AIR-SPACE-CYBERSPACE

AIR FORCE RECRUITING

Air Force Application Package

THIS APPLICATION IS DUE BACK TO YOUR

RECRUITER BY:

Accurate, legible, and detailed information in this application will ensure there are no delays in your process!
Read every section carefully and be truthful

Americas Air Force

AIRFORCE.COM

AIRFORCE.COM

Information in this packet is subject to the Privacy Act of 1974 and is for official use only

Applicant PIR Worksheet

BRIEFING ITEMS

PROCESSING PROGRAMS
Program

Sub Program

Specialty

Briefed on Privacy Act

Regerstered to Vote

Reviewed Applicable Films

DD Form 2644
DD Form 2645

DEMOGRAPHICS
Gender

Lead Source

Verified SSN

Lead Date:

Name (Last, First, MI, Maiden, Suffix):

Maiden Name / Alias / Other Names

Alien Registration:

Citzenship:
Race:

Ethnicity:

Hair Color:

Eye Color:

#:

Religious Preferences:
Height / Weight:

Contact #

Date of Birth

Foreign Languages:

Selective Service #:

Current Address:

Email

Home of Record:
Driver's License #:

ST:

Expiration Date:
Place of Birth (City, St, Country):
CCMAPPEDDS Verification (Y/N):

Additional Comments:
Y

Citizenship

Prior Service

Conscientious Objector

Education

Morals

Dependents

Age

Drugs

Physical

SSN Verified

Waivers Required to join

Civil Court

PERPETUATED LEADS:

Medical Hx:

Navigate to: (Digital App Only)

Marital Status/Dependents
Morals
Financial Records

Law violations:

Education
Drug Use
Prior Service Records

Drugs:

Additional Residence

Law Violations
(Completed by the applicant)
Date

Instructions The applicant is the primary source of information about criminal activities and law violations. Record
all law violations (to include juvenile and minor traffic offenses regardless of disposition) all court documents the
applicant can provide and include legible copies (for estimated dates select "est")
Violation or Charge

Place(City/ST/ZIP)

Court Type

Disposition/Final Result

1
2
3
4
5
6
7
8
9
10

Drug Use History

(Completed by the applicant)
Type of Drug

Instructions The applicant is the primary source of information about past or present drug use. Answer Yes/No to initial 7
questions. (If yes, to question 1 thru 6, complete section 2. If yes, to question 7, complete section 2 & 3) For estimated
dates select "est"

Date of First Use

Date of Last Use

EST

EST

EST

EST

EST

EST

Nature/Frequency/Ingestion

# of Uses

Name Use:

Name Use

Instructions Record your Entrance Name and any other names you may have gone by. Record must include
"birth" name or "maiden" name for married females (select "EST" for Estimated date)

(Completed by the applicant)

Reason (Must be Birth, Marriage, Decree, Maiden, Preference, or Other) you went by that name. Record
the date that you first used the name and the date you last used the name.

First

Last

Middle

Suffix

Reason
(see above)

First Used

Last Used
EST

EST

EST

EST

EST

EST

U.S. Passport Information

1. Do you possess a U.S. passport (current or expired)?
Date Issued:
US Passport
Information

Expiration Date:

Passport Number:
Name Issued Under (First Last Middle):

Citizenship:
Select One:

U.S citizen By Birth

U.S citizen By Birth Abroad

US Naturalized

US Non- Citizen

Res Alien

1. Do you now or have you EVER held dual/multiple citizenships?

YES

2. Have you EVER been issued a passport (or identity card for travel) by a country other than the
U.S.?

YES

NO
NO

Residence History:

Residence
History

Instructions List the places where you have lived, beginning with the most recent and working back 10 years. All periods must be
accounted for in your list. Be sure to indicate the actual physical location of your residence. Do not use a post office box as an
address. Do not list a permanent address when you were actually living at a school address, etc. Be sure to specify your location as
closely as possible: For example Do not list only your base or ship. List your barracks number or home port. You may omit
temporary military duty locations less than 90 days (list your permanent address instead), and you should use your APO/FPO address
if you lived overseas. NOTE: 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 references for addresses completely outside the 5-year period, and do not list your spouse, former
spouse, or other relatives). Provide Directions for addresses in the last 5 years if the address is General Delivery, a Rural or Star
Route, or may be difficult to locate. (select "EST" for Estimated dates)

From Date

To Date
EST

Resident Type (rent/own

/military/other)
Date Last Contacted

City/Postal Code

Street Address

Present
Name of Person who knew you (First Last, Mid, Suffix)

Relationship (neighbor, landlord, friend, work assoc, other)

Phone # (or list Dont Know)

Email (or list Dont Know)

EST
Street Address

From Date

City/Postal Code

To Date
EST

Resident Type (rent/own

/military/other)
Date Last Contacted

City/Postal Code

Street Address

EST
Name of Person who knew you (First Last, Mid, Suffix)

Relationship (neighbor, landlord, friend, work assoc, other)

Phone # (or list Dont Know)

Email (or list Dont Know)

EST
Street Address

From Date

City/Postal Code

To Date
EST

Resident Type (rent/own

/military/other)
Date Last Contacted

City/Postal Code

Street Address

EST
Name of Person who knew you (First Last, Mid, Suffix)

Relationship (neighbor, landlord, friend, work assoc, other)

Phone # (or list Dont Know)

Email (or list Dont Know)

EST
Street Address

From Date

City/Postal Code

To Date
EST

Resident Type (rent/own

/military/other)
Date Last Contacted

City/Postal Code
EST

Name of Person who knew you (First Last, Mid, Suffix)

Relationship (neighbor, landlord, friend, work assoc, other)

Phone # (or list Dont Know)

Email (or list Dont Know)

EST
Street Address

Street Address

City/Postal Code

Education Record:

1.Have you attended any schools in the last 10 years?

YES

NO

2. Have you received a degree or diploma more than 10 years ago?

YES

NO

Education
History
(Completed by the
applicant)
#

Instructions List the schools you have attended beyond Junior High School, beginning with the most recent
and working back 7 years. List College or University degrees and the dates they were received. If all of your
education occurred more than 7 years ago, list your most recent education beyond Junior High School no
matter when that education occurred. For schools you attended in the past 3 years, list a person who knew you
at the school (an instructor, student, etc.). Do not list people for education completely outside this 3-year
period. For correspondence and extension classes provide the address where the records are maintained.
Name of School

Postal Code/City

State

Country

1
Start Date

Graduated?
(Y/N)

End Date
EST

Date

DIPLOMA/DEGREE TYPE

Major/Minor

Postal
Code/City

Street Address

Cellular Phone #
(or list Dont Know)

EST

Title/Rank & Name of Person who knew you

(First Last, Mid, Suffix)

Frequency of Contact

Name of School

Email (or list Dont Know)

Postal Code/City

State

Country

2
Start Date

Graduated?
(Y/N)

End Date
EST

Date

If Yes, enter DEGREE TYPE

Major/Minor

Postal
Code/City

Street Address

Cellular Phone #
(or list Dont Know)

EST

Title/Rank & Name of Person who knew you

(First Last, Mid, Suffix)

Frequency of Contact

Name of School

Email (or list Dont Know)

Postal Code/City

State

Country

3
Start Date

Graduated?
(Y/N)

End Date
EST

Date

If Yes, enter DEGREE TYPE

Major/Minor

Postal
Code/City

Street Address

Cellular Phone #
(or list Dont Know)

EST

Title/Rank & Name of Person who knew you

(First Last, Mid, Suffix)

Frequency of Contact

Email (or list Dont Know)

Employment Record:
Instructions List your employment activities, beginning with the present (#1) and working back 7 years. You should list
all full-time work, part-time work, self-employment, other paid work, and all periods of unemployment. The entire 7-year
period must be accounted for without breaks, but you need not list employment before your 16th birthday. EXCEPTION:
Show all federal civilian, whether it occurred in the last 7 years or not. See additional instructions for acceptable list of
values for Employment Types and Termination Types. NOTE: DO NOT list your US Military Service employment
history here (You will cover that in the next section). List the supervisor (verifier if for unemployment) for each period of
employment.

Employment History
(Completed by the applicant)
Check Type

Civilian

Government

Foreign

Unemployment

Military
#

Name of Employer

Street Address

1
City/Postal Code

State

Country

Is/was your physical work address different from address (Y / N If Y provide work address provided above?)

Telephone Number

Position Title

Street Address, City, St. ZIP

Telephone Number

All Periods/This Employer

Start Date

EST

End
Date

Termination Type

Termination Remarks (if negative)

Part Time (Y/N)

EST
Wage $

Title/Rank & Name of Person who knew you (1st Period).

Postal
Code/City

(per hour or month)

Cellular Phone #
(or list Dont Know)

Street Address (if different than above)

(First Last, M. Suffix)

Email (or list Dont Know)
Check Type

Civilian

Government

Foreign

Unemployment

Military
#

Name of Employer

Street Address

2
City/Postal Code

State

Country

Is/was your physical work address different from address (Y / N If Y provide work address provided above?)

Telephone Number

Position Title

Street Address, City, St. ZIP

Telephone Number

All Periods/This Employer

Start Date

EST

End
Date

Termination Type

Termination Remarks (if negative)

Part Time (Y/N)

EST
Wage $

Title/Rank & Name of Person who knew you (1st Period).

Postal
Code/City

Street Address (if different than above)

(First Last, M. Suffix)

Email (or list Dont Know)

(per hour or month)

Cellular Phone #
(or list Dont Know)

Check Type

Civilian

Government

Foreign

Unemployment

Military
#

Name of Employer

Street Address

3
City/Postal Code

State

Country

Is/was your physical work address different from address (Y / N If Y provide work address provided above?)

Telephone Number

Position Title

Street Address, City, St. ZIP

Telephone Number

All Periods/This Employer

Start Date

EST

End
Date

Termination Type

Termination Remarks (if negative)

Part Time (Y/N)

EST
Wage $

Title/Rank & Name of Person who knew you (1st Period).

Postal
Code/City

(per hour or month)

Cellular Phone #
(or list Dont Know)

Street Address (if different than above)

(First Last, M. Suffix)

Email (or list Dont Know)
Check Type

Civilian

Government

Foreign

Unemployment

Military
#

Name of Employer

Street Address

4
City/Postal Code

State

Country

Is/was your physical work address different from address (Y / N If Y provide work address provided above?)

Telephone Number

Position Title

Street Address, City, St. ZIP

Telephone Number

All Periods/This Employer

Start Date

EST

End
Date

Termination Type

Termination Remarks (if negative)

Part Time (Y/N)

EST
Wage $

Title/Rank & Name of Person who knew you (1st Period).

Postal
Code/City

Street Address (if different than above)

(per hour or month)

Cellular Phone #
(or list Dont Know)

(First Last, M. Suffix)

Email (or list Dont Know)

2. Do you have former federal civilian employment, excluding military service, NOT indicated
previously, to report?

YES

NO

3. Have any of the following happened to you in the last seven (7) years at employment activities that
you have not previously listed? (If 'Yes', you will be required to add an additional employment in
Section 13A.)
- Fired from a job?
- Quit a job after being told you would be fired?
- Have you left a job by mutual agreement following charges or allegations of misconduct?
- Left a job by mutual agreement following notice of unsatisfactory performance?
- Received a written warning, been officially reprimanded, suspended, or disciplined for misconduct
in the workplace, such as violation of a security policy?

YES

NO

Selective Service Record:

YES

NO

YES

NO

YES

NO

2. In the last 7 years, have you been subject to court martial or other disciplinary procedure under the
Uniform Code of Military Justice (UCMJ), such as Article 15, Captain's mast, Article 135 Court of
Inquiry, etc.?

YES

NO

3. Have you EVER served, as a civilian or military member in a foreign country's military,
intelligence, diplomatic, security forces, militia, other defense force, or government agency?

YES

NO

1. Were you born a male after December 31, 1959?

2. Have you registered with the Selective Service System (SSS)?
SSS#:

Military History:
1. Have you EVER served in the U.S. Military?

If served, complete the following for EACH instance of service

From Date

EST

Last Duty Station for this Period:

To Date

EST

Branch of Service:

Officer

Current Status:

Enlisted

Type of Service (Reserve/Guard/Active Duty):

Not Applicable

State of Service:

Type of Discharge:

Assignment

Service Number:
From

To

Duty Title

Date of Discharge:

If served, complete the following for EACH instance of service

From Date

EST

Last Duty Station for this Period:

To Date

EST

Branch of Service:

Officer
Enlisted
Not Applicable
Type of Discharge:
Date of Discharge:

Current Status:
Type of Service (Reserve/Guard/Active Duty):
State of Service:
Assignment

Service Number:
From

To

Duty Title

Personal
References

Instructions List three people who know you well and live in the United States. They should be good friends, peers,
colleagues, college roommates, etc., whose combined association with you covers as much as possible the last 10 years. Do
not list spouse, former spouse, or other relatives, and try not to list anyone who is listed elsewhere on this form.
Full Name(First Last, M. Suffix)

Friend
Neighbor
School Mate

From
Date
To
Date

Work Associate

EST
(must cover 10 years)
EST
Street Address:

Other

Postal Code/City/State

Cellular Number (or

"don't know)
Email (or "don't
know)

Full Name(First Last, M. Suffix)

Friend
Neighbor
School Mate

From
Date
To
Date

Work Associate

EST
(must cover 10 years)
EST
Street Address:

Other

Postal Code/City/State

Cellular Number (or

"don't know)
Email (or "don't
know)

Full Name(First Last, M. Suffix)

Friend
Neighbor
School Mate
Work Associate
Other
Cellular Number (or
"don't know)
Email (or "don't
know)

From
Date
To
Date

EST
(must cover 10 years)
EST
Street Address:
Postal Code/City/State

Marital Status:

Single

Married to civilian

Married to Military

Divorced

Separated

Widowed

Relatives&Associates

Instructions:Providedetailsforallimmediatefamily.Mother,Father,Spouse,Children,Siblingsareall
mandatory.ForEstimateddates,select"EST"

Spouse's Information
Full Name (First Last, M. Suffix):

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

US Citizen: (Y/N)

SSN:
DoB (or list "dont know"

EST

Should person be notified in case of

emergency? (Y/N)

Known From Date

EST

Is this a Dependent? (Y/N)

Known to Date

EST

Capable of self-care? (Y/N)

EST

Separation Date if applicable:

Marriage Date:

Do you have legal and/or

physical custody? (Y/N)

Marriage Certificate Date Issued:

Maiden Name
Court of Record:

Contact Data
Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Biological Mother's Information

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

US Citizen: (Y/N)

Full Name (First Last, M. Suffix):

DoB (or list "dont know"

EST

Should person be notified in case of

emergency? (Y/N)

Known From Date

EST

Is this a Dependent? (Y/N)

Known to Date

EST

Capable of self-care? (Y/N)

Do you have legal and/or

physical custody? (Y/N)

Contact Data
Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Biological Father's Information

Full Name (First Last, M. Suffix):
DoB (or list "dont know"

EST

Known From Date

EST

Known to Date

EST

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

Should person be notified in case of
emergency? (Y/N)

US Citizen: (Y/N)

Is this a Dependent? (Y/N)

Do you have legal and/or

physical custody? (Y/N)

Capable of self-care? (Y/N)

Contact Data

Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Other Family Information

Step-Father

Step-Mother

Foster Parent

In law

Child

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

US Citizen: (Y/N)

Full Name (First Last, M. Suffix):

DoB (or list "dont know"

EST

Should person be notified in case of

emergency? (Y/N)

Known From Date

EST

Is this a Dependent? (Y/N)

Known to Date

EST

Capable of self-care? (Y/N)

Do you have legal and/or

physical custody? (Y/N)

Contact Data
Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Other Family Information

Step-Father

Step-Mother

Foster Parent

In law

Child

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

US Citizen: (Y/N)

Full Name:
DoB (or list "dont know"

EST

Should person be notified in case of

emergency? (Y/N)

Known From Date

EST

Is this a Dependent? (Y/N)

Known to Date

EST

Capable of self-care? (Y/N)

Do you have legal and/or

physical custody? (Y/N)

Contact Data
Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Sibling's Information

Brother

Sister

Step-Brother

Step-Sister

Half-Brother

Half-Sister

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

US Citizen: (Y/N)

Full Name (First Last, M. Suffix):

DoB (or list "dont know"

EST

Should person be notified in case of

emergency? (Y/N)

Known From Date

EST

Is this a Dependent? (Y/N)

Known to Date

EST

Capable of self-care? (Y/N)

Do you have legal and/or

physical custody? (Y/N)

Contact Data
Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Sibling's Information

Brother

Sister

Step-Brother

Step-Sister

Half-Brother

Half-Sister

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

US Citizen: (Y/N)

Full Name (First Last, M. Suffix):

DoB (or list "dont know"

EST

Should person be notified in case of

emergency? (Y/N)

Known From Date

EST

Is this a Dependent? (Y/N)

Known to Date

EST

Capable of self-care? (Y/N)

Do you have legal and/or

physical custody? (Y/N)

Contact Data
Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Sibling's Information

Brother

Sister

Step-Brother

Step-Sister

Half-Brother

Half-Sister

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

US Citizen: (Y/N)

Full Name (First Last, M. Suffix):

DoB (or list "dont know"

EST

Should person be notified in case of

emergency? (Y/N)

Known From Date

EST

Is this a Dependent? (Y/N)

Known to Date

EST

Capable of self-care? (Y/N)

Do you have legal and/or

physical custody? (Y/N)

Contact Data
Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Sibling's Information

Brother

Sister

Step-Brother

Step-Sister

Half-Brother

Half-Sister

Is this person a foreign relative? (Y/N)

Place of Birth (city/st):

Is person Deceased? (Y/N)

US Citizen: (Y/N)

Full Name (First Last, M. Suffix):

DoB (or list "dont know"

EST

Should person be notified in case of

emergency? (Y/N)

Known From Date

EST

Is this a Dependent? (Y/N)

Known to Date

EST

Capable of self-care? (Y/N)

Do you have legal and/or

physical custody? (Y/N)

Contact Data
Zip Code:

Same As Applicant

Street Address:

Cellular Phone:

Email:
If not born in the US, complete the following:

INS Registration #:

Date Issued:

City, State Issued:

Court of Record

Exp. Date:

Foreign Contact:
1. Do you have, or have you had, close and/or continuing contact with a foreign national within the
last seven (7) years with whom you, or your spouse, or cohabitant are bound by affection,
influence, common interests, and/or obligation? Include associates as well as relatives, not
previously listed in Section 18.

YES

NO

YES

NO

YES

NO

3. Have you, your spouse, cohabitant, or dependent children EVER owned, or do you anticipate
owning, or plan to purchase real Estate in a foreign country?

YES

NO

4. Do you, your spouse, cohabitant, or dependent children receive any additional benefits from a
foreign country?

YES

NO

5. Have you additionally provided financial support for any foreign national?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

Foreign Activities:
1. Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial
interests (such as stocks, property, investments, bank accounts, ownership of corporate entities,
corporate interests or businesses) in which you or they have direct control or direct ownership?
(Exclude financial interests in companies or diversified mutual funds that are publicly traded on a
U.S. exchange.)
2. Have you, your spouse, cohabitant, or dependent children EVER had any foreign financial
interests that someone controlled on your behalf?

Foreign Business, Professional Activities, and Foreign Government Contacts:

1. Have you in the past seven (7) years provided advice or support to any individual associated
with a foreign business or other foreign organization that you have not previously listed as a former
employer? (Answer 'No' if all your advice or support was authorized pursuant to official U.S.
Government business.)
2. Have you, your spouse, cohabitant, or any member of your immediate family in the past seven
(7) years been asked to provide advice or serve as a consultant, even informally, by any foreign
government official or agency? (Answer 'No' if all the advice or support was authorized pursuant to
official U.S. Government business.)
3. Has any foreign national in the past seven (7) years offered you a job, asked you to work as a
consultant, or consider employment with them?
4. Have you in the past seven (7) years been involved in any other type of business venture with
a foreign national not described above (own, co-own, serve as business consultant, provide
financial support, etc.)?
5. Have you in the past seven (7) years attended or participated in any conferences, trade
shows, seminars, or meetings outside the U.S.? (Do not include those you attended or participated
in on official business for the U.S. government.)
6. Have you or any member of your immediate family in the past seven (7) years had any contact
with a foreign government, its Establishment (such as embassy, consulate, agency, military
service, intelligence or security service, etc.) 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 on a U.S. passport.)

7. Have you in the past seven (7) years sponsored any additional foreign national to come to the
U.S. as a student, for work, or for permanent residence?
8. Have you EVER held political office in a foreign country?
9. Have you EVER voted in the election of a foreign country?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

Foreign Travel:
1. Have you traveled outside the U.S. in the last seven (7) years?

Country

# of Day

Start Date

End Date

PURPOSE
(business/leisure/
education/tourism)

While traveling to, or in this country, were you questioned, searched, or otherwise detained
(other than for normal customs requirements) by the local customs or security service
officials when entering or leaving this country?
While traveling to or in this country, were you involved in any encounter with the police?
While traveling to or in this country, were you contacted by, or in contact with any person
known or suspected of being involved or associated with foreign intelligence, terrorist,
security, or military organizations?
While traveling to, or in this country, were you involved in any counterintelligence or security
issues not reported?
While traveling to or in this country, were you contacted by, or in contact with anyone
exhibiting excessive knowledge of or undue interest in you or your job?
While traveling to or in this country, were you contacted by, or in contact with anyone
attempting to obtain classified information or unclassified, sensitive information?
While traveling to, or in this country, were you threatened, coerced, or pressured in any way
to cooperate with a foreign government official or foreign intelligence or security service?

2. Has your travel in the last seven (7) years been solely for U.S. Government business (i.e., no
personal trips in conjunction with the official U.S. Government business)?

Psychological and Emotional Health:

1. In the last seven (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:
Strictly marital, family, grief not related to violence by you; or
Strictly related to adjustments from service in a military combat environment.
Please respond to this question with the following additional instruction: Victims of sexual
assault who have consulted with the health care professional regarding an emotional or
mental health condition during this period strictly in relation to the sexual assault are
instructed to answer NO.
2. Has a court or administrative agency EVER declared you mentally incompetent?

Police Record:
1. Have any of the following happened? (If 'Yes' you will be asked to provide details for each
offense that pertains to the actions that are identified below.) In the past seven (7) years
- Have you been issued a summons, citation, or ticket to appear in court in a criminal
proceeding against you? (Do not check if all the citations involved traffic infractions where
the fine was less than $300 and did not include alcohol or drugs)
- Have you been arrested by any police officer, sheriff, marshal or any other type of law
enforcement official?
- Have you been charged, convicted, or sentenced of a crime in any court? (Include all
qualifying charges, convictions or sentences in any Federal, state, local, military, or non-U.S.
court, even if previously listed on this form).
- Have you been or are you currently on probation or parole?
- Are you currently on trial or awaiting a trial on criminal charges?

YES

NO

YES

NO

YES

NO

1. In the last seven (7) years, have you illegally used any drugs or controlled substances? Use of
a drug or controlled substance includes injecting, snorting, inhaling, swallowing, experimenting
with or otherwise consuming any drug or controlled substance.

YES

NO

2. In the last seven (7) years, have you been involved in the illegal purchase, manufacture,
cultivation, trafficking, production, transfer, shipping, receiving, handling or sale of any drug or
controlled substance?

YES

NO

3. Have you EVER illegally used or otherwise been involved with a drug or controlled substance
while possessing a security clearance other than previously listed?

YES

NO

4. Have you EVER illegally used or otherwise been involved with a drug or controlled substance
while employed as a law enforcement officer, prosecutor, or courtroom official; or while in a
position directly and immediately affecting the public safety other than previously listed?

YES

NO

5. In the last seven (7) years have you intentionally engaged in the misuse of prescription drugs,
regardless of whether or not the drugs were prescribed for you or someone else?

YES

NO

6. Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of
your illegal use of drugs or controlled substances?

YES

NO

YES

NO

2. Other than those offenses already listed, have you EVER had the following happen to you?
- Have you EVER been convicted in any court of the United States of a crime, sentenced to
imprisonment for a term exceeding 1 year for that crime, and incarcerated as a result of that
sentence for not less than 1 year? (Include all qualifying convictions in Federal, state, local,
or military court, even if previously listed on this form)
- Have you EVER been charged with any felony offense? (Include those under the Uniform
- Code of Military Justice and non-military/civilian felony offenses)
- Have you EVER been convicted of an offense involving domestic violence or a crime of
violence (such as battery or assault) against your child, dependent, cohabitant, spouse,
former spouse, or someone with whom you share a child in common?
- Have you EVER been charged with an offense involving firearms or explosives?
- Have you EVER been charged with an offense involving alcohol or drugs?

3. Is there currently a domestic violence protective order or restraining order issued against you?

Illegal Use of Drug or Activity:

7. Have you EVER voluntarily sought counseling or treatment as a result of your use of a drug or
controlled substance?

Use Of Alcohol:
1. In the last seven (7) years 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?

YES

NO

2. Have you EVER been ordered, advised, or asked to seek counseling or treatment as a result of
your use of alcohol?

YES

NO

3. Have you EVER voluntarily sought counseling or treatment as a result of your use of alcohol?

YES

NO

4. Have you EVER received counseling or treatment as a result of your use of alcohol in addition
to what you have already listed on this form?

YES

NO

1. Has the U.S. Government (or a foreign government) EVER investigated your background and/or
granted you a security clearance eligibility/access?

YES

NO

2. Have you EVER had a security clearance eligibility/access authorization denied, suspended, or
revoked? (Note: An administrative downgrade or administrative termination of a security clearance
is not a revocation.)

YES

NO

3. Have you EVER been debarred from government employment?

YES

NO

1. Have you EVER experienced financial problems due to gambling?

YES

NO

2. In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when
required by law or ordinance?

YES

NO

3. In the past seven (7) years have you failed to file or pay Federal, state, or other taxes when
required by law or ordinance?

YES

NO

4. Are you currently utilizing, or seeking assistance from, a credit counseling service or similar
resource to resolve your financial difficulties?

YES

NO

5. Other than previously listed, have any of the following happened to you? (You will be asked to
provide details about each financial obligation that pertains to the items identified below) In the
past seven (7) years,
You have been delinquent on alimony or child support payments.
You had a judgment entered against you. (Include financial obligations for which you were
the sole debtor, as well as those for which you were a cosigner or guarantor).
You had a lien placed against your property for failing to pay taxes or other debts. (Include
financial obligations for which you were the sole debtor, as well as those for which you were
a cosigner or guarantor).
You are currently delinquent on any Federal debt. (Include financial obligations for which
you are the sole debtor, as well as those for which you are a cosigner or guarantor).

YES

NO

Investigation Clearance Record:

Financial Record:

6. Other than previously listed, have any of the following happened: In the past seven (7) years,
- You had any possessions or property voluntarily or involuntarily repossessed or foreclosed?
(Include financial obligations for which you were the sole debtor, as well as those for which
you were a cosigner or guarantor)
- You defaulted on any type of loan? (Include financial obligations for which you were the sole
debtor, as well as those for which you were a cosigner or guarantor)
- You had bills or debts turned over to a collection agency? (Include financial obligations for
which you were the sole debtor, as well as those for which you were a cosigner or
guarantor)
- You had any account or credit card suspended, charged off, or cancelled for failing to pay as
agreed? (Include financial obligations for which you were the sole debtor, as well as those
for which you were a cosigner or guarantor)
- You were evicted for non-payment?
- You had your wages, benefits, or assets garnished or attached for any reason?
- You have been over 120 days delinquent on any debt not previously entered? (Include
financial obligations for which you were the sole debtor, as well as those for which you were
a cosigner or guarantor)
- You are currently over 120 days delinquent on any debt? (Include financial obligations for
which you are the sole debtor, as well as those for which you are a cosigner or guarantor)

YES

NO

YES

NO

2. In the last seven (7) years, have you illegally or without authorization, modified, destroyed,
manipulated, or denied others access to information residing on an information technology system
or attempted any of the above?

YES

NO

3. In the last seven (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 or attempted any of the
above?

YES

NO

YES

NO

Use of Information Technology Systems:

1. In the last seven (7) years have you illegally or without proper authorization accessed or
attempted to access any information technology system?

Non-Criminal Court Actions:

1. In the last ten (10) years, have you been a party to any public record civil court action not listed
elsewhere on this form?

Association Record:
1. Are you now or have you EVER been a member of an organization dedicated to terrorism,
either with an awareness of the organization's dedication to that end, or with the specific intent to
further such activities?

YES

NO

2. Have you EVER knowingly engaged in any acts of terrorism?

YES

NO

3. Have you EVER advocated any acts of terrorism or activities designed to overthrow the U.S.
Government by force?

YES

NO

YES

NO

YES

NO

6. Have you EVER knowingly engaged in activities designed to overthrow the U.S. Government by
force?

YES

NO

7. Have you EVER associated with anyone involved in activities to further terrorism?

YES

NO

4. Have you EVER been a member of an organization dedicated to the use of violence or force to
overthrow the United States Government, and which engaged in activities to that end with an
awareness of the organization's dedication to that end or with the specific intent to further such
activities?
5. Have you EVER been a member of an organization dedicated to the use of violence or force to
overthrow the United States Government, and which engaged in activities to that end with an
awareness of the organization's dedication to that end or with the specific intent to further such
activities?

OTHER REMARKS: