United States Secret Service
Security Clearance Forms
08/2013
Instructions
You are being considered for a position with the United States Secret Service.
Since all Secret Service employees are required to have a Top Secret Security
Clearance, the enclosed background investigation forms are being provided for
your immediate completion.
Once you have been asked by a Secret Service representative to complete this
package, please note the following instructions.
All forms must be typed. If the paper-based version of this package has
been provided to you, and if you are able to complete this package in
electronic format, please call your designated Secret Service point-of-contact
so an Adobe Acrobat-based version of this package can be provided to you.
Ensure that ALL questions are answered or addressed. If a question does
not apply (and it is not a yes/no question), indicate N/A for not applicable.
Do not sign or initial any of the forms unless otherwise indicated. (Your
signatures must be witnessed by Secret Service representatives.)
NAME OF CANDIDATE
DEPARTMENT OF HOMELAND SECURITY
United States Secret Service
ACKNOWLEDGMENT OF SECURITY
CLEARANCE REQUIREMENTS
THIS FORM MUST BE SIGNED BY ALL CANDIDATES WHO ARE TO BE APPOINTED ON A CONTINGENCY BASIS.
I understand that I am being considered for
appointment with the U.S. Secret Service
based on a contingent security investigation.
I understand that, if accepted, continued
employment with the U.S. Secret Service is
contingent on the satisfactory completion of a
special security background investigation and,
if the position is considered critical-sensitive,
the granting of a Top Secret clearance.
SIGNATURE OF CANDIDATE
DATE SIGNED
SIGNATURE OF WITNESS
DATE SIGNED
DISTRIBUTION: ORIGINAL - OFFICIAL PERSONNEL FILE CC - SECURITY CLEARANCE DIVISION CC - CANDIDATE
SSF 1871 (2/2003) Page 1 of 1
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 
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
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 
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
     
         
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       
 
   
      
        
   
  
  
    
      
  
   
    
   
     
   
       
    

         

      
   
    
 



          
        
      
      
      
  
 
  

  
   
  

  


    
 
  
   
  
   
 
    



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     

  

 
 

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 
 
  

    
    
     




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
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     
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  
  
          
      
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
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 
      

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   
       
 
  
   
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 
       
 
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     
  
       
   
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 
 
      
     
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 



  
  

 

 
    
     

  
  
 
 

 
  
  
        
  
 
 
     
 
  
  
 
    
    
   
    
     

   
       
 






 










 

 




   



    
 

 
 


 




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, United States
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 (CFR).
Your Social Security Number (SSN) is needed to identify records unique to
you. 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.
This form will be used by the United States (U.S.) Government in conducting
background investigations, reinvestigations, and continuous evaluations of
persons under consideration for, or retention of, national security positions as
defined in 5 CFR 732, and for individuals requiring eligibility for access to
classified information under Executive Order 12968. This form may also be
used by agencies in determining whether a subject performing work for, or on
behalf of, the Government under a contract should be deemed eligible for
logical or physical access when the nature of the work to be performed is
sensitive and could bring about an adverse effect on the national security .
This form is a permanent document that may be used as the basis for future
investigations, eligibility determinations for access to classified information, or
to hold a sensitive position, suitability or fitness for Federal employment,
fitness for contract employment, or eligibility for physical and logical access to
federally controlled facilities or information systems. Your responses to this
form may be compared with your responses to previous SF-86
questionnaires.
Providing 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, eligibility for access to classified information, or logical or physical
access. It is imperative that the information provided be true and accurate, to
the best of your knowledge. Any information that you provide is evaluated on
the basis of its currency, seriousness, relevance to the position and duties,
and consistency with all other information about you. Withholding,
misrepresenting, or falsifying information may affect your eligibility for access
to classified information, eligibility for a sensitive position, or your ability to
obtain or retain Federal or contract employment. In addition, withholding,
misrepresenting, or falsifying information may affect your eligibility for
physical and logical access to federally controlled facilities or information
systems. Withholding, misrepresenting, or falsifying information may also
negatively affect your employment prospects and job status, and the potential
consequences include, but are not limited to, removal, debarment from
Federal service, loss of eligibility for access to classified information, or
prosecution.
Purpose of this Form
Authority to Request this Information
Follow instructions completely or your form will be unable to be processed. If
you have any questions, contact the office that provided you the form.
All questions on this form must be answered completely and truthfully in
order that the Government may make the determinations described below on
a complete record. Penalties for inaccurate or false statements are discussed
below. If you are a current civilian employee of the federal government:
failure to answer any questions completely and truthfully could result in an
adverse personnel action against you, including loss of employment; with
respect to Sections 23, 27, and 29, however, neither your truthful responses
nor information derived from those responses will be used as evidence
against you in a subsequent criminal proceeding.
The investigation conducted on the basis of information provided on this form
may be selected for studies and analyses in support of evaluating and
improving the effectiveness and efficiency of the investigative and
adjudicative methodologies. All study results released to the general public
will delete personal identifiers such as name, social security number, and
date and place of birth.
Background investigations for national security positions are conducted to
gather information to determine 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,
although you may have previously indicated on applications or other forms
that you do not want your current employer to be contacted. If you have a
security freeze on your consumer or credit report file, then we may not be
able to complete your investigation, which can adversely affect your eligibility
for a national security position. To avoid such delays, you should request that
the consumer reporting agencies lift the freeze in these instances.
The Investigative Process
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 demonstrate a person is not
reliable, trustworthy, or loyal. Federal agency records checks may be
conducted on your spouse, cohabitant(s), and immediate family members.
After an eligibility determination has been completed, you also may be
subject to continuous evaluation, which may include periodic reinvestigations,
to determine whether retention in your position is clearly consistent with the
interests of national security.
For the interview, you will be required to provide photo identification, such as
a valid state driver's license. You may be required to provide other documents
to verify your identity, as instructed by your investigator. These documents
may include certification of any legal name change, Social Security card,
passport, and/or your birth certificate. You may also be asked to provide
documents regarding information that you provide on this form, or about other
matters requiring specific attention. These matters include (a) alien
registration or naturalization documents; (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.
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
assists in completing your investigation. It is imperative that the interview be
conducted immediately 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.
Your Personal Interview
Instructions for Completing this Form
2.
3.
1. Follow the instructions, provided to you by the office that gave you this
form and any other clarifying instructions provided by that office to assist
you with 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.
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.
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.
Any changes that you make to this form, after you sign it, must be
initialed and dated by you. Under extremely limited circumstances,
agencies may modify your response(s) with your consent.
4.
5. You must use the Location codes (abbreviations), immediately following
the Privacy Act Routine Uses, when you fill out this form. Do not
abbreviate the names of cities or foreign countries.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
6. Place of birth requires Country entry, even if in the U.S.
To the Office of Management and Budget when necessary to the review of
private relief legislation.
7.
9.
10.
8.
The 5-digit postal Zip Codes are required to process your investigation
more rapidly. Refer to an automated system approved by the U.S. Postal
Service to assist you with Zip Codes.
For telephone numbers in the U.S., ensure that the area code is included.
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 are unable to report an
exact date, approximate or estimate the date to the best of your ability,
and indicate "APPROX." or "EST" in the field.
If additional space is required for an explanation or to list your residences,
employment/self- employment/unemployment, or education, you should
use a continuation sheet, SF 86A, located at http://www.opm.gov/forms,
select standard forms. If additional space is required to answer other
items, use the Continuation Space, on page 121, or a blank sheet(s) of
paper. Include your name and SSN at the top of each blank sheet (s)
used.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
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 five (5) years 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
provide on this form and to make your comments part of the record.
Penalties for Inaccurate or False Statements
The information you provide is for the purpose of investigating you for a
national security position, and the information will be protected from
unauthorized disclosure. The collection, maintenance, and disclosure of
background investigative information are 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 your records will be maintained. The information
you provide 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, a list of which are published by the agency in
the Federal Register. The office that gave you this form will provide you a
copy of its routine uses.
Disclosure Information
Privacy Act Routine Uses
2.
3.
4.
5.
6.
7.
9.
10.
8.
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
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.
Except as noted in Sections 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.
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.
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.
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.
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.
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.
To the National Archives and Records Administration for records
management inspections conducted under 44 U.S.C. 2904 and 2906.
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.
11.
Final determination on your eligibility for a national security position is the
responsibility of the Federal agency that requested your investigation and the
agency that conducted your investigation. You will be provided the opportunity
to explain, refute, or clarify any information before a final decision is made, if
an unfavorable decision is considered. The United States Government does
not discriminate on the basis of race, color, religion, sex, national origin,
disability, or sexual orientation when granting access to classified information.
Final Determination on Your Eligibility
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.
Public burden reporting for this collection of information is estimated to average 150 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 U.S. Office of Personnel Management,
Federal Investigative Services, Attn: OMB Number 3206-0005, 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.
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Form approved:
OMB No. 3206 0005
LOCATION CODES
PUBLIC BURDEN INFORMATION
South Dakota SD
Tennessee TN
Texas TX
Utah UT
Vermont VT
Virginia VA
Washington WA
West Virginia WV
Wisconsin WI
Wyoming WY
Wake Island WQ
APO/FPO America AA
APO/FPO Europe AE
APO/FPO Pacific AP
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
Palmyra Atoll LQ
Puerto Rico PR
Virgin Islands, United VI
States
Massachusetts MA
Michigan MI
Minnesota MN
Mississippi MS
Missouri MO
Montana MT
Nebraska NE
Nevada NV
New Hampshire NH
New Jersey NJ
Midway Islands MQ
Navassa Island BQ
Northern Mariana Islands
MP
Palau PW
Hawaii HI
Idaho ID
Illinois IL
Indiana IN
Iowa IA
Kansas KS
Kentucky KY
Louisiana LA
Maine ME
Maryland MD
Johnson Atoll JQ
Kingman Reef KQ
Marshall Islands MH
Micronesia, Federated FM
States
Alabama AL
Alaska AK
Arizona AZ
Arkansas AR
California CA
Colorado CO
Connecticut CT
Delaware DE
District of Columbia DC
Florida FL
Georgia GA
American Samoa AS
Baker Island FQ
Guam GU
Howland Island HQ
Jarvis Island DQ
V Applicant affiliation
None
J SON
(Submitting Office Number)
Initial
Reinvestigation
S Investigative requirement
Investigating agency user only
Codes: (FIPC CODES)
Case Number:
P Obligating document number Q Business Event Type Code
R Accounting data and/or Agency case number
T Requesting official - Name
Title Signature
Title
Telephone number
(Include Ext.)
FED CIV
CON
Other
Other address/Web address of e-OPF
Zip Code
A Type of investigation
C Sensitivity level Compu/ADP D Access/Eligibility E Nature of action code
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 (Security Office Identifier) M Location of security folder
None
NPI
At SOI
Other
Other address
Email address
Email address Telephone number (Include Ext.) Date (Month/Day/Year)
FOR COMPETITIVE SERVICE INITIAL APPOINTMENTS ONLY: WHEN THE OF306, RESUME, AND OTHER INFORMATION PROVIDED
IN THE HIRING PROCESS APPEARS TO BE DISCREPANT WITH INFORMATION PROVIDED ON THIS QUESTIONNAIRE, THOSE
DISCREPANT DOCUMENTS MUST BE FORWARDED WITH THIS QUESTIONNAIRE TO OPM FOR ACTION.
Zip Code
MIL
N IPAC
O Treasury Account Symbol
AGENCY USE BLOCK "AUB"
W Deployment/PCS - (Do not provide deployment data if Classified or Sensitive information)
Point of contact at location Address/Unit/Duty location (Include City or Post Name)
Commercial and Government Entity (CAGE) Code Contract Number
F Date of action (Month/Day/Year)
Agency Special Instructions for the Investigative Service Provider.
Reason(s) for temporary duty assignment or PCSFrom (Month/Day/Year)
Location
(if imminent)
Telephone number (Include Ext.)
Est.
Permanent Relocation
Est. To
(Month/Day/Year)
Page 1
Provide your other name(s) used and the period of time you used it/them [for example: your maiden name(s), name(s) by a former marriage, former name(s),
alias(es), or nickname(es)]. If you have only initials in your name(s), provide them and indicate "Initial only." If you do not have a middle name (s), indicate "No
Middle Name" (NMN). If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle
Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix.
Enter your Social Security Number before going to the next page
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#1
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Section 5 - Other Names Used
Section 3 - Place of Birth
I have read the instructions and I understand that if I withhold, misrepresent, or falsify information on this form, I am subject
to the penalties for inaccurate or false statement (per U. S. Criminal Code, Title 18, section 1001), denial or revocation of a
security clearance, and/or removal and debarment from Federal Service.
PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW AFTER CAREFULLY READING
THE PRECEDING INSTRUCTIONS.
YES NO
Provide your place of birth.
Last name
First name
Middle name
City
County
Country (Required)
State
YES NO (If NO, proceed to Section 6)
Have you used any other names?
Not applicable
Provide your U.S. Social Security Number.
Section 4 - Social Security Number
Male
Female
Sex
Section 6 - Your Identifying Information
Weight
(in pounds) Hair color Eye color
Provide your identifying information.
Suffix
(feet) (inches)
Height
Section 2 - Date of Birth
Section 1 - Full Name
Provide your date of birth.
(Month/Day/Year)
Complete the following if you have responded 'Yes' to having used other names.
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#2
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#3
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Middle nameFirst name
Last name
Provide the reason(s) why the name changed
#4
From
(Month/Year) To (Month/Year)
Maiden name?
NOYES
Suffix
Est. Est.
Present
Page 2
Section 8 - U.S. Passport Information
Do you possess a U.S. passport (current or expired)?
YES NO (If NO, proceed to Section 9)
Provide the following information for the most recent U.S. passport you currently possess.
Passport number
The following link will provide U.S. State Department
passport help. http://travel.state.gov/passport
Issue date Expiration date
Est.
Provide the name in which passport was first issued.
Middle name
Last name
First name
Suffix
Section 9 - Citizenship
Select the box that reflects your current citizenship status.
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/commonwealth.
(Proceed to Section 10)
I am a U.S. citizen or national by birth, born to U.S. parent(s), in a foreign country.
(Complete 9.1)
I am not a U.S. citizen. (Complete 9.3)
I am a naturalized U.S. citizen. (Complete 9.2)
Provide document number for U.S. citizen born abroad.
Provide the place of issuance. (Provide City and Country if outside the United States; otherwise, provide City and State.)
Country
State
City
Provide the name in which document was issued.
Middle name
Last name
First name
Suffix
Provide the address of the court that issued the citizenship certificate.
Provide the name in which the certificate was issued.
Middle name
Last name
First name
Suffix
Were you born on a U.S. military installation?
YES NO (If NO, proceed to Section 10)
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Est.
9.1 Complete the following if you answered that you are a U.S. citizen or national by birth, born to U.S. parent(s) in a foreign country.
Provide the date the document was issued.
(Month/Day/Year)
Est.
Provide your citizenship certificate number.
Provide the date the certificate was issued. (Month/Day/Year)
Est.
Provide type of documentation of U.S. citizen born abroad.
FS240 or FS545 DS 1350 Other (Provide explanation)
(Month/Day/Year) (Month/Day/Year)
Section 7 - Your Contact Information
Provide your contact information.
Home e-mail address Work e-mail address
Home telephone number
Extension
International or DSN phone number
Night
Day
Work telephone number
Extension
International or DSN phone number
Night
Day
Mobile/Cell telephone number
Extension
International or DSN phone number
Night
Day
Provide the name of the court that issued the citizenship certificate.
State
City
Street
Zip Code
Provide the name of the base.
Page 3
Provide the address of the court that issued the naturalization certificate.
State
City
Provide the name in which the naturalization certificate was issued.
Middle name
Last name
First name
Suffix
Street
Zip Code
Provide the date the naturalization certificate was issued. (Month/Day/Year)
Est.
Provide your naturalization certificate number.
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Enter your Social Security Number before going to the next page
(Provide explanation)
9.3 Complete the following if you answered that you are not a U.S. Citizen.
Provide your date of entry in the U.S. (Month/Day/Year)
Est.
Provide your residence status.
Provide the date document was issued
Est.
Provide your alien registration number.
Provide the name in which the document was issued.
Middle name
Last name
First name
Suffix
Provide the expiration date of visa.
Provide document number.
Est.
Provide the basis of naturalization.
By operation of law through my U.S. citizen parent
OtherBased on my own individual naturalization application
Provide type of document issued. (I-94, etc.)
I-94 U.S. Visa Other (Provide explanation)
Provide the name of the court that issued the
naturalization certificate.
Section 9 - Citizenship - (Continued)
Provide the address of the court that issued the citizenship certificate.
State
City
Provide the name in which the citizenship certificate was issued.
Middle name
Last name
First name
Suffix
Street
Zip Code
(Month/Day/Year) (Month/Day/Year)
(Month/Day/Year)
Est.
Provide the date of entry into the U.S.
State
City
Provide country(ies) of prior citizenship.
#1 Country
Provide the location of entry into the U.S.
Do/did you have a U.S. alien registration number?
Provide your U.S. alien registration number.
Est.
Provide your citizenship certificate
number.
9.2 Complete the following if you answered that you are a naturalized U.S. citizen.
Provide the name of the court that issued the citizenship
certificate.
Provide the date the citizenship certificate was
issued. (Month/Day/Year)
YES
NO
#2 Country
Provide your place of entry in the U.S.
State
City
Provide country(ies) of prior citizenship.
#1 Country
#2 Country
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Page 4
Section 10 - Dual/Multiple Citizenship & Foreign Passport Information
10.1 Do you now or have you EVER held dual/multiple citizenships?
NO (If NO, proceed to 10.2)
YES
Complete the following if you answered 'Yes' to having EVER held dual/multiple citizenship.
Entry #1
Provide country of citizenship.
How did you acquire this non-U.S. citizenship you now have or previously had?
During what period of time did you hold citizenship with this country?
(Provide the date range that you held this citizenship, beginning with the date it
was acquired through its termination or "Present," whichever is appropriate.)
From Date (Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Have you taken any action to renounce your foreign citizenship?
NOYES
Provide explanation:
Do you currently hold citizenship with this country?
NOYES
Provide explanation:
Entry #2
How did you acquire this non-U.S. citizenship you now have or previously had?
During what period of time did you hold citizenship with this country?
(Provide the date range that you held this citizenship, beginning with the date it
was acquired through its termination or "Present," whichever is appropriate.)
From Date (Month/Year)
Est.
To Date (Month/Year)
Present
Est.
Have you taken any action to renounce your foreign citizenship?
YES NO
Provide explanation:
Provide explanation:
YES NO
Do you currently hold citizenship with this country?
Provide country of citizenship.
10.2 Have you EVER been issued a passport (or identity card for travel) by a country other than the U.S.?
NO (If NO, proceed to Section 11)YES
Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.
Entry #1
Provide the country in which the passport (or identity card) was issued.
Provide the date the passport (or identity card) was issued. (Month/Day/Year)
Est.
Provide the place the passport (or identity card) was issued.
Provide the name in which passport (or identity card) was issued.
City Country
Last name
First name
Middle name
Suffix
Provide the passport (or identity card) number.
Provide the passport (or identity card) expiration date.
(Month/Day/Year)
Est.
Have you EVER used this passport (or identity card) for foreign travel?
NOYES
Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.
Country From date (Month/Year) To date (Month/Year)
#1
Est. Est. Present
#2
Est. Est. Present
#3
Est. Est. Present
#4
Est. Est. Present
#5
Est. Est. Present
#6
Est. Est. Present
Enter your Social Security Number before going to the next page
Page 5
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 10 - Dual/Multiple Citizenship & Foreign Passport Information - (Continued)
Enter your Social Security Number before going to the next page
Complete the following if you answered 'Yes' to having been issued a passport (or identity card for travel) by a country other than the U.S.
Entry #2
Provide country in which the passport (or identity card) was issued.
Provide the date the passport (or identity card) was issued. (Month/Day/Year)
Est.
Provide the place the passport (or identity card) was issued.
Provide the name in which passport (or identity card) was issued.
City Country
Last name
First name
Middle name
Suffix
Provide the passport (or identity card) number.
Provide the passport (or identity card) expiration date.
(Month/Day/Year)
Est.
Have you EVER used this passport (or identity card) for foreign travel?
NOYES
Provide the countries to which you traveled on this passport (or identity card) and the dates involved with each.
Country From date (Month/Year) To date (Month/Year)
#1
Est. Est. Present
#2
Est. Est. Present
#3
Est. Est. Present
#4
Est. Est. Present
#5
Est. Est. Present
#6
Est. Est. Present
Page 6
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 11 - Where You Have Lived
List the places where you have lived beginning with your present residence and working back 10 years. Residences for the entire period must be accounted
for without breaks. Indicate the actual physical location of your residence, not a Post Office box or a permanent residence when you were not physically
located there. If you split your time between one or more residences during a time period, you must list all residences. Do not list residence before your 18th
birthday unless to provide a minimum of 2 years residence history.
You are not required to list temporary locations of less than 90 days that did not serve as your permanent or mailing address.
For any address in the last 3 years, provide a person who knew you at that address, and who preferably still lives in that area. Do not list people who knew
you well for residences completely outside this 3-year period, and do not list your spouse, cohabitant or other relatives.
Entry #1
Evening telephone number
Extension
International or DSN phone number
I don't know
Daytime telephone number
Extension
Cell/mobile telephone number
Extension
Provide the following contact information for this person.
International or DSN phone number
I don't know
International or DSN phone number
I don't know
Provide dates of residence.
From Date
Est.
To Date
Present
Est.
Owned by you
Military housing
Rented or leased by you
Other
Is/was this residence:
(Provide explanation)
Street
City
State
Country
Provide the street address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of a neighbor or other person who knows you at this address.
Middle name
Last name
First name
Suffix
Provide your relationship to this person (Check all that apply).
Neighbor Friend Landlord Business associate Other
(Provide explanation)
Street
City
State
Country
Provide street address for this person (including apartment number). (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide e-mail address for this person.
I don't know
(Month/Year) (Month/Year)
Enter residence information.
Est.
Provide date of last contact.
(Month/Year)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did you have an APO/FPO address while at this location?
(a)
(b)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(a)
YES
NO
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person who knew you have an APO/FPO address?(b)
YES
NO
Page 7
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 11 - Where You Have Lived - (Continued)
Entry #2
Evening telephone number
Extension
International or DSN phone number
I don't know
Daytime telephone number
Extension
Cell/mobile telephone number
Extension
Provide the following contact information for this person.
International or DSN phone number
I don't know
International or DSN phone number
I don't know
Provide dates of residence.
From Date
Est.
To Date
Present
Est.
Owned by you
Military housing
Rented or leased by you
Other
Is/was this residence:
(Provide explanation)
Street
City
State
Country
Provide the street address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of a neighbor or other person who knows you at this address.
Middle name
Last name
First name
Suffix
Provide your relationship to this person (Check all that apply).
Neighbor Friend Landlord Business associate Other
(Provide explanation)
Street
City
State
Country
Provide street address for this person (including apartment number). (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide e-mail address for this person.
I don't know
(Month/Year) (Month/Year)
Enter residence information.
Est.
Provide date of last contact.
(Month/Year)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did you have an APO/FPO address while at this location?
(a)
(b)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(a)
YES
NO
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person who knew you have an APO/FPO address?(b)
YES
NO
Page 8
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 11 - Where You Have Lived - (Continued)
Entry #3
Evening telephone number
Extension
International or DSN phone number
I don't know
Daytime telephone number
Extension
Cell/mobile telephone number
Extension
Provide the following contact information for this person.
International or DSN phone number
I don't know
International or DSN phone number
I don't know
Provide dates of residence.
From Date
Est.
To Date
Present
Est.
Owned by you
Military housing
Rented or leased by you
Other
Is/was this residence:
(Provide explanation)
Street
City
State
Country
Provide the street address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of a neighbor or other person who knows you at this address.
Middle name
Last name
First name
Suffix
Provide your relationship to this person (Check all that apply).
Neighbor Friend Landlord Business associate Other
(Provide explanation)
Street
City
State
Country
Provide street address for this person (including apartment number). (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide e-mail address for this person.
I don't know
(Month/Year) (Month/Year)
Enter residence information.
Est.
Provide date of last contact.
(Month/Year)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did you have an APO/FPO address while at this location?
(a)
(b)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(a)
YES
NO
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person who knew you have an APO/FPO address?(b)
YES
NO
Page 9
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 11 - Where You Have Lived - (Continued)
Entry #4
Evening telephone number
Extension
International or DSN phone number
I don't know
Daytime telephone number
Extension
Cell/mobile telephone number
Extension
Provide the following contact information for this person.
International or DSN phone number
I don't know
International or DSN phone number
I don't know
Provide dates of residence.
From Date
Est.
To Date
Present
Est.
Is/was this residence:
(Provide explanation)
Street
City
State
Country
Provide the street address.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of a neighbor or other person who knows you at this address.
Middle name
Last name
First name
Suffix
Provide your relationship to this person (Check all that apply).
Neighbor Friend Landlord Business associate Other
(Provide explanation)
Street
City
State
Country
Provide street address for this person (including apartment number). (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide e-mail address for this person.
I don't know
(Month/Year) (Month/Year)
Enter residence information.
Est.
Provide date of last contact.
(Month/Year)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did you have an APO/FPO address while at this location?
(a)
(b)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
(a)
YES
NO
Address
APO or FPO
APO/FPO State Code Zip Code
Does the person who knew you have an APO/FPO address?(b)
YES
NO
Owned by you
Military housing
Rented or leased by you
Other
Page 10
Do not list education before your 18th birthday, unless to provide a minimum of two years of education history.
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Entry #1
Section 12 - Where You Went to School
(a) Have you attended any schools in the last 10 years?
YES NO
(b) Have you received a degree or diploma more than 10 years ago?
YES NO (If NO to 12(a) and 12(b), proceed to Section 13A)
Provide the dates of attendance.
From Date
Est.
Present
Est.
High School
Vocational/Technical/Trade School
College/University/Military College
Correspondence/Distance/Extension/Online School
Select the most appropriate code to describe your school.
YES NO
Street
City
State
Country
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide current address for this person (including apartment number).
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Did you receive a degree/diploma?
Provide the name of the school.
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Last name
First name
I don't know
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide telephone number for this person.
I don't know
I don't know
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (High School Diploma, Associate's, Bachelor's, Master's,
Doctorate, Professional Degree (e.g. MD, DVM, JD), Other)
Other degree/diploma
Date awarded
(Month/Year)
Est.
Provide email address for this person.
(Month/Year) (Month/Year)
To Date
Entry #2
Provide the dates of attendance.
From Date
Est.
Present
Est.
High School
Vocational/Technical/Trade School
College/University/Military College
Correspondence/Distance/Extension/Online School
Select the most appropriate code to describe your school.
Street
City
State
Country
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide the name of the school.
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Last name
First name
I don't know
(Month/Year) (Month/Year)
To Date
Day Night
Page 11
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 12 - Where You Went to School - (Continued)
YES NO
Provide current address for this person (including apartment number).
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Did you receive a degree/diploma?
Street
City
State
Country
Zip Code
I don't know
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (High School Diploma, Associate's, Bachelor's, Master's,
Doctorate, Professional Degree (e.g. MD, DVM, JD), Other)
Other degree/diploma Date awarded (Month/Year) Est.
Provide email address for this person.
Entry #2 (Continued)
Entry #3
Provide the dates of attendance.
From Date
Est.
Present
Est.
High School
Vocational/Technical/Trade School
College/University/Military College
Correspondence/Distance/Extension/Online School
Select the most appropriate code to describe your school.
YES NO
Street
City
State
Country
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide current address for this person (including apartment number).
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Did you receive a degree/diploma?
Provide the name of the school.
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Last name
First name
I don't know
Street
City
State
Country
Zip Code
I don't know
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (High School Diploma, Associate's, Bachelor's, Master's,
Doctorate, Professional Degree (e.g. MD, DVM, JD), Other)
Other degree/diploma Date awarded (Month/Year) Est.
Provide email address for this person.
(Month/Year) (Month/Year)
To Date
I don't know
International or DSN phone number
Telephone number
Extension
Provide telephone number for this person.
Day Night
International or DSN phone number
I don't know
Telephone number
Extension
Provide telephone number for this person.
Day Night
Page 12
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 12 - Where You Went to School - (Continued)
Entry #4
Provide the dates of attendance.
From Date
Est.
Present
Est.
High School
Vocational/Technical/Trade School
College/University/Military College
Correspondence/Distance/Extension/Online School
Select the most appropriate code to describe your school.
YES NO
Street
City
State
Country
Provide the street address of the school. For correspondence/distance/extension/online schools, provide the address where the records are maintained.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide current address for this person (including apartment number).
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Did you receive a degree/diploma?
Provide the name of the school.
For schools you attended in the last 3 years, list a person who knew you at the school (instructor, student, etc.). Do not list people for education periods
completed more than 3 years ago. For correspondence/distance/extension/online schools, list someone who knew you while you received this education.
Last name
First name
I don't know
Street
City
State
Country
Zip Code
I don't know
Provide type of degrees(s)/diploma(s) received and date(s) awarded.
Degree/diploma (High School Diploma, Associate's, Bachelor's, Master's,
Doctorate, Professional Degree (e.g. MD, DVM, JD), Other)
Other degree/diploma Date awarded (Month/Year) Est.
Provide email address for this person.
(Month/Year) (Month/Year)
To Date
International or DSN phone number
I don't know
Telephone number
Extension
Provide telephone number for this person.
Day Night
Page 13
Provide the name of your supervisor.
Provide the rank/position title of your supervisor.
Provide supervisor's telephone number.
Extension
Provide physical work location of your supervisor.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
(Provide physical location data)
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
NightDay
International or DSN phone number
Street
City
State
Country
Provide address of duty station.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Section 13A - Employment Activities
Enter your Social Security Number before going to the next page
Telephone number
Extension
International or DSN phone number
Day Night
Provide the email address of your supervisor.
I don't know
Entry #1
List all of your employment activities, including unemployment and self-employment, beginning with the present and working back 10 years. The entire period
must be accounted for without breaks. If the employment activity was military duty, list separate employment activity periods to show each change of military
duty station. Do not list employment before your 18th birthday unless to provide a minimum of 2 years employment history.
Entry #1
Est.
Provide dates of employment.
Select the employment status for
this position:
Part-time
Full-time
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
From Date
(Month/Year)
Est.
Present
To Date
(Month/Year)
Provide your most recent rank/position title.
Provide your assigned duty station during this period.
Select your employment activity:
Active military duty station (Complete 13A.1,
13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5
and 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2,
13A.5 and 13A.6)
Self-employment (Complete 13A.3, 13A.5 and
13A.6)
State Government (Non-Federal employment)
(Complete 13A.2, 13A.5 and 13A.6)
Non-government employment (excluding self-
employment) (Complete 13A.2, 13A.5 and 13A.6)
Unemployment (Complete 13A.4)
Federal Contractor (Complete 13A.2,
13A.5 and 13A.6)
Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 14
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Provide the name of your supervisor.
Provide the position title of your supervisor.
Street
City
State
Country
Provide the address of employer.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide physical work location of your supervisor. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide telephone number
Extension
International or DSN phone number
Day Night
Entry #1
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
(b)
Is/was your physical work address different than your employer's address?
Provide telephone number
Extension
International or DSN phone number
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Day Night
YES NO (If NO, proceed to (b))
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Not
Applicable
From date (Month/Year)
To date (Month/Year)
Position Title Supervisor
Est. Est.
Est. Est.
Est. Est.
Est. Est.
Provide supervisor's telephone number.
Extension
NightDay
International or DSN phone number
Provide the email address of your supervisor.
I don't know
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did/does your supervisor have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 15
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Last name
First name
Provide the address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO (If NO, proceed to (b))
Is your physical work address different than your employment address?
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide the name of someone that can verify your self-employment.
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide the telephone number for this address.
Day Night
Street
City
State
Country
Provide address of this employment.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
13A.3 Complete the following if employment type is self-employment
Entry #1
(b)
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Street Address/Unit/Duty Location
City or Post Name
State
Country
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your self-employment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Page 16
Last name
First name
Provide the name of someone that can verify your unemployment activities
and means of support.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Provide dates of unemployment.
Provide address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street City
State
Country
Zip Code
Verifier telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 13A - Employment Activities - (Continued)
Provide the reason for leaving the employment activity.
YES NO (If NO, proceed to 13A.6)
For this employment have any of the following happened to you in the last seven (7) years?
Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following
notice of unsatisfactory performance.
Left by mutual agreement following
notice of unsatisfactory performance
Left by mutual agreement following
charges or allegations of misconduct
Quit after being told you would be
fired
Fired
Select your type of incident:
Provide the reason(s) for unsatisfactory performance.
Provide the charges or allegations of misconduct.
Provide the reason for quitting.
Provide the reason for being fired.
Reason:
Est.
Employment departure date
Provide the date you were fired.
(Month/Year)
Est.
Est.
Est.
Provide the date you left following charges or allegations
of misconduct.
(Month/Year)
Provide the date you quit after being told you would be
fired. (Month/Year)
Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#1
#2
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#3
#4
YES NO
For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as a violation of security policy?
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Entry #1Entry #1Entry #1
13A.4 Complete the following if employment type is unemployment.
13A.6
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your unemployment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
13A.5
Page 17
Provide the name of your supervisor.
Provide the rank/position title of your supervisor.
Provide supervisor's telephone number.
Extension
Provide physical work location of your supervisor.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
(Provide physical location data)
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
NightDay
International or DSN phone number
Street
City
State
Country
Provide address of duty station. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Section 13A - Employment Activities
Enter your Social Security Number before going to the next page
Telephone number
Extension
International or DSN phone number
Day Night
Provide the email address of your supervisor.
I don't know
Entry #2
Entry #2
Est.
Provide dates of employment.
Select the employment status for
this position:
Part-time
Full-time
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
From Date
(Month/Year)
Est.
Present
To Date
(Month/Year)
Provide your most recent rank/position title.
Provide your assigned duty station during this period.
Select your employment activity:
Active military duty station (Complete 13A.1,
13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5
and 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2,
13A.5 and 13A.6)
Self-employment (Complete 13A.3, 13A.5 and
13A.6)
State Government (Non-Federal employment)
(Complete 13A.2, 13A.5 and 13A.6)
Non-government employment (excluding self-
employment) (Complete 13A.2, 13A.5 and 13A.6)
Unemployment (Complete 13A.4)
Federal Contractor (Complete 13A.2,
13A.5 and 13A.6)
Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 18
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Provide the name of your supervisor.
Provide the position title of your supervisor.
Street
City
State
Country
Provide the address of employer.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide physical work location of your supervisor. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide telephone number
Extension
International or DSN phone number
Day Night
Entry #2
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
(b)
Is/was your physical work address different than your employer's address?
Provide telephone number
Extension
International or DSN phone number
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Day Night
YES NO (If NO, proceed to (b))
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Not
Applicable
From date (Month/Year)
To date (Month/Year)
Position Title Supervisor
Est. Est.
Est. Est.
Est. Est.
Est. Est.
Provide supervisor's telephone number.
Extension
NightDay
International or DSN phone number
Provide the email address of your supervisor.
I don't know
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did/does your supervisor have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 19
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Last name
First name
Provide the address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO (If NO, proceed to (b))
Is your physical work address different than your employment address?
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide the name of someone that can verify your self-employment.
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide the telephone number for this address.
Day Night
Street
City
State
Country
Provide address of this employment.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
13A.3 Complete the following if employment type is self-employment
Entry #2
(b)
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Street Address/Unit/Duty Location
City or Post Name
State
Country
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your self-employment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Page 20
Last name
First name
Provide the name of someone that can verify your unemployment activities
and means of support.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Provide dates of unemployment.
Provide address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street City
State
Country
Zip Code
Verifier telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 13A - Employment Activities - (Continued)
Provide the reason for leaving the employment activity.
YES NO (If NO, proceed to 13A.6)
For this employment have any of the following happened to you in the last seven (7) years?
Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following
notice of unsatisfactory performance.
Left by mutual agreement following
notice of unsatisfactory performance
Left by mutual agreement following
charges or allegations of misconduct
Quit after being told you would be
fired
Fired
Select your type of incident:
Provide the reason(s) for unsatisfactory performance.
Provide the charges or allegations of misconduct.
Provide the reason for quitting.
Provide the reason for being fired.
Reason:
Est.
Employment departure date
Provide the date you were fired.
(Month/Year)
Est.
Est.
Est.
Provide the date you left following charges or allegations
of misconduct.
(Month/Year)
Provide the date you quit after being told you would be
fired. (Month/Year)
Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#1
#2
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#3
#4
YES NO
For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as a violation of security policy?
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Entry #2Entry #2Entry #2
13A.4 Complete the following if employment type is unemployment.
13A.6
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your unemployment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
13A.5
Page 21
Provide the name of your supervisor.
Provide the rank/position title of your supervisor.
Provide supervisor's telephone number.
Extension
Provide physical work location of your supervisor.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
(Provide physical location data)
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
NightDay
International or DSN phone number
Street
City
State
Country
Provide address of duty station. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Section 13A - Employment Activities
Enter your Social Security Number before going to the next page
Telephone number
Extension
International or DSN phone number
Day Night
Provide the email address of your supervisor.
I don't know
Entry #3
Entry #3
Est.
Provide dates of employment.
Select the employment status for
this position:
Part-time
Full-time
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
From Date
(Month/Year)
Est.
Present
To Date
(Month/Year)
Provide your most recent rank/position title.
Provide your assigned duty station during this period.
Select your employment activity:
Active military duty station (Complete 13A.1,
13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5
and 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2,
13A.5 and 13A.6)
Self-employment (Complete 13A.3, 13A.5 and
13A.6)
State Government (Non-Federal employment)
(Complete 13A.2, 13A.5 and 13A.6)
Non-government employment (excluding self-
employment) (Complete 13A.2, 13A.5 and 13A.6)
Unemployment (Complete 13A.4)
Federal Contractor (Complete 13A.2,
13A.5 and 13A.6)
Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 22
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Provide the name of your supervisor.
Provide the position title of your supervisor.
Street
City
State
Country
Provide the address of employer.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide physical work location of your supervisor. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide telephone number
Extension
International or DSN phone number
Day Night
Entry #3
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
(b)
Is/was your physical work address different than your employer's address?
Provide telephone number
Extension
International or DSN phone number
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Day Night
YES NO (If NO, proceed to (b))
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Not
Applicable
From date (Month/Year)
To date (Month/Year)
Position Title Supervisor
Est. Est.
Est. Est.
Est. Est.
Est. Est.
Provide supervisor's telephone number.
Extension
NightDay
International or DSN phone number
Provide the email address of your supervisor.
I don't know
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Did/does your supervisor have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 23
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Last name
First name
Provide the address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
YES NO (If NO, proceed to (b))
Is your physical work address different than your employment address?
Provide the work address where you are/were physically located.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Provide the name of someone that can verify your self-employment.
Street
City
State
Country
Zip Code
Telephone number
Extension
International or DSN phone number
Provide the telephone number for this address.
Day Night
Street
City
State
Country
Provide address of this employment.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide telephone number.
Extension
International or DSN phone number
Day Night
Telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
13A.3 Complete the following if employment type is self-employment
Entry #3
(b)
(a)
Provide dates of employment. Select the employment status for
this position:
Part-time
Full-time
Provide the name of your employer.
Provide most recent position title.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
If you have indicated an APO/FPO address, complete (b.1). If you have indicated an address outside of the United States, complete (b.2).
Street Address/Unit/Duty Location
City or Post Name
State
Country
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and
Country if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(b.1)
(b.2)
YES
NO
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your self-employment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Last name
First name
Provide the name of someone that can verify your unemployment activities
and means of support.
Est.
Present
To Date
(Month/Year)
Est.
From Date
(Month/Year)
Provide dates of unemployment.
Provide address of this verifier.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street City
State
Country
Zip Code
Verifier telephone number
Extension
International or DSN phone number
Day Night
Provide the telephone number for this person.
Enter your Social Security Number before going to the next page
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Section 13A - Employment Activities - (Continued)
Provide the reason for leaving the employment activity.
YES NO (If NO, proceed to 13A.6)
For this employment have any of the following happened to you in the last seven (7) years?
Fired, quit after being told you would be fired, left by mutual agreement following charges or allegations of misconduct, left by mutual agreement following
notice of unsatisfactory performance.
Left by mutual agreement following
notice of unsatisfactory performance
Left by mutual agreement following
charges or allegations of misconduct
Quit after being told you would be
fired
Fired
Select your type of incident:
Provide the reason(s) for unsatisfactory performance.
Provide the charges or allegations of misconduct.
Provide the reason for quitting.
Provide the reason for being fired.
Reason:
Est.
Employment departure date
Provide the date you were fired.
(Month/Year)
Est.
Est.
Est.
Provide the date you left following charges or allegations
of misconduct.
(Month/Year)
Provide the date you quit after being told you would be
fired. (Month/Year)
Provide the date you left by mutual agreement following
a notice of unsatisfactory performance. (Month/Year)
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#1
#2
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Provide the reason(s) for being warned, reprimanded, suspended or disciplined.
Est.
Date:
(Month/Year)
Date: (Month/Year)
Est.
#3
#4
YES NO
For this employment, in the last seven (7) years have you received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as a violation of security policy?
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
Entry #3Entry #3Entry #3
13A.4 Complete the following if employment type is unemployment.
13A.6
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter.
(Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Does your unemployment verifier have an APO/FPO address?
(a)
(b)
YES
NO
Complete the following if employment type is Active Duty, National Guard/Reserve, USPHS Commissioned Corps, Other Federal employment, State
Government, Federal Contractor, Non-government employment, Self-Employment, or Other.
13A.5
Page 24
Page 25
Provide the name of your supervisor.
Provide the rank/position title of your supervisor.
Provide supervisor's telephone number.
Extension
Provide physical work location of your supervisor.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address; provide physical location data with either street address, base, post, embassy, unit, and country location or home
port/fleet headquarter.
(Provide physical location data)
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
NightDay
International or DSN phone number
Street
City
State
Country
Provide address of duty station. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Form approved:
OMB No. 3206 0005
Section 13A - Employment Activities
Enter your Social Security Number before going to the next page
Telephone number
Extension
International or DSN phone number
Day Night
Provide the email address of your supervisor.
I don't know
Entry #4
Entry #4
Est.
Provide dates of employment.
Select the employment status for
this position:
Part-time
Full-time
13A.1 Complete the following if employment type is Active Duty, National Guard/Reserve, or USPHS Commissioned Corps.
From Date
(Month/Year)
Est.
Present
To Date
(Month/Year)
Provide your most recent rank/position title.
Provide your assigned duty station during this period.
Select your employment activity:
Active military duty station (Complete 13A.1,
13A.5 and 13A.6)
National Guard/Reserve (Complete 13A.1, 13A.5
and 13A.6)
USPHS Commissioned Corps (Complete 13A.1,
13A.5 and 13A.6)
Other Federal employment (Complete 13A.2,
13A.5 and 13A.6)
Self-employment (Complete 13A.3, 13A.5 and
13A.6)
State Government (Non-Federal employment)
(Complete 13A.2, 13A.5 and 13A.6)
Non-government employment (excluding self-
employment) (Complete 13A.2, 13A.5 and 13A.6)
Unemployment (Complete 13A.4)
Federal Contractor (Complete 13A.2,
13A.5 and 13A.6)
Other (Provide explanation and complete 13A.2,
13A.5 and 13A.6)
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a). If you have indicated an address outside of the United States, complete (b).
Address
APO or FPO
APO/FPO State Code Zip Code
Zip Code
Provide physical location data with street address, base, post, embassy, unit, and country location or home port/fleet headquarter. (Provide City and Country
if outside the United States; otherwise, provide City, State and Zip Code for ports in the United States.)
Do you or did you have an APO/FPO address while at this location?
(a)
(b)
YES
NO
Page 26
Form approved:
OMB No. 3206 0005
QUESTIONNAIRE FOR
NATIONAL SECURITY POSITIONS
Standard Form 86
Revised December 2010
U.S. Office of Personnel Management
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 13A - Employment Activities - (Continued)
Additional Periods of Activity with this Employer - Provide additional periods of activity if you worked for this employer on more than one occasion at the
same physical location (for example, if you worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter information
concerning the most recent period of employment above, and provide dates, position titles, and supervisors for the two previous periods of employment
as entries below).
Provide the name of your supervisor.
Provide the position title of your supervisor.
Street
City
State
Country
Provide the address of employer.
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide physical work location of your supervisor. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Provide telephone number
Extension
International or DSN phone number
Day Night
Entry #4
13A.2 Complete the following if employment type is other federal employment, state government, federal contractor, non-government, or other.
(b)
Is/was your physical work address different than your employer's address?