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PERSONAL WAIVER I understand that the purpose of (Texas A&M University - College Station)

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Page 1 of 7
PERSONAL WAIVER
I understand that the purpose of completing the Personnel Security Prescreen Questionnaire is relative
to obtaining a security clearance or access to national security information, and that my answers and
statements on these forms are privileged information between the United States government, myself
and Texas A&M University System Research Security Office (RSO) personnel.
By submitting this form, I hereby voluntarily waive the privilege above and authorize designated RSO
personnel to review any portion necessary of the Personnel Security Prescreen Questionnaire for the
purpose of prescreening a security clearance or the submittal of a security clearance. I understand that
the Personnel Security Prescreen Questionnaire will only be used for official use only to help
determine my eligibility for, or verification of, a security clearance and/or access to national security
information. All personal information provided will be protected IAW the Privacy Act of 1974.
I agree to hold The Texas A&M University System, its agents, directors, employees, subsidiaries,
affiliates, and/or representatives, harmless from any claims, damages, losses, liabilities, costs and
expenses (including attorney and legal fees), or any other charge or complaint filed, arising from the
disclosing, retrieving, reporting, and use of the information referred to above during the preliminary
eligibility determination process for obtaining a security clearance.
I Accept I Decline
I certify that the entries made by me on the Personnel Security Prescreen Questionnaire are
voluntary, accurate, and complete to the best of my knowledge and belief and are made in good
faith. I also certify that the answers provided on this form will be consistent with information
that will be provided on any additional forms required by TAMUS/RSO to include, but not
limited to, the Standard Form 86 (SF-86) Personnel Security Investigation Questionnaire or
(eQIP) Electronic Questionnaires for Investigations Processing. I also acknowledge that I have
a right to decline to complete this Personnel Security Prescreen Questionnaire information. If I
choose to decline, then I understand this could significantly impact my ability to be considered
for a U.S. Government internship position.
Printed Name
Electronic or Hand Written Signature
Date
PRIVACY ACT OF 1974 APPLIES
click to sign
signature
click to edit
SECURITY QUESTIONNAIRE
Applicant Full Name: (Last, First, Full Middle) Prefix:
Maiden Name or aliases used since your 18
th
birthday:
Are you a U.S. citizen YES NO Do you carry dual citizenship? YES NO
If so, what countries?
Date of Birth: Place of Birth:
Phone: Home: Email address:
Please provide a telephone number where you can be reached during the workweek:
Current University:
Have you ever applied for a government staff position (not as a
government contractor) that required a security clearance?
YES NO
If yes, please provide the name of the agency
If yes, were you offered or denied a position?
Please Explain:
YES NO
1) What level of security clearance do you hold? TS/SCI Top Secret Secret
Other_______________
Unknown None
2) What government agency granted the clearance?
3) What is the date of your most recent background investigation?
4) Have you ever undergone a polygraph exam?
If yes, what type of polygraph was conducted?
YES NO
Counterintelligence Full Scope
Date:__________ Agency: ____________
5) If necessary, would you be willing to take a polygraph? NOTE: The
government reserves the right to require an individual to take a polygraph at any
time once an individual has been approved for a security clearance.
YES NO
6) Have you been debriefed from your security clearance or access or
do you have a debrief date scheduled?
If yes, why and when?
YES NO
7) Have you ever had a security clearance or access denied,
suspended, placed on inactive or revoked?
If yes, why?
YES NO
8) In the past twelve months have you had a security clearance
crossover denied or delayed?
YES NO UNKNOWN
PRIVACY ACT OF 1974 APPLIES
PRIVACY ACT OF 1974 APPLIES
Page 2 of 7
Page 3 of 7
9) Do you have members of your immediate family, to include spouse,
children, siblings, parents, and in-laws who are non-US citizens or hold
dual citizenship? Attachment addendum page if needed.
YES NO
Have you previously reported this information to the government of your
security office? YES NO N/A
9a) Name:
9b) Relationship:
9c) Country:
9d) Do they currently live in the U.S.?
YES NO
9e) Where?
9f) Are they attempting to obtain their U.S.
citizenship? YES NO
10) Are you currently living with a non-US citizen or Do you have a
close or continuing relationship with a non-US citizen to include an Au
Pair? YES NO
Have you previously reported this information to the government of your
security office? YES NO N/A
10a) Name:
10b) Relationship:
10c) Country:
10d) Are they attempting to obtain their U.S.
citizenship? YES NO
11) Do you hold citizenship with any country in addition to the US?
If yes, where?
YES NO
12) Are you willing to relinquish your foreign passport/citizenship (not
US), if requested?
YES NO N/A
13) Do you have any foreign property, business connections, or foreign
financial interests?
If yes, explain:
YES NO
14a) Have you ever had any contact with a representative of a foreign
government or an intelligence officer of a non-US agency? DO NOT
PROVIDE CLASSIFIED INFORMATION.
If yes, explain:
14b) Do you have relatives appointed, elected, or employed by a
foreign government?
If yes, explain:
YES NO
YES NO
PRIVACY ACT OF 1974 APPLIES
PRIVACY ACT OF 1974 APPLIES
Page 4 of 7
15a) Have you traveled to a foreign country within the last seven
years?
If yes, list the date(s), location(s), and purpose of your visit(s):
15b) Did any unusual incidents occur while you were on foreign travel?
If yes, explain:
YES NO
YES NO
16) Have you ever been arrested, investigated, detained, or charged
with a criminal offense to include UCMJ?
If yes, explain the type of incident, details/disposition, and date:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
17) Have you ever plead guilty or plead no contest to any charge
(felony, misdemeanor, military code or traffic offense over $300)?
If yes, explain the type of incident, details/disposition, and date:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
18) In the last seven years have you been a part of any civil court
proceedings?
If yes, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
19) Have you ever had any disciplinary or counseling action related to
your use of alcohol?
If yes, explain:
YES NO
PRIVACY ACT OF 1974 APPLIES
PRIVACY ACT OF 1974 APPLIES
Page 5 of 7
20) Have you EVER experimented with, purchased, distributed, or sold
any illegal drugs?
If yes, explain below:
Type of Drug(s) Last Date Used Explain Frequency
___________ ____________ ____________ _________
___________ ____________ ______
______ _________
___________ ____________ ____________ _________
___________ ____________ ____________ _________
___________ ____________ ____________ _________
___________ ____________ ____________ _________
___________ ____________ ____________ _________
Was this previously reported to the government or your security office?
YES NO
YES NO N/A
21) In the last seven years have you consulted with a medical
professional about a mental health condition other than marital, family,
or grief counseling?
If yes, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
22) In the last ten years have you ever defaulted on a loan, declared
bankruptcy, or had personal property repossessed?
If yes, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
23) Have you had any debt placed in collections in the last seven
years?
If yes, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
24) Have you ever had a tax lien or wage garnishment?
If yes, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
PRIVACY ACT OF 1974 APPLIES
PRIVACY ACT OF 1974 APPLIES
Page 6 of 7
25) Are you currently delinquent on any taxes (federal, state or local)?
If yes, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
26) Have you been late or are you currently delinquent on any child
support payments?
If yes, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
27) In the past ten years have any of the following situations occurred
regarding your employment
a) Fired from a job?
b) Quit a job after being told you would be fired?
c) Left a job by mutual agreement following allegations of misconduct?
d) Left a job by mutual agreement following allegations of
unsatisfactory performance?
e) Left a job for other reasons under unfavorable circumstances?
If yes to any of the above, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO N/A
28) Have you ever deliberately misused an automated computer
information system?
If yes, explain:
Was it previously reported to the government or your security office?
YES NO
YES NO N/A
29) If you currently hold an active security clearance, has any
information changed since you last reported it on a SF-86?
If yes, list the changes here:
YES NO
PRIVACY ACT OF 1974 APPLIES
PRIVACY ACT OF 1974 APPLIES
Page 7 of 7
30) Have you ever served in the U.S. Armed Forces?
If yes:
Branch Discharge Type
_____________________ Honorable
Less Than Honorable
Dishonorable
YES NO
31) Are you a male born after December 31, 1959?
If yes, provide Selective Service Number:
______________________
YES NO
DO NOT PROVIDE CLASSIFIED INFORMATION
When the form is completed please FAX to 979-458-4715 Attn: Chief Research Security Officer
You may also password protec
t this document and email it to RSO_PERSEC@tamus.edu. You
should then send the password in a separate email to the same address.
A member of TAMUS/RSO Personnel Security may contact you by telephone to obtain additional
information.
PRIVACY ACT OF 1974 APPLIES
PRIVACY ACT OF 1974 APPLIES
security123
1. With document open, click “Secure”
then click “Encrypt With Password”.
2. Click “Yes”
3. Check box “Require a Password to Open
the Document”
4. Enter password “security123” without
the quotes, lower case only. Then “Enter”
How To Encrypt PDF File
5. Re-enter the password “security123”
and click “OK”
6. Click “OK” then “Close” document
7. Attempt to “Reopen” the document. You
should be prompted for the password.
8. Attach encrypted document into your
email and send to the RSO email address
provided on the pre-screening form.
security123
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Completed 14 March 2021

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