continuation sheet, SF 86A. If additional space is needed to answer other
items, use the Continuation Space on page 17 or a blank sheet(s) of paper.
Each blank sheet of paper you use must contain your name and SSN at the
top of the page.
9. All dates provided in this form must be in Month/Day/Year or Month/Year
format. Use numbers (01-12) to indicate months. For example, July 29,
1968, should be written as 07/29/1968. If you find that you cannot report an
exact date, approximate or estimate the date to the best of your ability and
indicate this by writing "APPROX." or "EST."
8. For telephone numbers in the U.S., be sure to include the area code.
7. The 5-digit postal Zip Codes are needed to speed the processing of your
investigation. Refer to an automated system approved by the U.S. Postal
Service to assist you with Zip Codes.
6. Whenever "City (Country)" is shown in an address block, also provide in
that block the name of the country when the address is outside the U.S.
5. You must use the Location codes (abbreviations) listed on the back of this
page when you fill out this form. Do not abbreviate the names of cities or
foreign countries.
4. Any changes that you make to this form after you sign it must be initialed
and dated by you. Under certain limited circumstances, agencies may modify
your response(s) with your consent.
3. All questions on this form must be answered. If no response is necessary
or applicable, indicate this on the form with "N/A" unless otherwise noted.
2. Type or legibly print your answers in ink (if the form is not legible, it will not
be accepted). You may also be asked to submit your form using the
approved electronic format.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
The information you give to us is for the purpose of investigating you for a
national security position; we will protect it from unauthorized disclosure. The
collection, maintenance, and disclosure of background investigative
information is governed by the Privacy Act. The agency that requested the
investigation and the agency that conducted the investigation have published
notices in the Federal Register describing the systems of records in which
PRIVACY ACT ROUTINE USES
Public burden reporting for this collection of information is estimated to average 120 minutes per response, including time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the
burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to OPM Forms Officer, U.S. Office of
Personnel Management, 1900 E Street, N.W., Washington, DC 20415. Do not send your completed form to this address; send it to the office that provided you
the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect this information, and you are not required to respond, unless this
number is displayed.
4. To any source or potential source from which information is requested in
the course of an investigation concerning the hiring or retention of an
employee or other personnel action, or the issuing or retention of a security
clearance, contract, grant, license, or other benefit, to the extent necessary to
identify the individual, inform the source of the nature and purpose of the
investigation, and to identify the type of information requested.
11. To the Office of Management and Budget when necessary to the review
of private relief legislation.
Penalties for Inaccurate or False Statements
The U.S. Criminal Code (title 18, section 1001) provides that knowingly
falsifying or concealing a material fact is a felony which may result in fines
and/or up to 5 years of imprisonment. In addition, Federal agencies generally
fire, do not grant a security clearance, or disqualify individuals who have
materially and deliberately falsified these forms, and this remains a part of the
permanent record for future placements. Your prospects of placement or
security clearance are better if you answer all questions truthfully and
completely. You will have adequate opportunity to explain any information
you give to us on this form and to make your comments part of the record.
LOCATION CODES
PUBLIC BURDEN INFORMATION
DISCLOSURE INFORMATION
your records will be maintained. The information on this form, and information
collected during an investigation, may be disclosed without your consent by
an agency maintaining the information in a system of records as permitted by
the Privacy Act [5 U.S.C. 552a(b)], and by routine uses published by the
agency in the Federal Register. The office that gave you this form will
provide you a copy of its routine uses.
Wyoming WY
Puerto Rico PRMarshall Islands MH Federated States of Micronesia FM
1. To the Department of Justice when: (a) the agency or any component
thereof; or (b) any employee of the agency in his or her official capacity; or
(c) any employee of the agency in his or her individual capacity where the
Department of Justice has agreed to represent the employee; or (d) the
United States Government, is a party to litigation or has interest in such
litigation, and by careful review, the agency determines that the records are
both relevant and necessary to the litigation and the use of such records by
the Department of Justice is therefore deemed by the agency to be for a
purpose that is compatible with the purpose for which the agency collected
the records.
2. To a court or adjudicative body in a proceeding when: (a) the agency or
any component thereof; or (b) any employee of the agency in his or her
official capacity; or (c) any employee of the agency in his or her individual
capacity where the Department of Justice has agreed to represent the
employee; or (d) the United States Government is a party to litigation or has
interest in such litigation, and by careful review, the agency determines that
the records are both relevant and necessary to the litigation and the use of
such records is therefore deemed by the agency to be for a purpose that is
compatible with the purpose for which the agency collected the records.
3. Except as noted in Question 23 and 27, when a record on its face, or in
conjunction with other records, indicates a violation or potential violation of
law, whether civil, criminal, or regulatory in nature, and whether arising by
general statute, particular program statute, regulation, rule, or order issued
pursuant thereto, the relevant records may be disclosed to the appropriate
Federal, foreign, State, local, tribal, or other public authority responsible for
enforcing, investigating or prosecuting such violation or charged with
enforcing or implementing the statute, rule, regulation, or order.
5. To a Federal, State, local, foreign, tribal, or other public authority the fact
that this system of records contains information relevant to the retention of an
employee, or the retention of a security clearance, contract, license, grant, or
other benefit. The other agency or licensing organization may then make a
request supported by written consent of the individual for the entire record if it
so chooses. No disclosure will be made unless the information has been
determined to be sufficiently reliable to support a referral to another office
within the agency or to another Federal agency for criminal, civil,
administrative, personnel, or regulatory action.
6. To contractors, grantees, experts, consultants, or volunteers when
necessary to perform a function or service related to this record for which
they have been engaged. Such recipients shall be required to comply with
the Privacy Act of 1974, as amended.
7. To the news media or the general public, factual information the
disclosure of which would be in the public interest and which would not
constitute an unwarranted invasion of personal privacy.
8. To a Federal, State, or local agency, or other appropriate entities or
individuals, or through established liaison channels to selected foreign
governments, in order to enable an intelligence agency to carry out its
responsibilities under the National Security Act of 1947 as amended, the CIA
Act of 1949 as amended, Executive Order 12333 or any successor order,
applicable national security directives, or classified implementing procedures
approved by the Attorney General and promulgated pursuant to such
statutes, orders or directives.
9. To a Member of Congress or to a Congressional staff member in
response to an inquiry of the Congressional office made at the written request
of the constituent about whom the record is maintained.
10. To the National Archives and Records Administration for records
management inspections conducted under 44 U.S.C. 2904 and 2906.
Alabama AL
American Samoa AS
Alaska AK
Arizona AZ
Arkansas AR
California CA
Colorado CO
Connecticut CT
Delaware DE
District of Columbia DC
Florida FL
Georgia GA
Hawaii HI
Idaho ID
Illinois IL
Indiana IN
Iowa IA
Kansas
KS
Kentucky KY
Louisiana LA
Maine ME
Maryland MD
Guam GU
Massachusetts MA
Michigan MI
Minnesota MN
Mississippi MS
Missouri MO
Montana MT
Nebraska NE
Nevada NV
New Hampshire NH
New Jersey NJ
Northern Mariana Islands MP
New Mexico NM
New York NY
North Carolina NC
North Dakota ND
Ohio OH
Oklahoma OK
Oregon OR
Pennsylvania PA
Rhode Island RI
South Carolina SC
Palau PW
Virgin Islands of the U.S. VI
South Dakota SD
Tennessee TN
Texas TX
Utah UT
Vermont VT
Virginia VA
Washington WA
West Virginia WV
Wisconsin WI
8 YOUR CONTACT INFORMATION Check box(es) indicating when you can be reached at each phone number.
- If you have only initials in your name, use them and enter (I/O) after the initial(s). - If you have no middle name, enter "NMN."
- If you are a "Jr.," "Sr.," etc. enter this in the box after your middle name.
V Applicant affiliation
None
J SON
Initial
Reinvestigation
S Investigative requirement
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
Investigating agency use only
Codes Case number
P Obligating document number Q BETC
R Accounting data and/or Agency case number
T Requesting official - Name
Title
Signature
Title
Telephone number
FED CIV
CON
Other
1 FULL NAME
2 DATE OF BIRTH
First name Middle name Jr., II, etc.
City County State
Country (if outside the U.S.)
Name #1
Enter your Social Security Number before going to the next page
Page 1
Other address/Web address of e-OPF
ZIP Code
A Type of investigation
C Sensitivity level D Access/Eligibility E Nature of action code F Date of action
G Geographic location
H Position code I Position title
K Location of official personnel folder
U Secondary requesting official - Name
B Extra coverage/Advance results
NPRC
At SON
e-OPF
Other
L SOI
M Location of security folder
None
NPI
At SOI
Other
Other address
Email address
Last name
Month/Year To Month/Year
Name #2
Month/Year To Month/Year
Name #3
Email address
Telephone number Date
YES
AGENCY USE ONLY
Hair color Eye color
Sex
Female
Male
Work e-mail address
Height (feet and inches) Weight (pounds)
Last name First name Middle name
Name #4
Mobile telephone number
Day
EveningEvening
Day
Home telephone number
Evening
Day
Work telephone number
Home e-mail address
ZIP Code
MIL
If "Yes," give other names used and the period of time you used them [for example: your maiden name, name(s) by a former marriage, former
name(s), alias(es), or nickname(s)]. If the other name is your maiden name, put "maiden" in front of it.
N IPAC
O TAS
PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW AFTER CAREFULLY READING
THE FOREGOING INSTRUCTIONS.
7 YOUR IDENTIFYING INFORMATION
6 MOTHER'S MAIDEN NAME
5 OTHER NAMES USED Have you used any other names?
Month/Year To Month/Year
Month/Year To Month/Year
3 PLACE OF BIRTH 4 SOCIAL SECURITY NO.
NO
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
I am a U.S. citizen or national by birth, born outside the U.S. Go to 9A
I am a naturalized U.S. citizen. Go to 9B or 9C
I am not a U.S. citizen. Go to 9D
U.S. PASSPORT Current or most recent passport
Number
Date issued
ALIEN REGISTRATION NUMBER (if applicable)
NumberExpired
YES
NO
9A DOCUMENTATION OF U.S. CITIZENS BORN ABROAD [STATE DEPARTMENT FORM (FS) 240, DS 1350, FS 545, etc.]
Report information, if applicable.
Date form was completed
Document number
9B CITIZENSHIP CERTIFICATE (if applicable)
Where was this certificate issued?
City/Court
State
Date issued
Date issued
Certificate number
State
Where was this certificate issued? City/Court
9C NATURALIZATION CERTIFICATE (if applicable)
9D IMMIGRATION STATUS
Place you entered the U.S.
City
State
Date of entry
Type of document (I-94, etc.) Document number
Country(ies) of citizenship
Enter your Social Security Number before going to the next page
Page 2
Do you now hold or have you EVER held multiple citizenships?
NO
YES
Go to Question 11
A If "Yes," provide the name(s) of the country(ies).
B During what periods of time did you hold multiple citizenships?
C Is your non-U.S. citizenship based on your birth in a foreign country or the citizenship of your parents?
NO, explainYES
(If "No," explain.)
D Have you renounced or attempted to renounce your foreign citizenship(s)? (If "Yes," explain.)
List the places where you have lived, beginning with your present residence (#1) and working back 7 years (if an SSBI go back 10 years). Residences for
the entire 7 year period must be accounted for without breaks. Indicate the actual physical location of your residence. Do not use a Post Office Box as
an address, and do not list a permanent address when you were actually living at a school address, etc. Be sure to be as specific as possible when listing
an address location: for example, do not list only your base or ship, list your barracks number or home port. You may omit temporary military duty locations
(TDY) under 90 days (list your address of record instead), but you must list other part-time residences. Your actual physical location in addition to your APO/
FPO address is required for overseas assignments.
For any address in the last 3 years, list a person who knew you at that address, and who preferably still lives in that area. Do not list people for residences
completely outside this 3-year period, and do not list your spouse, former spouse, or other relatives. Also, for addresses in the last 3 years, if the address is
"General Delivery," a Rural or State Route, or may be difficult to locate, provide directions for locating the residence on an attached continuation sheet (SF
86A). Do not list residences before your 18th birthday unless to provide a minimum of 2 years of residence history.
#1
Month/Year To Month/Year
Present
Status
Own
Rent
Military housing
Other (Explain)
Street address
APO/FPO address
City (Country)
State
ZIP Code
Name of person who knows you at this address
Residence Information and Point of Contact for that Period of Residence
Relationship
Neighbor
Friend
Landlord
Business associate
Other (Explain)
Current address
Telephone number
APO/FPO address (if currently applicable)
City (Country)
State
ZIP Code
Alternate contact number
Certificate number
Apt.#
Place of issuance
NO YES, explain
9 CITIZENSHIP Mark the box that reflects your current citizenship status and follow its instructions.
10 CITIZENSHIP INFORMATION
11 WHERE YOU HAVE LIVED Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.
Apt.#
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Page 3
Enter your Social Security Number before going to the next page
#2
Month/Year To Month/Year
Status
Own Military housing
Other (Explain)
Street address
APO/FPO address
City (Country)
State
ZIP Code
#3 Month/Year To Month/Year
Status
Own
Rent
Military housing
Other (Explain)
APO/FPO address
City (Country)
State
ZIP Code
#4 Month/Year To Month/Year
Status
Own
Rent
Military housing
Other (Explain)
Street address
APO/FPO address
City (Country) State ZIP Code
Name of person who knows you at this address
Rent
11 WHERE YOU HAVE LIVED (Continued)
ZIP Code
Relationship
Neighbor
Friend
Landlord
Business associate
Other (Explain)
Current address
Telephone number
APO/FPO address (if currently applicable)
City (Country)
State
Alternate contact number
Apt.#
ZIP Code
Name of person who knows you at this address
Relationship
Neighbor
Friend
Landlord
Business associate
Other (Explain)
Current address
Telephone number
APO/FPO address (if currently applicable)
City (Country)
State
Alternate contact number
Apt.#
ZIP Code
Name of person who knows you at this address
Relationship
Neighbor
Friend
Landlord
Business associate
Other (Explain)
Current address
Telephone number
APO/FPO address (if currently applicable)
City (Country)
State
Alternate contact number
Apt.#
Street address
Apt.#
Apt.#
Apt.#
NO
NO
Page 4
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
SCHOOL INFORMATION
Month/Year To Month/Year#1 Code Name of school
Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.
YES
Street address and City (Country) of school
State
ZIP Code
Name of person who knows you
Current address
City (Country)
State
ZIP Code
Telephone number
Month/Year To Month/Year#2
Code Name of school Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.
YES
Street address and City (Country) of school
State
ZIP Code
Name of person who knows you Current address
City (Country)
State
ZIP Code
Telephone number
Month/Year To Month/Year
#3
Code Name of school Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.
YES
Street address and City (Country) of school
State
ZIP Code
Name of person who knows you
Current address
City (Country) State ZIP Code
Telephone number
NO
Month/Year To Month/Year#4
Code
Name of school
Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.
YES
Street address and City (Country) of school
State
ZIP Code
Name of person who knows you Current address
City (Country)
State
ZIP Code
Telephone number
NO
Month/Year To Month/Year#5 Code Name of school Degree/diploma received? If "Yes," identify type
of degree/diploma received and date awarded.
YES
Street address and City (Country) of school
State
ZIP Code
Name of person who knows you
Current address
City (Country) State ZIP Code Telephone number
NO
List all schools you have attended, beginning with the most recent (#1) working back 7 years (if an SSBI go back 10 years). List college or university degrees
and the dates they were received. If your most recent degree or diploma was received more than 7 years ago (10 years for an SSBI), list it below no matter
when it was received.
In the Code block, show the most appropriate code to describe your school.
1 - High School 3 - Vocational/Technical/Trade School
2 - College/University/Military College 4 - Correspondence/Distance/Extension/Online School
For Correspondence/Distance/Extension/Online School, provide the address where the records are maintained.
For schools you attended in the last 3 years, list a person who knew you at school (instructor, student, etc.).
Do not list people for education periods completed more than 3 years ago.
Apt. #
Apt. #
Apt. #
Apt. #
Apt. #
12 WHERE YOU WENT TO SCHOOL Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.
✔
✔
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Page 5
Enter your Social Security Number before going to the next page
13A EMPLOYMENT/UNEMPLOYMENT INFORMATION
#1 Dates of Employment
Month/Year To Month/Year
Type of Employment
Employment code
Employer/Verifier
Name of employer/verifier Telephone number
Part-time
Address of employer/verifier
City (Country)
Physical Location
Your actual work address (if different from employer address) Telephone number
Additional Periods of Activity with this Employer
Position title Supervisor
Position title Month/Year To Month/Year
Position title
Explanation/Reason for leaving
Month/Year To Month/Year
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
State ZIP Code
State ZIP Code
State ZIP Code
Present
City (Country)
City (Country)
Month/Year To Month/Year
Supervisor
Supervisor
Position title/Military rank Work hours
Full-time
List all your employment activities, beginning with the present (#1) and working back 7 years (if an SSBI go back 10 years). You should list all full-time and
part-time work, paid or unpaid, consulting/contracting work, all military service duty locations, temporary military duty locations (TDY) over 90 days, self-
employment, other paid work, and all periods of unemployment. The entire period must be accounted for without breaks. EXCEPTION: Do not list
employments that occurred before your 18th birthday unless it is necessary for providing a minimum of 2 years of employment history. If you require additional
space, use a continuation sheet (SF 86A).
7 - Unemployment (include name of verifier)
8 - Federal Contractor
9 - Other (explain)
Employer/Verifier Information. List the business name of your employer or the name of a person who can verify your self-employment or
unemployment in this block. If military service is being listed, include your duty location or home port here as well as your branch of service. You
should provide separate listings to reflect changes in your military duty locations or home ports. If you are a Federal Contractor, list company name,
not Federal agency.
Additional Periods of Activity. Complete this block if you worked for an employer on more than one occasion at the same physical location. After
entering the most recent period of employment in the initial numbered block, provide previous periods of employment at the same location on the
additional lines provided. For example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and
information concerning the most recent period of employment first, and provide dates, position titles, and supervisors for the two previous periods of
employment on the lines below that information.
13 EMPLOYMENT ACTIVITIES Use the Continuation Sheet(s) (SF 86A) or the Continuation Space on page 17 for additional answers.
Employment Code: Use one of the codes listed below to identify the type of employment.
1 - Active military duty stations
2 - National Guard/Reserve
3 - U.S.P.H.S. Commissioned Corps
4 - Other Federal employment
5 - State Government (Non-Federal employment)
6 - Self-employment (include business name and/or
name of person who can verify)
Physical Location
Employer/Verifier
Name of employer/verifier
Telephone number
Address of employer/verifier
City (Country)
Your actual work address (if different from employer address)
Telephone number
Additional Periods of Activity with this Employer
Month/Year To Month/Year
Position title
Supervisor
Position title
Month/Year To Month/Year
Supervisor
Position title
Month/Year To Month/Year
Supervisor
City (Country)
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Page 6
Enter your Social Security Number before going to the next page
13A EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued)
Employer/Verifier
Name of employer/verifier
Telephone number
Address of employer/verifier
City (Country)
#3 Dates of Employment
Month/Year To Month/Year
Type of Employment
Physical Location
Your actual work address (if different from employer address)
Telephone number
City (Country)
Explanation/Reason for leaving
#2
Dates of Employment
Month/Year To Month/Year
Type of Employment
Full-time
Work hours
Position title/Military rankEmployment code
Part-time
Employment code
Full-time
Work hours
Position title/Military rank
Part-time
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country)
State
ZIP Code
State ZIP Code
State
ZIP Code
State
ZIP Code
State
ZIP Code
Supervisor (if different from employer)
Work address of supervisor
City (Country)
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Page 7
Enter your Social Security Number before going to the next page
#4 Dates of Employment Type of Employment
Month/Year To Month/Year
Employer/Verifier
Name of employer/verifier
Telephone number
Address of employer/verifier
City (Country)
Physical Location
Your actual work address (if different from employer address)
Telephone number
City (Country)
Supervisor (if different from employer)
Name and title
Telephone number
Work address of supervisor
City (Country)
13A EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued)
Employment code
Work hours
Full-time
Part-time
Position title/Military rank
Telephone number Name and title
Position title
Month/Year To Month/Year
Supervisor
Position title
Month/Year To Month/Year
Supervisor
Explanation/Reason for leaving
Additional Periods of Activity with this Employer
Month/Year To Month/Year
Position title
Supervisor
Additional Periods of Activity with this Employer
Month/Year To Month/Year
Position title Supervisor
Position title
Month/Year To Month/Year
Supervisor
Position title
Month/Year To Month/Year
Supervisor
Explanation/Reason for leaving
State
ZIP Code
State
ZIP Code
State
ZIP Code
State ZIP Code
Enter your Social Security Number before going to the next page
Page 8
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
13B FORMER FEDERAL SERVICE, EXCLUDING MILITARY SERVICE, NOT INDICATED PREVIOUSLY (list below if applicable)
Dates of Federal Service
Month/Year To Month/Year
#1
#2
#3
Agency/City (Country)/State/ZIP Code
Position Title
13C EMPLOYMENT RECORD
If you answered "Yes," to 13C(2) and/or 13C(3), provide the name(s) of the employer(s), date(s) of incident(s), month/day/year of official action(s), location(s)
or facility(ies) of incident(s), and the nature of the violation(s) in the space below. If additional space is needed, use a blank sheet(s) of paper.
YES
NO
a Are you a male born after December 31, 1959? If "No," go to Question 15. If "Yes," go to b.
b Have you registered with the Selective Service System (SSS)? If "Yes," provide your registration number below. If "No," explain the
reason for not registering below. Please consult the SSS if you are unaware of your status before signing this form.
Registration Number
Explanation
1. Has any of the following happened to you in the last 7 years? If "Yes," begin with the most recent occurrence and go backward, providing date
fired, quit, or left, and other information requested.
14 SELECTIVE SERVICE RECORD
YES NO
1 - Fired from a job
2 - Quit a job after being
told you would be fired
Use the following codes and explain the reason your employment was ended.
3 - Left a job by mutual agreement following charges or allegations of misconduct
4 - Left a job by mutual agreement following notice of
unsatisfactory performance
Month/Year
Code Specify Reason
Employer's Name and Address (Include City/Country if outside U.S.)
State
ZIP Code
5 - Left a job for other reasons under
unfavorable circumstances
6 - Laid off from job by employer
3. Have you received a written warning, been officially reprimanded, suspended, or disciplined for violating a security rule or policy?
2. Have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct in the workplace?
NO
YES
List three people who know you well and who preferably live in the U. S. They should be friends, peers, colleagues, college roommates, associates, etc., who
are collectively aware of your activities outside of the workplace, school, or neighborhoods and whose combined association with you covers at least the last 7
years. Do not list your spouse, former spouse(s), other relatives, or anyone listed elsewhere on this form.
#1
ZIP Code
State
City (Country)
Telephone number
Reference name
Home or work address
Dates known
Month/Year To Month/Year
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
16 PEOPLE WHO KNOW YOU WELL
Day Evening
Alternate telephone no.
Relationship to you (Check all that apply)
Neighbor
Friend
Work associate
Schoolmate
Other (Explain)
#2
ZIP CodeState
City (Country)
Telephone number
Reference name
Home or work address
Dates known
Month/Year To Month/Year
Day
Evening
Alternate telephone no.
Relationship to you (Check all that apply)
Neighbor
Friend
Work associate
Schoolmate
Other (Explain)
#3
ZIP CodeStateCity (Country)
Telephone number
Reference name
Home or work address
Dates known
Month/Year To Month/Year
Day
Evening
Alternate telephone no.
Relationship to you (Check all that apply)
Neighbor
Friend
Work associate
Schoolmate
Other (Explain)
Enter your Social Security Number before going to the next page
Page 9
a Have you EVER served in the U.S. military or the U.S. Merchant Marine?
b Have you EVER served in a foreign country's military, security forces, merchant marine, militia, or other defense forces?
c Have you EVER received a discharge that was not honorable?
If you answered "Yes" to any question above, list all details of your military service below, starting with the most recent period of service and working back.
If you had a break in service, each separate time of service should be listed.
Code (Branch of Service): Use one of the codes listed below to identify your branch of service.
O/E: Mark "O" block for Officer or "E" block for Enlisted, if applicable.
Status: "X" the appropriate block for the status of your service during the time that you served. If your service was in the National Guard, do not use an
"X": use the two-letter code for the state to mark the block.
Country: Identify the country for which you served.
Code (Type of Discharge): Use one of the codes listed below to indicate your separation status from your military service.
1 - Honorable 2 - Dishonorable 3 - Other Than Honorable 4 - General 5 - Bad Conduct 6 - Other (Explain)
Branch of
Service Code
Month/Year To Month/Year Service Number O E
Active
Duty
Active
Reserve
Inactive
Reserve
Air NG
State
Country
Type of
Discharge Code
1 - Air Force
2 - Army
3 - Navy
4 - Marine Corps
5 - Coast Guard
6 - Merchant Marine
7 - Air National Guard (NG)
8 - Army NG
15 MILITARY HISTORY Account for all of your military service through the questions below. If you answer "No" to both 15a and 15b, go to Question 16.
YES
NO
d In the last 7 years (if an SSBI go back 10 years), have you been subject to court martial or other disciplinary proceedings under the Uniform
Code of Military Justice? (Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s), charge(s), military court(s) or authority(ies), and
outcome(s).
Army NG
State
Status
9 - Foreign military, defense, militia, security forces
Apt. #
Apt. #
Apt. #
17A CURRENT SPOUSE
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Page 10
Enter your Social Security Number before going to the next page
If applicable, complete the following about your current spouse only. If your current spouse was born outside the U.S., provide citizenship information.
Last name
Date of birth
Place of birth (include Country if outside the U.S.)
Social Security Number
Other names used (specify maiden name, names by other marriages, etc., and show dates used for each name)
Country(ies) of citizenship
Date married
Place married (City, include Country if outside the U.S.)
State
If separated, date of separation
If legally separated, where is the record located? City (Country)
State
ZIP Code
Current address of spouse, if different than your current address (Street, City, include Country if outside the U.S.)
Telephone numberState ZIP Code
If spouse was born outside the U.S. indicate one type of documentation that he or she possesses and the document numbers.
U.S. Passport (current or most recent)
Alien registration
Naturalization certificate
Other (Explain)
Document number
17B FORMER SPOUSE(S)
Complete the following about your former spouse(s). Use blank sheets if needed.
Place of birth (include Country if outside the U.S.)
Date of birth
State
Country(ies) of citizenship
Date married
Place married (City, include Country if outside the U.S.)
State
Check one, then
give date
Widowed
If divorced/annulled, where is the record located? City (Country)
ZIP CodeState
Last known address of former spouse (Street, City, include Country if outside the U.S.)
ZIP Code
State
Explain "Other"
Telephone number
17C COHABITANT [A cohabitant is a person with whom you share bonds of affection, obligation, or other commitment, as opposed to a person with whom you live for reasons of
convenience (a roommate)]. If applicable, complete the following about your cohabitant. If your cohabitant was born outside the U.S., provide
citizenship information.
If cohabitant was born outside the U.S., indicate one type of documentation that he or she possesses and the document numbers.
Document number
Other names used (specifically maiden names, names by other marriages, etc., and show dates used for each name)
Country(ies) of citizenship
Date cohabitation began
Mark one box to show your current marital status and provide information about your spouse(s) or cohabitant below. If there is not a middle name, enter as
"NMN."
DS 1350
FS 240 or 545
Citizenship certificate
Divorced Annulled
Date
U.S. Passport (current or most recent)
Alien registration
Naturalization certificate
Other (Explain)
DS 1350
FS 240 or 545
Citizenship certificate
17 MARITAL STATUS
1 - Never married
2 - Married (incl. Common Law)
3 - Separated
5 - Divorced
4 - Annulled
6 - Widowed
First name Middle name
Middle name
First name
Last name
Middle name
First name
Last name
Explain "Other"
Place of birth (include Country if outside the U.S.)
Date of birth
Social Security Number
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
Enter your Social Security Number before going to the next page
Page 11
Full name Date of birth Place of birth Country(ies) of citizenship
Code
1
18 RELATIVES
Relative Code - Use one of the following codes (1-16) listed below for each relative and give the full name and other requested information, if applicable, for
each of your relatives, living or deceased, specified below.
1 - Mother
2 - Father
3 - Stepmother
4 - Stepfather
5 - Foster parent
6 - Child (incl. adopted and foster)
7 - Stepchild
8 - Brother
9 - Sister
10 - Stepbrother
11 - Stepsister
12 - Half-brother
13 - Half-sister
14 - Father-in-law
15 - Mother-in-law
16 - Guardian
Current address (Street, City, and State, include Country if outside the U.S.)
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
FS 240 or 545
Citizenship certificate
Naturalization certificate
DS 1350
U.S. Passport
Alien registration
Full name
Date of birth
Place of birth
Country(ies) of citizenship
Code
2
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
Deceased
Full name Date of birth Place of birth Country(ies) of citizenship
Code
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
Deceased
Full name Date of birth Place of birth Country(ies) of citizenship
Code
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
Deceased
Full name Date of birth Place of birth Country(ies) of citizenship
Code
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
Deceased
Full name Date of birth Place of birth Country(ies) of citizenship
Code
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
Deceased
Full name Date of birth Place of birth Country(ies) of citizenship
Code
If relative was born outside the U.S., indicate one type of documentation that he or she possesses and provide the document number below.
Deceased
Current address (Street, City, and State, include Country if outside the U.S.)
Current address (Street, City, and State, include Country if outside the U.S.)
Current address (Street, City, and State, include Country if outside the U.S.)
Current address (Street, City, and State, include Country if outside the U.S.)
Current address (Street, City, and State, include Country if outside the U.S.)
Current address (Street, City, and State, include Country if outside the U.S.)
Other (Explain below)
Document number
Deceased
FS 240 or 545
Citizenship certificate
Naturalization certificate
DS 1350
U.S. Passport
Alien registration
Other (Explain below) Document number
FS 240 or 545
Citizenship certificate
Naturalization certificate
DS 1350
U.S. Passport
Alien registration
Other (Explain below) Document number
FS 240 or 545
Citizenship certificate
Naturalization certificate
DS 1350
U.S. Passport
Alien registration
Other (Explain below) Document number
FS 240 or 545
Citizenship certificate
Naturalization certificate
DS 1350
U.S. Passport
Alien registration
Other (Explain below) Document number
FS 240 or 545
Citizenship certificate
Naturalization certificate
DS 1350
U.S. Passport
Alien registration
Other (Explain below) Document number
FS 240 or 545
Citizenship certificate
Naturalization certificate
DS 1350
U.S. Passport
Alien registration
Other (Explain below) Document number
Do you have or have you had close and/or continuing contact with foreign nationals within the last 7 years with whom you, your spouse, or your cohabitant are
bound by affection, influence, and/or obligation? Include associates, as well as relatives, not already listed in Question 18. (A foreign national is defined as any
person who is not a citizen or national of the U.S.)
20 FOREIGN ACTIVITIES Respond for the time frame of the last 7 years.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
Enter your Social Security Number before going to the next page
Page 12
20A Foreign Financial Interests Include stocks, personal property, company shares, investments, or ownership of corporate entities.
Exclude U.S.-based fund managers and accounts managed through your employer.
1.
Do you have or have you EVER had any foreign financial businesses, foreign bank accounts, or other foreign financial interests of
which you have direct control or direct ownership?
Type of financial interest Amount of funds in U.S. dollars
YES NO
2.
Do you have or have you had any foreign financial interests that someone controls on your behalf?
Type of financial interest and name of party who controls it
Amount of funds in U.S. dollars
3.
Do you own or have you owned real estate in a foreign country?
Type of property and date(s) owned Location of property
Estimated value of
property in U.S. dollars
4.
Do you receive or have you received any educational, medical, retirement, social welfare, or other such benefits from a
foreign country?
Type of benefit
Estimated value in
U.S. dollars
19 FOREIGN CONTACTS
Country(ies) of citizenship1. Full name
Business
Personal
Other (Explain)
Telephone
Electronic correspondence
Written correspondence
In person
Other (Explain)
Type of contact (check all that apply)Nature of relationship
Country(ies) of citizenship2. Full name
Business
Personal
Other (Explain)
Telephone
Electronic correspondence
Written correspondence
In person
Other (Explain)
Type of contact (check all that apply)Nature of relationship
Country(ies) of citizenship3. Full name
Business
Personal
Other (Explain)
Telephone
Electronic correspondence
Written correspondence
In person
Other (Explain)
Type of contact (check all that apply)Nature of relationship
Country(ies) of citizenship4. Full name
Business
Personal
Other (Explain)
Telephone
Electronic correspondence
Written correspondence
In person
Other (Explain)
Type of contact (check all that apply)Nature of relationship
Country(ies) of citizenship5. Full name
Business
Personal
Other (Explain)
Telephone
Electronic correspondence
Written correspondence
In person
Other (Explain)
Type of contact (check all that apply)Nature of relationship
Country(ies) of citizenship6. Full name
Business
Personal
Other (Explain)
Telephone
Electronic correspondence
Written correspondence
In person
Other (Explain)
Type of contact (check all that apply)Nature of relationship
Number of contacts per year
1 - 2
3 - 7
8 - 15
More than 15
Number of contacts per year
1 - 2
3 - 7
8 - 15
More than 15
Number of contacts per year
1 - 2 3 - 7
8 - 15
More than 15
Number of contacts per year
1 - 2 3 - 7
8 - 15
More than 15
Number of contacts per year
1 - 2
3 - 7
8 - 15
More than 15
Number of contacts per year
1 - 2 3 - 7
8 - 15
More than 15
Country of residence
Country of residence
Country of residence
Country of residence
Country of residence
Country of residence
Dates known
Month/Year To Month/Year
Dates known
Month/Year To Month/Year
Dates known
Month/Year To Month/Year
Dates known
Month/Year To Month/Year
Dates known
Month/Year To Month/Year
Dates known
Month/Year To Month/Year
Yes No
Name/Address of Provider
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Page 13
Enter your Social Security Number before going to the next page
Use these codes to indicate the purpose(s) of your visit:
1 - Business/Professional conference
2 - Volunteer activities
3 - Education
4 - Tourism
5 - Visit family or friends
6 - Other
Code
Month/Year To Month/Year
Number
of Days
Country
Code
Month/Year To Month/Year
Country
4.
Have you or any of your immediate family members had any contact with a foreign government, its establishment
(embassies, consulates, agencies, or military services), or its representatives, whether inside or outside the U.S.?
Answer "No" if the contact was for routine visa applications and border crossings related to either official U.S. Government travel
or foreign travel listed below in Question 20C. If contact was outside of official U.S. Government business, identify the foreign
government(s), establishment(s), and/or representative(s) involved and provide the circumstance(s), date(s), and location(s) of
contact(s).
5.
Have you sponsored any foreign citizen to come to the U.S. as a student, for work, or for permanent residence?
#5
#2
#3
#6
21 MENTAL AND EMOTIONAL HEALTH
NO
YES
Mental health counseling in and of itself is not a reason to revoke or deny a clearance.
In the last 7 years, have you consulted with a health care professional regarding an emotional or mental health condition or were you
hospitalized for such a condition? Answer "No" if the counseling was for any of the following reasons and was not court-ordered:
1) strictly marital, family, grief not related to violence by you; or
2) strictly related to adjustments from service in a military combat environment.
Dates of Treatment and/or Counseling
Month/Year To Month/Year
State
ZIP Code
20B Foreign Business, Professional Activities, and Foreign Government Contacts
Respond for the time frame of the last 7
years, unless otherwise noted. Indicate if activity was on official U.S. Government business.
If "Yes" AND the activity was outside of official U.S. Government business, describe advice/support provided, name(s) of
foreign national and/or organization(s) to which it was provided, the name(s) of foreign country(ies), timeframe(s), and if
compensation was provided.
Have you provided advice or support to anyone associated with a foreign business or other foreign organization that you have
not previously listed as a former employer regarding any of the following: management, strategy, financing, or technology?
6.
Have you EVER held or do you now hold a passport that was issued by a foreign government?
If "Yes," provide the name(s), in which your foreign passport(s) was issued, the issuing country(ies), the passport number(s), the date(s) issued, the
expiration date(s), and the status of each.
20C Foreign Countries You Have Visited Respond for the time frame of the last 7 years.
Have you traveled outside the U.S. in the last 7 years?
Respond for foreign countries you have visited in the last 7 years, beginning with the most current and working back. If you have lived near a border and
have made short (one day or less) trips to the neighboring country (e.g. Canada or Mexico), you do not need to list each trip. Instead, provide the time
period, the code, the country, and a note ("Many Short Trips"). Do not list travel under official U.S. Government business, but you must include any
personal trips made in conjunction with the official U.S. Government travel.
If you answered "Yes," indicate who conducted the treatment and/or counseling, provide the following information, and sign the Authorization for Release of
Medical Information Pursuant to the Health Insurance Portability and Accountability Act (HIPAA).
#1
#4
#1
#2
YES NO
Number
of Days
If "Yes," provide the name of the foreign citizen(s) you sponsored, the country(ies) of citizenship, the date(s) of the foreign
citizen's stay in the U.S., their current address (if known), and the purpose of the foreign citizen's stay in the U.S.
1.
2.
Have you attended any international conferences, trade shows, seminars, or other meetings outside of the U.S.?
If "Yes" AND the activity was outside of official U.S. Government business, provide locations, including the name(s) of foreign
country(ies), date(s), sponsoring organization(s), and purpose of event(s).
3.
Have you or any of your immediate family members been asked to provide advice or serve as a consultant, even informally, by
any foreign government official or agency?
If "Yes" AND the activity was outside of official U.S. Government business, provide the date(s) of request and/or consultation(s),
including the name(s) of foreign country(ies), location of consultation(s), and circumstance(s).
NO
YES
Official Govt.
Business
22 POLICE RECORD
In the last 7 years, have you received counseling or treatment or have you been ordered, advised, or asked to seek counseling or treatment
as a result of your use of drugs? If you answered "Yes," provide date(s) of treatment and name(s) and address(es) of provider(s). You will
be asked to sign an additional release if information is needed concerning any treatment.
The following questions pertain to the illegal use of drugs or drug activity. You are required to answer the questions fully and truthfully, and your
failure to do so could be grounds for an adverse employment decision or action against you. Neither your truthful responses nor information
derived from your responses will be used as evidence against you in any subsequent criminal proceeding.
If you answered "Yes" to any question above, explain below, providing information for each and every offense.
#2
#1
Month/Year
Offense
Action Taken
Law Enforcement Authority/Court
City and Country (if outside U.S.)
State
ZIP Code
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Have you EVER illegally used a controlled substance while possessing a security clearance; while employed as a law enforcement officer,
prosecutor, or courtroom official; or while in a position directly and immediately affecting the public safety?
23 ILLEGAL USE OF DRUGS OR DRUG ACTIVITY
NO
YES
a
In the last 7 years, have you illegally used any controlled substance, for example, cocaine, crack cocaine, THC (marijuana, hashish, etc.),
narcotics (opium, morphine, codeine, heroin, etc.), stimulants (amphetamines, speed, crystal methamphetamine, Ecstacy, ketamine, etc.),
depressants (barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.), steroids, inhalants (toluene, amyl nitrate,
etc.) or prescription drugs (including painkillers)? Use of a controlled substance includes injecting, snorting, inhaling, swallowing,
experimenting with or otherwise consuming any controlled substance.
b
In the last 7 years, have you been involved in the illegal possession, purchase, manufacture, trafficking, production, transfer, shipping,
receiving, handling, or sale of any controlled substance (see question a above) including prescription drugs?
Dates of Use/Activity
Month/Year To Month/Year
Type of Controlled Substance(s) Explain (nature of use/activity, frequency of activity and number of times used)
#1
#2
c
Page 14
Enter your Social Security Number before going to the next page
Has your use of alcohol had a negative impact on your work performance, your professional or personal relationships, your finances, or
resulted in intervention by law enforcement/public safety personnel? (If "Yes," explain.)
Month/Year To Month/Year
YES
NO
a
b
Have you been ordered, advised, or asked to seek counseling or treatment as a result of your use of alcohol?
c
Have you received counseling or treatment as a result of your use of alcohol?
If you answered "Yes" to question b or c above, provide the date(s) of treatment and the name(s) and address(es) of the counselor(s) or doctor(s)
below. Do not repeat information reported in response to Question 21. You will be asked to sign an additional release if information is needed
concerning any treatment.
Name/Address of Counselor or Doctor
#1
#2
24 USE OF ALCOHOL Respond for the time frame of the last 7 years.
NO
YES
e Have you EVER been charged with any offense(s) related to alcohol or drugs?
d Have you EVER been charged with a firearms or explosives offense?
c Have you EVER been charged with any felony offense? (Include those under Uniform Code of Military Justice.)
b. Have you been arrested by any police officer, sheriff, marshal, or any other type of law enforcement officer?
a. Have you been issued a summons, citation, or ticket to appear in court in a criminal proceeding against you; are you on trial or awaiting a
trial on criminal charges; or are you currently awaiting sentencing for a criminal offense?
For questions a and b, respond for the timeframe of the last 7 years (if an SSBI go back 10 years). Exclude any fines of less than $300 for
traffic offenses that do not involve alcohol or drugs.
For this item, report information regardless of whether the record in your case has been sealed, expunged, or otherwise stricken from the court record, or the
charge was dismissed. You need not report convictions under the Federal Controlled Substances Act for which the court issued an expungement order under
the authority of 21 U.S.C. 844 or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or abroad.
State
ZIP Code
d
If you answered "Yes" to a - d above, provide the date(s) of use or activity, identify the controlled substance(s), and explain the use or activity.
Foreign Government or Other Agency
(If necessary)
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Page 15
Enter your Social Security Number before going to the next page
Has the U.S. Government or a foreign government EVER investigated your background and/or granted you a security clearance? If
"Yes," use the codes that follow to provide the requested information below. If "Yes," but you can't recall the investigating agency and/or
the security clearance received, enter the code for "Unknown." If your response is "No," or you don't know or can't recall if you were
investigated and cleared, check the "No" box.
NO
YES
Month/Year
a
Investigating Agency Codes
1 - Defense Department
2 - State Department
3 - Office of Personnel
Management
5 - Treasury Department
6 - Department of Homeland Security
7 - Foreign government (Specify country)
9 - Other (Explain below)
Security Clearance Codes
0 - Not Required
1 - Confidential
2 - Secret
3 - Top Secret
4 - Sensitive Compartmented
Information
5 - Q
6 - L
7 - Issued by foreign
country (specify
country)
8 - Unknown
Agency
Code
Clearance
Code
#1
#2
#3
#4
25 INVESTIGATIONS AND CLEARANCE RECORD
Month/Year
Department or Agency Taking Action
Circumstances
#1
#2
n Are you currently over 90 days delinquent on any debt(s)?
e Have you had a judgment entered against you?
f Have you defaulted on any type of loan?
26 FINANCIAL RECORD
For the following, answer for the last 7 years, unless otherwise specified in the question. Disclose all financial obligations, including
those for which you are a cosigner or guarantor, on the following page.
YES
NO
a Have you filed a petition under any chapter of the bankruptcy code? If "Yes," indicate type.
b Have you had any possessions or property voluntarily or involuntarily repossessed or foreclosed?
c Have you failed to pay Federal, state, or other taxes, or to file a tax return, when required by law or ordinance?
d Have you had a lien placed against your property for failing to pay taxes or other debts?
g Have you had bills or debts turned over to a collection agency?
h Have you had any account or credit card suspended, charged off, or cancelled for failing to pay as agreed?
i Have you been evicted for non-payment of financial obligations?
j Have you been delinquent on court-imposed alimony or child support payments?
k Have you had your wages, benefits, or assets garnished or attached for any reason?
l Have you been counseled, warned, or disciplined for violating terms of agreement for a travel or credit card provided by your employer?
m Have you been over 180 days delinquent on any debt(s)?
o Have you EVER experienced financial problems due to gambling?
To your knowledge, have you EVER had a clearance or access authorization denied, suspended, or revoked; or been debarred from
government employment? If "Yes," give the action(s), date(s) of action(s), agency(ies), and circumstances. Note: An administrative
downgrade or termination of a security clearance is not a revocation.
p Are you currently delinquent on any Federal debt?
NOYES
b
4 - Federal Bureau of
Investigation
8 - Unknown
9 - Other (Explain below)
Amount of Property
Value Involved
26 FINANCIAL RECORD (Continued)
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Indicate
(a-p)
Date Satisfied
Month/Year
Amount of Property
Value Involved
Loan/Account Number/
Bankruptcy Type
Names of Agency/Organization/Individual to Whom Debt is/was Owed
Name/Address of Company, Court, or Agency Handling Case
Name Action/Debt is Recorded Under
Status of Action or Debt
#1
a
In the last 7 years, have you illegally or without authorization modified, destroyed, manipulated, or denied others access to information
residing on an information technology system?
b
In the last 7 years, have you illegally or without proper authorization entered into any information technology system?
Page 16
Enter your Social Security Number before going to the next page
27 USE OF INFORMATION TECHNOLOGY SYSTEMS
YES
NO
The following questions ask about your use of information technology systems. Information technology systems include all related computer
hardware, software, firmware, and data used for the communication, transmission, processing, manipulation, storage, or protection of
information. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds for an adverse employment
decision or action against you. Neither your truthful responses nor information derived from your responses will be used as evidence against
you in any subsequent criminal proceeding.
For the following, answer for the last 7 years, unless otherwise specified in the question. Disclose all financial obligations, including those for which you
are a cosigner or guarantor. If you answered "Yes" on the previous page (a-p), provide the information requested below. For each "Yes" answer, provide
the corresponding letters.
c
In the last 7 years, have you introduced, removed, or used hardware, software, or media in connection with any information technology
system without authorization, when specifically prohibited by rules, procedures, guidelines, or regulations?
Indicate
(a-p)
Date Satisfied
Month/Year
Loan/Account Number/
Bankruptcy Type
Names of Agency/Organization/Individual to Whom Debt is/was Owed
Name/Address of Company, Court, or Agency Handling Case
Name Action/Debt is Recorded Under
Status of Action or Debt
#2
Indicate
(a-p)
Date Satisfied
Month/Year
Amount of Property
Value Involved
Loan/Account Number/
Bankruptcy Type
Names of Agency/Organization/Individual to Whom Debt is/was Owed
Name/Address of Company, Court, or Agency Handling Case
Name Action/Debt is Recorded Under
Status of Action or Debt
#3
Indicate
(a-p)
Date Satisfied
Month/Year
Amount of Property
Value Involved
Loan/Account Number/
Bankruptcy Type
Names of Agency/Organization/Individual to Whom Debt is/was Owed
Name/Address of Company, Court, or Agency Handling Case
Name Action/Debt is Recorded Under
Status of Action or Debt
#4
State ZIP Code
State
ZIP Code
State
ZIP Code
State
ZIP Code
Date of Incident
(Month/Year)
Nature of Incident/Offense
Location Incident Took Place Action Taken
#1
#2
#3
#4
#5
#6
#7
Have you EVER been an officer or a member of, or made a contribution to, an organization that unlawfully advocates or practices the
commission of acts of force or violence to discourage others from exercising their rights under the U.S. Constitution or any state of the U.S.
with the specific intent to further such unlawful activities?
29 ASSOCIATION RECORD
Enter your Social Security Number before going to the next page
Page 17
YES
NO
a
b
Have you EVER been an officer or a member of, or made a contribution to, an organization dedicated to the use of violence or force to
overthrow the U.S. Government, and which engaged in illegal activities to that end, either with an awareness of the organization's dedication
to that end or with the specific intent to further such illegal activities?
c
If you answered "Yes" to any of the questions above, explain below.
Use the continuation sheet(s) (SF 86A) for additional answers for items 11, 12, and 13. Use the space below to continue answers to all other items and to
provide any information you would like to add. If more space is needed than is provided below, use a blank sheet(s) of paper. Start each sheet with your
name and SSN. Before each answer, identify the number of the item and try to maintain question format.
After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate,
and then sign and date the following certification and the attached release(s).
Certification
My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I
have carefully read the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this form can be punished by fine
or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information may have a negative effect on my
security clearance, employment prospects, or job status, up to and including denial or revocation of my security clearance, or my removal and debarment from
Federal service.
Signature
Date (mm/dd/yyyy)
CONTINUATION SPACE
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Court Information
28 INVOLVEMENT IN NON-CRIMINAL COURT ACTIONS
YES NO
In the last 7 years (if an SSBI go back 10 years), have you been a party to any public record civil court action(s) not listed elsewhere on this form?
If you answered "Yes," provide the information about each public record civil court action(s) requested below.
Name of Principal Parties Involved
(if more space is needed,
use Continuation Space on page 17)
Result of Action
Nature of Action
Month/Year
#1
#2
Court name
Court name
Street address
Street address
City State ZIP Code
City State
ZIP Code
The following questions pertain to your associations. You are required to answer the questions fully and truthfully, and your failure to do so could be grounds
for an adverse employment decision or action against you. For the purpose of this question, terrorism is defined as any criminal acts that involve violence or
are dangerous to human life and appear to be intended to intimidate or coerce a civilian population to influence the policy of a government by intimidation or
coercion, or to affect the conduct of a government by mass destruction, assassination or kidnapping.
Have you EVER been an officer or a member of, or made a contribution to, an organization dedicated to terrorism, and which engaged in illegal
activities to that end, either with an awareness of the organization's dedication to that end or with the specific intent to further such illegal
activities?
d
Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S. Government by force with the specific intent to
incite others to unlawful action in furtherance of such aims?
Have you EVER knowingly engaged in any activities designed to overthrow the U.S. Government by force?
e
Have you EVER knowingly engaged in any acts of terrorism? Neither your truthful response nor information derived from your response to
this question will be used as evidence against you in any subsequent criminal proceeding.
f
g
Have you EVER participated in militias (not including official state government militias) or paramilitary groups?
AUTHORIZATION FOR RELEASE OF INFORMATION
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86-1
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
UNITED STATES OF AMERICA
Carefully read this authorization to release information about you, then sign and date it in ink.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency
conducting my background investigation, to obtain any information relating to my activities from individuals, schools,
residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection
agencies, retail business establishments, or other sources of information. This information may include, but is not limited to,
my academic, residential, achievement, performance, attendance, disciplinary, employment history, criminal history record
information, and financial and credit information. I authorize the Federal agency conducting my investigation to disclose the
record of my background investigation to the requesting agency for the purpose of making a determination of suitability or
eligibility for a national security position.
I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security
Number, and date of birth with information in SSA records and provide the results of the match) to the Office of Personnel
Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I
authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting my
investigation, in the event of a discrepancy.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other
sources of information, separate specific releases may be needed, and I may be contacted for such releases at a later date.
I Authorize any investigator, special agent, or other duly accredited representative of the OPM, the Federal Bureau of
Investigation, the Department of Defense, the Department of State, and any other authorized Federal agency, to request
criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for assignment
to, or retention in, a national security position, in accordance with 5 U.S.C. 9101. I understand that I may request a copy of
such records as may be available to me under the law.
I Authorize custodians of records and other sources of information pertaining to me to release such information upon request
of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless
of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by the Federal
Government only for the purposes provided in this Standard Form 86, and that it may be disclosed by the Government only as
authorized by law.
Photocopies of this authorization that show my signature are valid. This authorization is valid for five (5) years from the date
signed or upon the termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink)
Full name (Type or print legibly) Date signed (mm/dd/yyyy)
Other names used
Social Security Number
Current street address
City (Country)
State ZIP Code
Home telephone number
Apt. #
Enter your Social Security Number before going to the next page
Date of birth
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86-2
Revised July 2008
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
NSN 7540-00 634-4036
86-111
Enter your Social Security Number before going to the next page
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PURSUANT
TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
If you answered "Yes" to Question 21, carefully read this authorization to release information about you, then sign and date it in ink.
Instructions for Completing this Release
This is a release for the investigator to ask your health practitioner(s) the questions below concerning your mental health
consultations. Your signature will allow the practitioner(s) to answer only these questions.
Authorization
I am seeking assignment to or retention in a national security position. As part of the clearance process, I hereby authorize
the investigator, special agent, or duly accredited representative of the authorized Federal agency conducting my
background investigation, to obtain the following information relating to my mental health consultations.
In accordance with HIPAA, I understand that I have the right to revoke this authorization at any time by writing to the U.S.
Office of Personnel Management. I understand that I may revoke this authorization except to the extent that action has
already been taken based on this authorization. Further, I understand that this authorization is voluntary. My treatment,
payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
I understand the information disclosed pursuant to this release is for use by the Federal Government only for purposes
provided in the Standard Form 86 and that it may be disclosed by the Government only as authorized by law, but will no
longer be subject to the HIPAA privacy rule.
Photocopies of this authorization with my signature are valid. This authorization is valid for one (1) year from the date signed
or upon termination of my affiliation with the Federal Government, whichever is sooner.
Signature (Sign in ink)
Full name (Type or print legibly) Date signed (mm/dd/yyyy)
Other names used
Social Security Number
Current street address
City (Country)
State ZIP Code
Home telephone number
For Use By Practitioner(s) Only
Does the person under investigation have a condition that could impair his or her judgment, reliability, or ability to properly
safeguard classified national security information?
If so, describe the nature of the condition and the extent and duration of the impairment or treatment.
What is the prognosis?
Signature (Sign in ink)
Practitioner name
Date signed (mm/dd/yyyy)
Apt. #
Yes No
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Orientation 16 Questionnaire National Security Positions (Jacksonville University)

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Completed 21 July 2020

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