Fillable Printable SF 86

SF 86

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

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.

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.

10.

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

10.

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

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

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

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

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

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

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

#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:

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)

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)

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

Address

APO or FPO

APO/FPO State Code Zip Code

Does the person who knew you have an APO/FPO address?(b)

YES

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

Address

APO or FPO

APO/FPO State Code Zip Code

Does the person who knew you have an APO/FPO address?(b)

YES

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

Address

APO or FPO

APO/FPO State Code Zip Code

Does the person who knew you have an APO/FPO address?(b)

YES