Supervisor Security
Resume:
MEMORANDUM FOR RECORD
RELEASE OF SECURITY INFORMATION
Per the National Industrial Security Program Operating Manuel (NISPOM)
Directive 2-202 (Procedures for Completing the SF 86), the SF 86 shall be
completed jointly by the employee and the FSO or an equivalent Mission
Essential Personnel, LLC security employee(s) who has been specifically
designated by Mission Essential Personnel, LLC to review an employee's SF
86. The SF 86 is subject to review and a Mission Essential Personnel, LLC
security employee shall review the application solely to determine its
adequacy and to ensure that necessary information has not been omitted.
Mission Essential Personnel, LLC shall maintain the retained documentation
in such a manner that the confidentiality of the documents is preserved and
protected against access by anyone within the company other than the FSO or
security designees'. When the applicant's eligibility for access to
classified information has been granted or denied, the retained
documentation shall be destroyed.
By signing below, I acknowledge the security information protection
measures outlined in this memorandum and give Mission Essential Personnel,
LLC permission to review, store and destroy my personal security
information outlined above.
Hussain Syed Kalbe
Last First Middle
5/15/10
Signature Date
SF86 WORKSHEET
PERSONS COMPLETING THIS FORM SHOULD BEGIN WITH THE QUESTIONS BELOW AFTER CAREFULLY
READING THE FOREGOING INSTRUCTIONS.
1 FULL NAME - If you have only initials in your name, use them and enter 2 DATE OF
(I/O) after the initial(s). - If you have no middle name, enter "NMN BIRTH
- If you are a "Jr.," "Sr.," etc. enter this in the box after your middle
name.
8/20/43
Last name First name Middle name Jr., II,
Hussain Syed Kalbe etc.
3 PLACE OF BIRTH 4 SOCIAL SECURITY NO.
City County Stat Country (if outside
e the U.S.)
5 OTHER NAMES USED Have you used any other names?
NO YES If "Yes," give other names used and the period of time you used them [for
example: your maiden name, name(s) by a former marriage, former name(s), alias(es),
or nickname(s)]. If the other name is your maiden name, put "maiden" in front of it.
Name #1 Month/Year TO
Month/Year
Name #2 Month/Year TO
Month/Year
Name #3 Month/Year TO
Month/Year
Name #4 Month/Year TO
Month/Year
6 MOTHER'S MAIDEN NAME
Last name First name Middle name
7 YOUR IDENTIFYING INFORMATION
Height (feet and Weight (pounds) Hair color Eye color Sex Female
inches)
Male
8 YOUR CONTACT INFORMATION Check box(es) indicating when you can be reached at each
phone number.
Home e-mail address Work e-mail address
Home telephone Day Work telephone number Day Mobile telephone Day
number number
Evening Evening Evening
9 CITIZENSHIP
U.S. PASSPORT Current or most recent passport ALIEN REGISTRATION NUMBER (if
applicable)
Number Date issued Expired YES Number
NO
Mark the box that reflects your current citizenship status and follow its
instructions.
I am a U.S. citizen or national by birth in I am a naturalized U.S. citizen. Go
the U.S. or U.S. territory/commonwealth. to 9B or 9C
I am a U.S. citizen or national by birth, born I am not a U.S. citizen. Go to 9D
outside the U.S. Go to 9A
9A DOCUMENTATION OF U.S. CITIZENS BORN ABROAD [STATE DEPARTMENT FORM (FS) 240, DS
1350, FS 545, etc.]
Report information, if applicable.
Date form was Document number Place of issuance
completed
9B CITIZENSHIP CERTIFICATE (if applicable)
Where was this certificate issued? City/Court Stat Certificate number Date issued
e
Enter your Social Security Number before going to the next page
9 CITIZENSHIP (Continued)
9C NATURALIZATION CERTIFICATE (if applicable)
Where was this certificate issued? City/Court Stat Certificate number Date issued
e
9D IMMIGRATION STATUS Place you entered the U.S.
City Stat Country(ies) of citizenship
e
Date of entry Type of document (I-94, Document number
etc.)
10 CITIZENSHIP INFORMATION
Do you now hold or have you EVER held YES
multiple citizenships?
NO Go to Question 11
A If "Yes," provide the name(s) of the B During what periods of time did you hold
country(ies). multiple citizenships?
C Is your non-U.S. citizenship based on your birth in a foreign country or the
citizenship of your parents? (If "No," explain.)
YES NO, explain
D Have you renounced or attempted to renounce your foreign citizenship(s)? (If "Yes,"
explain.)
YES NO, explain
11 WHERE YOU HAVE LIVED Use the Continuation Sheet(s) (SF 86A) or the Continuation
Space on page 17 for additional answers.
List the places where you have lived, beginning with your present residence (#1) and
working back 10 years or until your 16th birthday. Residences for the entire 10 year
period must be accounted for without breaks. Indicate the actual physical location of
your residence. Do not use a Post Office Box as an address and do not list a permanent
address when you were actually living at a school address, etc. Be sure to be as
specific as possible when listing an address location: for example, do not list only
your base or ship, list your barracks number or home port. You may omit temporary
military duty locations (TDY) under 90 days (list your address of record instead), but
you must list other part-time residences. Your actual physical location in addition to
your APO/FPO address is required for overseas assignments.
For any address in the last 5 years, list a person who knew you at that address, and
who preferably still lives in that area. Do not list people for residences completely
outside this 5-year period, and do not list your spouse, former spouse, or other
relatives. Also, for addresses in the last 5 years, if the address is "General
Delivery," a Rural or State Route, or may be difficult to locate, provide directions
for locating the residence on an attached continuation sheet (SF 86A). Do not list
residences before your 16th birthday unless to provide a minimum of 2 years of
residence history.
Residence Information and Point of Contact for that Period of Residence
#1 Month/Year TO Stat Own Military Street address Apt #
Month/Year us housing
Present
Rent Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
Enter your Social Security Number before going to the next page
11 WHERE YOU HAVE LIVED (Continued)
#2 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
#3 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
#4 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
Enter your Social Security Number before going to the next page
11 WHERE YOU HAVE LIVED (Continued)
#5 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
#6 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
#7 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
Enter your Social Security Number before going to the next page
11 WHERE YOU HAVE LIVED (Continued)
#8 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
#9 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
#10 Month/Year TO Stat Own Military Street address Apt #
Month/Year us Rent housing
Other
(Explain)
APO/FPO address
City (Country) State Zip code
Name of person who knows you at Current address Apt #
this address
APO/FPO address (if currently applicable)
City (Country) State Zip code
Telephone number Alternate Relations Neighbor Landlord Other (Explain)
contact number hip Business
Friend associate
Enter your Social Security Number before going to the next page
12 WHERE YOU WENT TO SCHOOL Use the Continuation Sheet(s) (SF 86A) or the Continuation
Space on page 17 for additional answers.
List all schools you have attended, beginning with the most recent (#1) working back
10 years. List college or university degrees and the dates they were received. If your
most recent degree or diploma was received more than 10 years ago, list it below no
matter when it was received.
In the Code block, show the most appropriate code to describe your school.
1 - High School
2 - College/University/Military College
3 - Vocational/Technical/Trade School
4 - Correspondence/Distance/Extension/Online School
For Correspondence/Distance/Extension/Online School, provide the address where the
records are maintained. For schools you attended in the last 3 years, list a person
who knew you at school (i.e. spouse, teacher, instructor, classmate, parent, neighbor,
or friend). Do not list people for education periods completed more than 3 years ago.
SCHOOL INFORMATION
#1 Month/Year TO Code Name of school Degree/diploma received? If YES
Month/Year "Yes," identify type of
degree/diploma received and
date awarded.
NO
Street address and City (Country) of school State Zip
code
Name of person who knows you Current address Apt #
City (Country) State Zip Telephone number
code
#2 Month/Year TO Code Name of school Degree/diploma received? If YES
Month/Year "Yes," identify type of
degree/diploma received and
date awarded.
NO
Street address and City (Country) of school State Zip
code
Name of person who knows you Current address Apt #
City (Country) State Zip Telephone number
code
#3 Month/Year TO Code Name of school Degree/diploma received? If YES
Month/Year "Yes," identify type of
degree/diploma received and
date awarded.
NO
Street address and City (Country) of school State Zip
code
Name of person who knows you Current address Apt #
City (Country) State Zip Telephone number
code
#4 Month/Year TO Code Name of school Degree/diploma received? If YES
Month/Year "Yes," identify type of
degree/diploma received and
date awarded.
NO
Street address and City (Country) of school State Zip
code
Name of person who knows you Current address Apt #
City (Country) State Zip Telephone number
code
Enter your Social Security Number before going to the next page
13 EMPLOYMENT ACTIVITIES Use the Continuation Sheet(s) (SF 86A) or the Continuation
Space on page 17 for additional answers.
List all your employment activities, beginning with the present (#1) and working back
10 years or until your 16th birthday. You should list all full-time and part-time
work, paid or unpaid, consulting/contracting work, all military service duty
locations, temporary military duty locations (TDY) over 90 days, self-employment,
other paid work, and all periods of unemployment. Indicate the actual physical
location of your employment. Do not use a Post Office Box as an address. The entire
period must be accounted for without breaks. EXCEPTION: Do not list employments that
occurred before your 16th birthday unless it is necessary for providing a minimum of 2
years of employment history. If you require space, use a continuation sheet (SF 86A).
Employer/Verifier Information. List the business name of your employer or the name of
a person who can verify your self-employment or unemployment in this block. If
military service is being listed, include your duty location or home port here as well
as your branch of service. You should provide separate listings to reflect changes in
your military duty locations or home ports. If you are a Federal Contractor, list
company name, not Federal agency.
Additional Periods of Activity. Complete this block if you worked for an employer on
more than one occasion at the same physical location. After entering the most recent
period of employment in the initial numbered block, provide previous periods of
employment at the same location on the additional lines provided. For example, if you
worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would
enter dates and information concerning the most recent period of employment first, and
provide dates, position titles, and supervisors for the two previous periods of
employment on the lines below that information.
Employment Code: Use one of the codes listed below to identify the type of employment.
1 - Active military duty stations
2 - National Guard/Reserve
3 - U.S.P.H.S. Commissioned Corps
4 - Other Federal employment
5 - State Government (Non-Federal employment)
6 - Self-employment (include business name and/or name of person who can verify)
7 - Unemployment (include name of verifier)
8 - Federal Contractor
9 - Other (explain)
13A EMPLOYMENT/UNEMPLOYMENT INFORMATION
#1 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Present Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
Enter your Social Security Number before going to the next page
13 EMPLOYMENT ACTIVITIES (Continued)
#2 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
#3 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Enter your Social Security Number before going to the next page
13 EMPLOYMENT ACTIVITIES (Continued)
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
#4 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
Enter your Social Security Number before going to the next page
13 EMPLOYMENT ACTIVITIES (Continued)
#5 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
#6 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Enter your Social Security Number before going to the next page
13 EMPLOYMENT ACTIVITIES (Continued)
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
#7 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
Enter your Social Security Number before going to the next page
13 EMPLOYMENT ACTIVITIES (Continued)
#8 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
#9 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Enter your Social Security Number before going to the next page
13 EMPLOYMENT ACTIVITIES (Continued)
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
#10 Dates of Type of Employment
Employment
Month/Year TO Employment Position title/Military rank Work Full-time
Month/Year code hours
Part-time
Employer/Verifier
Name of employer/verifier Telephone number
Address of employer/verifier
City (Country) State Zip code
Physical Location
Your actual work address (if different from employer address) Telephone number
City (Country) State Zip code
Supervisor (if different from employer)
Name and title Telephone number
Work address of supervisor
City (Country) State Zip code
Additional Periods of Activity with this Employer
Month/Year TO Position title Supervisor
Month/Year
Month/Year TO Position title Supervisor
Month/Year
Explanation/Reason for leaving
Enter your Social Security Number before going to the next page
13B FORMER FEDERAL SERVICE, EXCLUDING MILITARY SERVICE, NOT INDICATED PREVIOUSLY (list
below if applicable)
Dates of Federal Agency/City (Country)/State/ZIP Code Position Title
Service
Month/Year TO
Month/Year
1.
2.
3.
13C EMPLOYMENT RECORD YES NO
1. Has any of the following happened to you in the last 7 years? If "Yes,"
begin with the most recent occurrence and go backward, providing date fired,
quit, or left, and other information requested.
Use the following codes and explain the reason your employment was ended.
1 - Fired from a job 4 - Left a job by mutual agreement following notice of
unsatisfactory performance
2 - Quit a job after being told you would be fired 5 - Left a job for other reasons
under unfavorable circumstances
3 - Left a job by mutual agreement following charges or 6 - Laid off from job by
employer
allegations of misconduct
Month/Y Code Specify Reason Employer's Name and Address State ZIP
ear (Include City/Country if Code
outside U.S.)
YES NO
2. Have you received a written warning, been officially reprimanded,
suspended, or disciplined for misconduct in the workplace?
3. Have you received a written warning, been officially reprimanded,
suspended, or disciplined for violating a security rule or policy?
If you answered "Yes," to 13C(2) and/or 13C(3), provide the name(s) of the
employer(s), date(s) of incident(s), month/day/year of official action(s), location(s)
or facility(ies) of incident(s), and the nature of the violation(s) in the space
below. If additional space is needed, use a blank sheet(s) of paper.
14 SELECTIVE SERVICE RECORD YES NO
a Are you a male born after December 31, 1959? If "No," go to Question 15.
If "Yes," go to b.
b Have you registered with the Selective Service System (SSS)? If "Yes,"
provide your registration number below. If "No," explain the reason for not
registering below. Please consult the SSS if you are unaware of your status
before signing this form.
Registration Explanation
Number
Enter your Social Security Number before going to the next page
15 MILITARY HISTORY Account for all of your military service through the YES NO
questions below. If you answer "No" to both 15a and 15b, go to Question 16.
a Have you EVER served in the U.S. military or the U.S. Merchant Marine?
b Have you EVER served in a foreign country's military, security forces,
merchant marine, militia, or other defense forces?
c Have you EVER received a discharge that was not honorable?
d In the last 7 years, have you been subject to court martial or other
disciplinary proceedings under the Uniform Code of Military Justice?
(Include non-judicial, Captain's mast, etc.) If "Yes," provide date(s),
charge(s), military court(s) or authority(ies), and outcome(s).
If you answered "Yes" to any question above, list all details of your
military service below, starting with the most recent period of service and
working back. If you had a break in service, each separate time of service
should be listed.
Code (Branch of Service): Use one of the codes listed below to identify
your branch of service.
1 - Air Force 3 - Navy 5 - Coast Guard 7 - Air National Guard
(NG) 9 - Foreign military, defense, militia, security forces
2 - Army 4 - Marine Corps 6 - Merchant Marine 8 - Army NG
O/E: Mark "O" block for Officer or "E" block for Enlisted, if applicable.
Status: "X" the appropriate block for the status of your service during
the time that you served. If your service was in the National Guard, do
not use an "X": use the two-letter code for the state to mark the block.
Country: Identify the country for which you served.
Code (Type of Discharge): Use one of the codes listed below to indicate
your separation status from your military service.
1 - Honorable 2 - Dishonorable 3 - Other Than Honorable 4 - General 5
- Bad Conduct 6 - Other (Explain)
Branch of Service Code
List three people who know you well and who preferably live in the U. S. They should
be friends, peers, colleagues, college roommates, associates, etc., who are
collectively aware of your activities outside of the workplace, school, or
neighborhoods and whose combined association with you covers at least the last 7
years. Do not list your spouse, former spouse(s), other relatives, or anyone listed
elsewhere on this form.
Reference name Dates known Relationship to you Telephone
#1 Month/Year To (Check all that apply) number
Month/Year Neighbor Work
associate Day Evening
Friend Schoolmate
Other (Explain)
Home or work address Apt # City (Country) State ZIP Alternate
Code phone no.
Reference name Dates known Relationship to you Telephone
#2 Month/Year To (Check all that apply) number
Month/Year Neighbor Work
associate Day Evening
Friend Schoolmate
Other (Explain)
Home or work address Apt # City (Country) State ZIP Alternate
Code phone no.
Reference name Dates known Relationship to you Telephone
#3 Month/Year To (Check all that apply) number
Month/Year Neighbor Work
associate Day Evening
Friend Schoolmate
Other (Explain)
Home or work address Apt # City (Country) State ZIP Alternate
Code phone no.
Enter your Social Security Number before going to the next page
17 MARITAL STATUS
Mark one box to show your current marital status and provide information about your
spouse(s) or cohabitant below. If there is not a middle name, enter as "NMN."
1 - Never married 3 - Separated 5 - Divorced
2 - Married (incl. Common Law) 4 - Annulled 6 - Widowed
17A CURRENT SPOUSE If applicable, complete the following about your current spouse
only. If your current spouse was born outside the U.S., provide citizenship
information
Last name First name Middle name Date of City/State of birth (include
birth Country if outside U.S.)
Social Security Other names used (specify maiden name, names by other marriages,
Number etc., and show dates used for each name)
Country(ies) of citizenship Date married
Place married (City, include Country if outside the U.S.) State
If separated, date If legally separated, where is the record State Zip
of separation located? City (Country)
Current address of spouse, if different than your State Zip Telephone
current address (Street, City, include Country if Number
outside the U.S.)
If spouse was born outside the U.S. indicate all types of documentation that he or she
possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other (Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization certificate
Document number Explain "Other"
17B FORMER SPOUSE(S) Complete the following about your former spouse(s). Use blank
sheets if needed.
Last name First name Middle name Date of
birth
City/State of birth (include Country State Country(ies) of citizenship
if outside the U.S.)
Date married Place married (City, include Country if State
(MM/YYYY) outside the U.S.)
Check one, then give Date If divorced/annulled, where is the State ZIP Code
date: record located? City (Country)
Divorced Widowed
Annulled
Last known address of former spouse (Street, City, State Zip Telephone
include Country if outside the U.S.) Number
17C COHABITANT [A cohabitant is a person with whom you share bonds of affection,
obligation, or other commitment, as opposed to a person with whom you live for reasons
of convenience (a roommate)]. If applicable, complete the following about your
cohabitant. If your cohabitant was born outside the U.S., provide citizenship
information.
Last name First name Middle name Date of City/State of birth (include
birth Country if outside U.S.)
Social Security Other names used (specifically maiden names, names by other
Number marriages, etc., and show dates used for each name)
Country(ies) of citizenship Date cohabitation began
If cohabitant was born outside the U.S. indicate all types of documentation that he or
she possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other (Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization certificate
Document number Explain "Other"
Enter your Social Security Number before going to the next page
18 RELATIVES
Relative Code - Use one of the following codes (1-16) listed below for each relative
and give the full name and other requested information, if applicable, for each of
your relatives, living or deceased, specified below.
1 - Mother 5 - Foster parent 9 - Sister 13 - Half-sister
2 - Father 6 - Child (incl. adopted and foster) 10 - Stepbrother 14 -
Father-in-law
3 - Stepmother 7 - Stepchild 11 - Stepsister 15 - Mother-in-law
4 - Stepfather 8 - Brother 12 - Half-brother 16 - Guardian
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
1
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document Number
documentation that he or she possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
2
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document Number
documentation that he or she possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document Number
documentation that he or she possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document Number
documentation that he or she possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document Number
documentation that he or she possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document Number
documentation that he or she possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document Number
documentation that he or she possesses and the document numbers.
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Enter your Social Security Number before going to the next page
18 RELATIVES (Continued)
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document
documentation that he or she possesses and the document numbers. Number
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document
documentation that he or she possesses and the document numbers. Number
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document
documentation that he or she possesses and the document numbers. Number
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document
documentation that he or she possesses and the document numbers. Number
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document
documentation that he or she possesses and the document numbers. Number
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document
documentation that he or she possesses and the document numbers. Number
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Code Full name Deceased Date of City/State of birth (include Country of
birth Country if outside U.S.) citizenship
Current address (Street, City, State and Zip Code, include Country if outside the
U.S.)
If relative was born outside the U.S. indicate all types of Document
documentation that he or she possesses and the document numbers. Number
FS 240 or 545 Citizenship certificate Alien registration Other
(Explain)
DS 1350 U.S. Passport (current or most recent) Naturalization
certificate
Enter your Social Security Number before going to the next page
19 FOREIGN CONTACTS
Do you have or have you had close and/or continuing contact with foreign nationals
within the last 7 years with whom you, your spouse, or your cohabitant are bound by
affection, influence, and/or obligation? Include associates, as well as relatives, not
already listed in Question 18. (A foreign national is defined as any person who is not
a citizen or national of the U.S.) YES NO
1. Full name Dates known Country(ies) of citizenship Pakistan
Syed Agha Hussain Month/Year To
Month/Year
01/50 5/10 Country of residence Pakistan
Nature of relationship Type of contact (check all that apply) Number of
Cousin Telephone Electronic correspondence Other contacts per year
(Explain)
In person Written correspondence 1-2 3-7
8-15 More than
15
2. Full name Dates known Country(ies) of citizenship
Month/Year To
Month/Year
Country of residence
Nature of relationship Type of contact (check all that apply) Number of
Telephone Electronic correspondence Other contacts per year
(Explain)
In person Written correspondence 1-2 3-7
8-15 More than
15
3. Full name Dates known Country(ies) of citizenship
Month/Year To
Month/Year
Country of residence
Nature of relationship Type of contact (check all that apply) Number of
Telephone Electronic correspondence Other contacts per year
(Explain)
In person Written correspondence 1-2 3-7
8-15 More than
15
4. Full name Dates known Country(ies) of citizenship
Month/Year To
Month/Year
Country of residence
Nature of relationship Type of contact (check all that apply) Number of
Telephone Electronic correspondence Other contacts per year
(Explain)
In person Written correspondence 1-2 3-7
8-15 More than
15
20 FOREIGN ACTIVITIES Respond for the time frame of the last 7 years.
20A Foreign Financial Interests Include stocks, personal property, company YES NO
shares, investments, or ownership of corporate entities. Exclude U.S.-based
fund managers and accounts managed through your employer.
1. Do you have or have you EVER had any foreign financial businesses, foreign
bank accounts, or other foreign financial interests of which you have direct
control or direct ownership?
Type of financial interest Amount of funds in U.S. dollars
2. Do you have or have you had any foreign financial interests that someone
controls on your behalf?
Type of financial interest Amount of funds in U.S. dollars
3. Do you own or have you owned real estate in a foreign country?
Type of property and date(s) Location of property Estimated value of
owned property in U.S. dollars
4. Do you receive or have you received any educational, medical, retirement,
social welfare, or other such benefits from a foreign country?
Type of benefit Estimated value in U.S.
dollars
20B Foreign Business, Professional Activities, and Foreign YES NO Official
Government Contacts Respond for the time frame of the last 7 years, Govt.
unless otherwise noted. Indicate if activity was on official U.S. Business
Government business
1. Have you provided advice or support to anyone associated with a
foreign business or other foreign organization that you have not
previously listed as a former employer regarding any of the
following: management, strategy, financing, or technology?
If "Yes" AND the activity was outside of official U.S. Government business, describe
advice/support provided, name(s) of foreign national and/or organization(s) to which
it was provided, the name(s) of foreign country(ies), timeframe(s), and if
compensation was provided.
2. Have you attended any international conferences, trade shows,
seminars, or other meetings outside of the U.S.?
If "Yes" AND the activity was outside of official U.S. Government business, provide
locations, including the name(s) of foreign country(ies), date(s), sponsoring
organization(s), and purpose of event(s).
Enter your Social Security Number before going to the next page
20B Foreign Business, Professional Activities, and Foreign YES NO Official
Government Contacts (Continued) Respond for the time frame of the Govt.
last 7 years, unless otherwise noted. Indicate if activity was on Business
official U.S. Government business
3. Have you or any of your immediate family members been asked to
provide advice or serve as a consultant, even informally, by any
foreign government official or agency?
If "Yes" AND the activity was outside of official U.S. Government business, provide
the date(s) of request and/or consultation(s), including the name(s) of foreign
country(ies), location of consultation(s), and circumstance(s).
4. Have you or any of your immediate family members had any contact
with a foreign government, its establishment (embassies, consulates,
agencies, or military services), or its representatives, whether
inside or outside the U.S.?
Answer "No" if the contact was for routine visa applications and border crossings
related to either official U.S. Government travel or foreign travel listed below in
Question 20C. If contact was outside of official U.S. Government business, identify
the foreign government(s), establishment(s), and/or representative(s) involved and
provide the circumstance(s), date(s), and location(s) of contact(s).
5. Have you sponsored any foreign citizen to come to the U.S. as a
student, for work, or for permanent residence?
If "Yes," provide the name of the foreign citizen(s) you sponsored, the country(ies)
of citizenship, the date(s) of the foreign citizen's stay in the U.S., their current
address (if known), and the purpose of the foreign citizen's stay in the U.S.
6. Have you EVER held or do you now hold a passport that was issued
by a foreign government?
If "Yes," provide the name(s), in which your foreign passport(s) was issued, the
issuing country(ies), the passport number(s), the date(s) issued, the expiration
date(s), and the status of each.
20C Foreign Countries You Have Visited Respond for the time frame of the last YES NO
7 years.
Have you traveled outside the U.S. in the last 7 years?
Respond for foreign countries you have visited in the last 7 years, beginning with the
most current and working back. If you have lived near a border and have made short
(one day or less) trips to the neighboring country (e.g. Canada or Mexico), you do not
need to list each trip. Instead, provide the time period, the code, the country, and a
note ("Many Short Trips"). Do not list travel under official U.S. Government business,
but you must include any personal trips made in conjunction with the official U.S.
Government travel.
Use these codes to indicate the purpose(s) of your visit: 1 - Business/Professional
conference 3 - Education 5 - Visit family or friends
2 - Volunteer activities 4 - Tourism 6 - Other
Code
Mental health counseling in and of itself is not a reason to revoke or deny a YES NO
clearance. In the last 7 years, have you consulted with a health care
professional regarding an emotional or mental health condition or were you
hospitalized for such a condition? Answer "No" if the counseling was for any
of the following reasons and was not court-ordered:
1) strictly marital, family, grief not related to violence by you; or
2) strictly related to adjustments from service in a military combat
environment.
If you answered "Yes," indicate who conducted the treatment and/or counseling, provide
the following information, and sign the Authorization for Release of Medical
Information Pursuant to the Health Insurance Portability and Accountability Act
(HIPAA).
Dates of Treatment Name/Address of Provider State ZIP
and/or Counseling Code
Month/Year To
Month/Year
#1
#2
Enter your Social Security Number before going to the next page
22 POLICE RECORD
For this item, report information regardless of whether the record in your case has
been sealed, expunged, or otherwise stricken from the court record, or the charge was
dismissed. You need not report convictions under the Federal Controlled Substances Act
for which the court issued an expungement order under the authority of 21 U.S.C. 844
or 18 U.S.C. 3607. Be sure to include all incidents whether occurring in the U.S. or
abroad.
For questions a and b, respond for the timeframe of the last 7 years (if an YES NO
SSBI go back 10 years). Exclude any fines of less than $300 for traffic
offenses that do not involve alcohol or drugs.
a. Have you been issued a summons, citation, or ticket to appear in court in a
criminal proceeding against you; are you on trial or awaiting a trial on
criminal charges; or are you currently awaiting sentencing for a criminal
offense?
b. Have you been arrested by any police officer, sheriff, marshal, or any
other type of law enforcement officer?
c Have you EVER been charged with any felony offense? (Include those under
Uniform Code of Military Justice.)
d Have you EVER been charged with a firearms or explosives offense?
e Have you EVER been charged with any offense(s) related to alcohol or drugs?
If you answered "Yes" to any question above, explain below, providing information for
each and every offense.
Month/Year
The following questions pertain to the illegal use of drugs or drug activity. YES NO
You are required to answer the questions fully and truthfully, and your
failure to do so could be grounds for an adverse employment decision or action
against you. Neither your truthful responses nor information derived from your
responses will be used as evidence against you in any subsequent criminal
proceeding.
a. In the last 7 years, have you illegally used any controlled substance, for
example, cocaine, crack cocaine, THC (marijuana, hashish, etc.), narcotics
(opium, morphine, codeine, heroin, etc.), stimulants (amphetamines, speed,
crystal methamphetamine, Ecstacy, ketamine, etc.), depressants (barbiturates,
methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.),
steroids, inhalants (toluene, amyl nitrate, etc.) or prescription drugs
(including painkillers)? Use of a controlled substance includes injecting,
snorting, inhaling, swallowing, experimenting with or otherwise consuming any
controlled substance.
b. Have you EVER illegally used a controlled substance while possessing a
security clearance; while employed as a law enforcement officer, prosecutor,
or courtroom official; or while in a position directly and immediately
affecting the public safety?
c. In the last 7 years, have you been involved in the illegal possession,
purchase, manufacture, trafficking, production, transfer, shipping, receiving,
handling, or sale of any controlled substance (see question a above) including
prescription drugs?
d. In the last 7 years, have you received counseling or treatment or have you
been ordered, advised, or asked to seek counseling or treatment as a result of
your use of drugs? If you answered "Yes," provide date(s) of treatment and
name(s) and address(es) of provider(s). You will be asked to sign an
additional release if information is needed concerning any treatment.
If you answered "Yes" to a - d above, provide the date(s) of use or activity,
identify the controlled substance(s), and explain the use or activity.
Dates of Type of Controlled Explain (nature of use/activity, frequency
Use/Activity Substance(s) of activity and number of times used)
Month/Year To
Month/Year
#1
#2
#3
#4
24 USE OF ALCOHOL Respond for the time frame of the last 7 years. YES NO
a. Has your use of alcohol had a negative impact on your work performance,
your professional or personal relationships, your finances, or resulted in
intervention by law enforcement/public safety personnel? (If "Yes," explain.)
b. Have you been ordered, advised, or asked to seek counseling or treatment as
a result of your use of alcohol?
c. Have you received counseling or treatment as a result of your use of
alcohol?
If you answered "Yes" to question b or c above, provide the date(s) of treatment and
the name(s) and address(es) of the counselor(s) or doctor(s) below. Do not repeat
information reported in response to Question 21. You will be asked to sign an
additional release if information is needed concerning any treatment.
Month/Year To Name/Address of Counselor or Doctor State Zip Code
Month/Year
#1
#2
Enter your Social Security Number before going to the next page
25 INVESTIGATIONS AND CLEARANCE RECORD YES NO
a. Has the U.S. Government or a foreign government EVER investigated your
background and/or granted you a security clearance? If "Yes," use the codes
that follow to provide the requested information below. If "Yes," but you
can't recall the investigating agency and/or the security clearance received,
enter the code for "Unknown." If your response is "No," or you don't know or
can't recall if you were investigated and cleared, check the "No" box.
Investigating Agency Codes Security Clearance Codes
1 - Defense Department 5 - Treasury 0 - Not Required 5 - Q
Department 1 - Confidential 6 - L
2 - State Department 6 - Department of 2 - Secret 7 - Issued by foreign country
Homeland Security 3 - Top Secret (specify country)
3 - Office of Personnel 7 - Foreign 4 - Sensitive Compartmented 8 - Unknown
government (specify country Information 9 - Other (explain below)
Management 8 - Unknown
4 - Federal Bureau of 9 - Other (explain
below)
Investigation
Month/Y Agency Foreign Government or Other Agency Clearan
ear Code (If necessary) ce Code
#1
#2
#3
#4
b. To your knowledge, have you EVER had a clearance or access authorization YES NO
denied, suspended, or revoked; or been debarred from government employment? If
"Yes," give the action(s), date(s) of action(s), agency(ies), and
circumstances. Note: An administrative downgrade or termination of a security
clearance is not a revocation.
Month/Y Department or Agency Taking Circumstances
ear Action
#1
#2
#3
26 FINANCIAL RECORD YES NO
For the following, answer for the last 7 years, unless otherwise specified in
the question. Disclose all financial obligations, including those for which
you are a cosigner or guarantor, on the following page.
a Have you filed a petition under any chapter of the bankruptcy code? If
"Yes," indicate type.
b Have you had any possessions or property voluntarily or involuntarily
repossessed or foreclosed?
c Have you failed to pay Federal, state, or other taxes, or to file a tax
return, when required by law or ordinance?
d Have you had a lien placed against your property for failing to pay taxes or
other debts?
e Have you had a judgment entered against you?
f Have you defaulted on any type of loan?
g Have you had bills or debts turned over to a collection agency?
h Have you had any account or credit card suspended, charged off, or cancelled
for failing to pay as agreed?
i Have you been evicted for non-payment of financial obligations?
j Have you been delinquent on court-imposed alimony or child support payments?
k Have you had your wages, benefits, or assets garnished or attached for any
reason?
l Have you been counseled, warned, or disciplined for violating terms of
agreement for a travel or credit card provided by your employer?
m Have you been over 180 days delinquent on any debt(s)?
n Are you currently over 90 days delinquent on any debt(s)?
o Have you EVER experienced financial problems due to gambling?
p Are you currently delinquent on any Federal debt?
Enter your Social Security Number before going to the next page
26 FINANCIAL RECORD (Continued)
For the following, answer for the last 7 years, unless otherwise specified in the
question. Disclose all financial obligations, including those for which you are a
cosigner or guarantor. If you answered "Yes" on the previous page (a-p), provide the
information requested below. For each "Yes" answer, provide the corresponding letters.
Indica Date Amount of Loan/Account Names of Agency/Organization/Individual
te Satisfied Property Number/Bankruptc to Whom Debt is/was Owed
(a-p) Month/Yea Value y Type
r Involved
#1 8/08 2700 013******* St Lukes Hospital
Name/Address of Company, Court, or Agency Name Action/Debt is Status of Action
Handling Case Recorded Under or Debt
3500 Depauw Blvd Ste 3050 State Zip Senex Services Paid, Closed
46268
IN
Indica Date Amount of Loan/Account Names of Agency/Organization/Individual
te Satisfied Property Number/Bankruptc to Whom Debt is/was Owed
(a-p) Month/Yea Value y Type
r Involved
#2
Name/Address of Company, Court, or Agency Name Action/Debt is Status of Action
Handling Case Recorded Under or Debt
State Zip
Indica Date Amount of Loan/Account Names of Agency/Organization/Individual
te Satisfied Property Number/Bankruptc to Whom Debt is/was Owed
(a-p) Month/Yea Value y Type
r Involved
#3
Name/Address of Company, Court, or Agency Name Action/Debt is Status of Action
Handling Case Recorded Under or Debt
State Zip
Indica Date Amount of Loan/Account Names of Agency/Organization/Individual
te Satisfied Property Number/Bankruptc to Whom Debt is/was Owed
(a-p) Month/Yea Value y Type
r Involved
#4
Name/Address of Company, Court, or Agency Name Action/Debt is Status of Action
Handling Case Recorded Under or Debt
State Zip
Indica Date Amount of Loan/Account Names of Agency/Organization/Individual
te Satisfied Property Number/Bankruptc to Whom Debt is/was Owed
(a-p) Month/Yea Value y Type
r Involved
#5
Name/Address of Company, Court, or Agency Name Action/Debt is Status of Action
Handling Case Recorded Under or Debt
State Zip
Indica Date Amount of Loan/Account Names of Agency/Organization/Individual
te Satisfied Property Number/Bankruptc to Whom Debt is/was Owed
(a-p) Month/Yea Value y Type
r Involved
#6
Name/Address of Company, Court, or Agency Name Action/Debt is Status of Action
Handling Case Recorded Under or Debt
State Zip
Indica Date Amount of Loan/Account Names of Agency/Organization/Individual
te Satisfied Property Number/Bankruptc to Whom Debt is/was Owed
(a-p) Month/Yea Value y Type
r Involved
#7
Name/Address of Company, Court, or Agency Name Action/Debt is Status of Action
Handling Case Recorded Under or Debt
State Zip
Indica Date Amount of Loan/Account Names of Agency/Organization/Individual
te Satisfied Property Number/Bankruptc to Whom Debt is/was Owed
(a-p) Month/Yea Value y Type
r Involved
#8
Name/Address of Company, Court, or Agency Name Action/Debt is Status of Action
Handling Case Recorded Under or Debt
State Zip
Enter your Social Security Number before going to the next page
27 USE OF INFORMATION TECHNOLOGY SYSTEMS
The following questions ask about your use of information technology systems. YES NO
Information technology systems include all related computer hardware,
software, firmware, and data used for the communication, transmission,
processing, manipulation, storage, or protection of information. You are
required to answer the questions fully and truthfully, and your failure to do
so could be grounds for an adverse employment decision or action against you.
Neither your truthful responses nor information derived from your responses
will be used as evidence against you in any subsequent criminal proceeding.
a. In the last 7 years, have you illegally or without proper authorization
entered into any information technology system?
b. In the last 7 years, have you illegally or without authorization modified,
destroyed, manipulated, or denied others access to information residing on an
information technology system?
c. In the last 7 years, have you introduced, removed, or used hardware,
software, or media in connection with any information technology system
without authorization, when specifically prohibited by rules, procedures,
guidelines, or regulations?
Date of Nature of Location Incident Took Action Taken
Incident Incident/Offense Place
(Month/Year)
#1
#2
28 INVOLVEMENT IN NON-CRIMINAL COURT ACTIONS YES NO
In the last 7 years (if an SSBI go back 10 years), have you been a party to
any public record civil court action(s) not listed elsewhere on this form?
If you answered "Yes," provide the information about each public record civil court
action(s) requested below.
Month/Y Nature of Result of Name of Principal Court Information
ear Action Action Parties Involved (if
more space is needed,
use Continuation Space
on page 17)
#1 Court name
Street address
City
Street address
The following questions pertain to your associations. You are required to YES NO
answer the questions fully and truthfully, and your failure to do so could be
grounds for an adverse employment decision or action against you. For the
purpose of this question, terrorism is defined as any criminal acts that
involve violence or are dangerous to human life and appear to be intended to
intimidate or coerce a civilian population to influence the policy of a
government by intimidation or coercion, or to affect the conduct of a
government by mass destruction, assassination or kidnapping.
a. Have you EVER been an officer or a member of, or made a contribution to, an
organization dedicated to terrorism, and which engaged in illegal activities
to that end, either with an awareness of the organization's dedication to that
end or with the specific intent to further such illegal activities?
b. Have you EVER been an officer or a member of, or made a contribution to, an
organization dedicated to the use of violence or force to overthrow the U.S.
Government, and which engaged in illegal activities to that end, either with
an awareness of the organization's dedication to that end or with the specific
intent to further such illegal activities?
c. Have you EVER been an officer or a member of, or made a contribution to, an
organization that unlawfully advocates or practices the commission of acts of
force or violence to discourage others from exercising their rights under the
U.S. Constitution or any state of the U.S. with the specific intent to further
such unlawful activities?
d. Have you EVER advocated any acts of terrorism or activities designed to
overthrow the U.S. Government by force with the specific intent to incite
others to unlawful action in furtherance of such aims?
e. Have you EVER knowingly engaged in any activities designed to overthrow the
U.S. Government by force?
f. Have you EVER knowingly engaged in any acts of terrorism? Neither your
truthful response nor information derived from your response to this question
will be used as evidence against you in any subsequent criminal proceeding.
g. Have you EVER participated in militias (not including official state
government militias) or paramilitary groups?
If you answered "Yes" to any of the questions above, explain on the following page.
Enter your Social Security Number before going to the next page
CONTINUATION SPACE
Use the continuation sheet(s) (SF 86A) for additional answers for items 11, 12, and
13. Use the space below to continue answers to all other items and to provide any
information you would like to add. If more space is needed than is provided below, use
a blank sheet(s) of paper. Start each sheet with your name and SSN. Before each
answer, identify the number of the item and try to maintain question format.
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