Standard Form 85
Revised September 1995
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
Form approved:
OMB No. 3206-0005
NSN 7540-00-634-4035
85-111
Questionnaire for Non-Sensitive Positions
Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 5 and the release on
Page 6. If you have any questions, call the office that gave you the form.
Purpose of this Form
The U.S. Government conducts background investigations to establish
that applicants or incumbents either employed by the Government or
working for the Government under contract, are suitable for the job.
Information from this form is used primarily as the basis for this
investigation. Complete this form only after a conditional offer of
employment has been made.
Giving us the information we ask for is voluntary. However, we may
not be able to complete your investigation, or complete it in a timely
manner, if you don’t give us each item of information we request. This
may affect your placement or employment prospects.
Authority to Request this Information
The U.S. Government is authorized to ask for this information under
Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code;
and parts 5, 731, and 736 of Title 5, Code of Federal Regulations.
Your Social Security Number is needed to keep records accurate,
because other people may have the same name and birth date. Executive
Order 9397 also asks Federal agencies to use this number to help
identify individuals in agency records.
The Investigative Process
Background investigations are conducted using your responses on this
form and on your Declaration for Federal Employment (OF 306) to
develop information to show whether you are reliable, trustworthy, and
of good conduct and character. Your current employer must be
contacted as part of the investigation, even if you have previously
indicated on applications or other forms that you do not want this.
2. Type or legibly print your answers in black ink (if your form is not
legible, it will not be accepted). You may also be asked to submit your
form in an approved electronic format.
3. All questions on this form must be answered. If no response is
necessary or applicable, indicate this on the form (for example, enter
"None" or "N/A"). If you find that you cannot report an exact date,
approximate or estimate the date to the best of your ability and indicate
this by marking "APPROX." or "EST."
4. Any changes that you make to this form after you sign it must be
initialed and dated by you. Under certain limited circumstances,
agencies may modify the form consistent with your intent.
5. You must use the State codes (abbreviations) listed on the back of
this page when you fill out this form. Do not abbreviate the names of
cities or foreign countries.
6. The 5-digit postal ZIP codes are needed to speed the processing of
your investigation. The office that provided the form will assist you in
completing the ZIP codes.
7. All telephone numbers must include area codes.
8. All dates provided on this form must be in Month/Day/Year or
Month/Year format. Use numbers (1-12) to indicate months. For
example, June 10, 1978, should be shown as 6/10/78.
9. Whenever "City (Country)" is shown in an address block, also
provide in that block the name of the country when the address is
outside the United States.
Instructions for Completing this Form
1. Follow the instructions given to you by the person who gave you the
form and any other clarifying instructions furnished by that person to
assist you in completion of the form. Find out how many copies of the
form you are to turn in. You must sign and date, in black ink, the
original and each copy you submit.
10.
If you need additional space to list your residences or
employments/self-employments/unemployment or education, you
should use a continuation sheet, SF 86A. If additional space is needed
to answer other items, use a blank piece of paper. Each blank piece of
paper you use must contain your name and Social Security Number
at the top of the page.
Final Determination on Your Eligibility
Final determination on your eligibility for a position is the responsibility
of the Office of Personnel Management or the Federal agency that
requested your investigation. You may be provided the opportunity
personally to explain, refute, or clarify any information before a final
decision is made.
Penalties for Inaccurate or False Statements
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 of up to $10,000, and/or 5 years imprisonment, or both. In
addition, Federal agencies generally fire, or disqualify individuals who
have materially and deliberately falsified these forms, and this remains a
part of the permanent record for future placements. Your
trustworthiness is a very important consideration in deciding your
suitability. Your prospects of placement are better if you answer
all questions truthfully and completely. You will have adequate
opportunity to explain any information you give us on the form and to
make your comments part of the record.
Disclosure of Information
The information you give us is for the purpose of determining your
suitability for Federal employment; we will protect it from unauthorized
disclosure. The collection, maintenance, and disclosure of background
investigative information is governed by the Privacy Act. The agency
which requested the investigation and the agency which conducted the
investigation have published notices in the Federal Register describing
the systems of records in which your records will be maintained. You
may obtain copies of the relevant notices from the person who gave you
this form. The information on this form, and information we collect
during an investigation may be disclosed without your consent as
permitted by the Privacy Act (5 USC 552a(b)) and as follows:
PRIVACY ACT ROUTINE USES
1. To the Department of Justice when: (a) the agency or any component thereof; or
(b) any employee of the agency in his or her official capacity; or (c) any employee of
the agency in his or her individual capacity where the Department of Justice has
agreed to represent the employee; or (d) the United States Government, is a party to
litigation or has interest in such litigation, and by careful review, the agency
determines that the records are both relevant and necessary to the litigation and the
use of such 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.
2. 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.
3. Except as noted in Question 14, 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. To the National Archives and Records Administration for records management
inspections conducted under 44 USC 2904 and 2906.
11. To the Office of Management and Budget when necessary to the review of
private relief legislation.
STATE CODES (ABBREVIATIONS)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
American Samoa
Trust Territory
AS
TT
District of Columbia
Virgin Islands
DC
VI
Guam
GU
Northern Marianas
CM
Puerto Rico
PR
PUBLIC BURDEN INFORMATION
Public reporting burden for this collection of information is estimated to average 30 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 Reports
and Forms Management Officer, U.S. Office of Personnel Management, 1900 E Street, N.W., Room CHP-500, Washington, D.C. 20415. Do not send
your completed form to this address.
Standard Form 85 (EG)
Revised September 1995
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
Form approved:
OMB No. 3206-0005
NSN 7540-00-634-4035
85-111
QUESTIONNAIRE FOR
NON-SENSITIVE POSITIONS
Codes
OPM
USE
ONLY
Case Number
Agency Use Only (Complete items A through K using instructions provided by USOPM)
A
B
Type of
Investigation
C
Extra
Coverage
E Geographic
F
Location
I
J
OPAC-ALC
Number
K Requesting
D
Nature of
Action Code
Date of
Action
Month
G
Position
Title
Day
Year
H
SON
SOI
Accounting Data and/or
Agency Case Number
Name and Title
Signature
Telephone Number
Date
Official
(
)
Persons completing this form should begin with the questions below.
1
FULL
NAME
If you have only initials in your name, use them and state (IO).
If you have no middle name, enter "NMN".
Last Name
3
5
First Name
#2
a
c
4
State
To
Month/Year Month/Year
Name
7
Jr., II, etc.
DATE OF
BIRTH
Month
Day
Year
SOCIAL SECURITY
Country (if not in the United States)
OTHER NAMES USED
Give other names you 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 "nee" in front of it.
Name
Month/Year Month/Year
Name
Month/Year Month/Year
#1
6
Middle Name
PLACE OF BIRTH - Use the two letter code for the State.
City
County
2
- If you are a "Jr.," "Sr.," "II," etc., enter this in the
box after your middle name.
Female
CITIZENSHIP
To
Month/Year Month/Year
Name
#4
To
SEX (Mark one box)
#3
To
Male
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. (Answer
items b and d)
Mark the box at the right that
reflects your current citizenship
status, and follow its instructions.
UNITED STATES CITIZENSHIP
b
Your Mother’s Maiden Name
I am a U.S. citizen, but I was NOT born in the U.S. (Answer items b , c and d)
I am not a U.S. citizen. (Answer items b and e)
If you are a U.S. citizen, but were not born in the U.S., provide information about one or more of the following proofs of your citizenship.
Naturalization Certificate (Where were you naturalized?)
Court
City
State
Certificate Number
Month/Day/Year Issued
Citizenship Certificate (Where was the certificate issued?)
City
State
Certificate Number
Month/Day/Year Issued
State Department Form 240 - Report of Birth Abroad of a Citizen of the United States
Give the date the form was
Month/Day/Year
Explanation
prepared and give an explanation
if needed
U.S. Passport
Passport Number
Month/Day/Year Issued
This may be either a current or previous U.S. Passport.
d
DUAL CITIZENSHIP
e
ALIEN If you are an alien, provide the following information:
City
Place You
Entered the
United States:
If you are (or were) a dual citizen of the United States and
another country, provide the name of that country in the space to
the right.
State
Country
Date You Entered U.S.
Month
Day
Year
Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995.
Designed using Perform Pro, WHS/DIOR, Sep 95
Alien Registration Number
Country(ies) of Citizenship
Page 1
8
WHERE YOU HAVE LIVED
List the places where you have lived, beginning with the most recent (#1) and working back 5 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 under 90 days (list your permanent address instead), and you should use your APO/FPO address if you lived overseas.
For any address in the last 3 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 3-year period, and do not list your spouse, former spouses, or other relatives).
Month/Year
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
Street Address
Apt. #
City (Country)
State
ZIP Code
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
To
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
#1
To
Present
Name of Person Who Knows You
Month/Year
#2
Month/Year
#3
Month/Year
#4
Month/Year
#5
9
WHERE YOU WENT TO SCHOOL
List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 5 years. List all College or University degrees
and the dates they were received. If all of your education occurred more than 5 years ago, list your most recent education beyond high school, no matter when that
education occurred.
- Use one of the following codes in the "Code" block:
1 - High School
2 - College/University/Military College
3 - Vocational/Technical/Trade School
- For correspondence schools and extension classes, provide the address where the records are maintained.
Month/Year
Month/Year
Code
Name of School
Degree/Diploma/Other
Month/Year Awarded
#1
To
Street Address and City (Country) of School
Month/Year
Month/Year
Code
State
Name of School
Degree/Diploma/Other
ZIP Code
Month/Year Awarded
#2
To
Street Address and City (Country) of School
Month/Year
Month/Year
Code
State
Name of School
Degree/Diploma/Other
ZIP Code
Month/Year Awarded
#3
To
Street Address and City (Country) of School
State
ZIP Code
Enter your Social Security Number before going to the next page
Page 2
10
YOUR EMPLOYMENT ACTIVITIES
List your employment activities, beginning with the present (#1) and working back 5 years. You should list all full-time work, part-time work, military service, temporary
military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment. The entire 5-year period must be accounted for without breaks,
but you need not list employments before your 16th birthday.
Code. Use one of the codes listed below to identify the type of employment:
5 - State Government (Non-Federal
1 - Active military duty stations
employment)
2 - National Guard/Reserve
6 - Self-employment (Include business name
3 - U.S.P.H.S. Commissioned Corps
and/or name of person who can verify)
4 - Other Federal employment
7 - Unemployment (Include name of
person who can verify)
8 - Federal Contractor (List Contractor,
not Federal agency)
9 - Other
Employer/Verifier Name. List the business name of your employer or the name of the 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.
Previous Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same 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.
Month/Year
#1
Month/Year
To
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
Present
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
(
Month/Year
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #1)
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
)
)
To
Month/Year
To
Month/Year
To
Month/Year
Month/Year
#2
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
To
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
(
(
Month/Year
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #2)
Position Title
Supervisor
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
)
)
To
Month/Year
To
Month/Year
To
Month/Year
Month/Year
#3
Month/Year
)
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
To
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
(
(
Month/Year
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #3)
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
)
)
)
To
Month/Year
To
Month/Year
To
Enter your Social Security Number before going to the next page
Page 3
YOUR EMPLOYMENT ACTIVITIES (CONTINUED)
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
#4
Your Position Title/Military Rank
To
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
(
(
Month/Year
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #4)
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
)
)
)
To
Month/Year
To
Month/Year
To
Month/Year
Month/Year
#5
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
To
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
(
(
Month/Year
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #5)
Position Title
Supervisor
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
)
)
To
Month/Year
To
Month/Year
To
Month/Year
Month/Year
#6
Month/Year
)
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
To
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
(
(
Month/Year
PREVIOUS
PERIODS
OF
ACTIVITY
(Block #6)
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
Month/Year
Position Title
Supervisor
)
)
)
To
Month/Year
To
Month/Year
To
11
PEOPLE WHO KNOW YOU WELL
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 well as possible the last 5 years. Do not list your spouse, former spouses, or other relatives, and try not to list anyone who is listed
elsewhere on this form.
Dates Known
Name
Telephone Number
Month/Year
Month/Year
Day
#1
)
Night (
To
Home or Work Address
City (Country)
State ZIP Code
Name
#2
Home or Work Address
Name
#3
Home or Work Address
Dates Known
Telephone Number
Month/Year
Month/Year
Day
(
Night
To
City (Country)
)
Dates Known
Telephone Number
Month/Year
Month/Year
Day
(
Night
To
City (Country)
)
State
ZIP Code
State
ZIP Code
Enter your Social Security Number before going to the next page
Page 4
12
YOUR SELECTIVE SERVICE RECORD
a
Are you a male born after December 31, 1959? If "No," go to 13. If "Yes," go to b.
b
Have you registered with the Selective Service System? If "Yes," provide your registration number. If "No," show the reason for your legal
exemption below.
Registration Number
13
Yes
No
Yes
No
Legal Exemption Explanation
YOUR MILITARY HISTORY
a
Have you served in the United States military?
b
Have you served in the United States Merchant Marine?
List all of your military service below, including service in Reserve, National Guard, and U.S. Merchant Marine. Start with the most recent period of service (#1) and work
backward. If you had a break in service, each separate period should be listed.
Code. Use one of the codes listed below to identify your branch of service:
1 - Air Force
2 - Army
3 - Navy
4 - Marine Corps
5 - Coast Guard
6 - Merchant Marine
7 - National Guard
O/E. Mark "O" block for Officer or "E" block for Enlisted.
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. If your service was with other than the U.S. Armed Forces, identify the country for which you served.
Month/Year
Month/Year
Code
Service/Certificate #
O
E
Status
Active
Active
Reserve
Country
Inactive
Reserve
National
Guard
(State)
To
To
14
Yes
ILLEGAL DRUGS
No
In the last year, have you used, possessed, supplied, or manufactured illegal drugs? When used without a prescription, illegal drugs include
marijuana, cocaine, hashish, narcotics (opium, morphine, codeine, heroin, etc.), stimulants (cocaine, amphetamines, etc.), depressants
(barbiturates, methaqualone, tranquilizers, etc.), hallucinogenics (LSD, PCP, etc.). (NOTE: Neither your truthful response nor information derived
from your response will be used as evidence against you in any subsequent criminal proceeding.)
If you answered "Yes," provide information relating to the types of substance(s), the nature of the activity, and any other details relating to your
involvement with illegal drugs. Include any treatment or counseling received.
Month/Year
Month/Year
Type of Substance
Explanation
To
To
To
Continuation Space
Use the continuation sheet(s) (SF86A) for additional answers to items 8, 9, and 10. Use the space below to continue answers to all other items and 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 Social Security number. Before each answer,
identify the number of the item.
After completing this form you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the following certification
and sign and date the release on Page 6.
Certification That My Answers Are True
My statements on this form, and any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are
made in good faith. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or
both. (See section 1001 of title 18, United States Code).
Signature (Sign in ink)
Date
Enter your Social Security Number before going to the next page
Page 5
Standard Form 85
Revised September 1995
U.S. Office of Personnel Management
5 CFR Parts 731 and 736
Form approved:
OMB No. 3206-0005
NSN 7540-00-634-4035
85-111
UNITED STATES OF AMERICA
AUTHORIZATION FOR RELEASE OF INFORMATION
Carefully read this authorization to release information about you, then sign and date it in black ink.
I Authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting
my background investigation, to obtain any information relating to my activities from schools, residential management agents,
employers, criminal justice agencies, retail business establishments, or other sources of information. This information may
include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment
history, and criminal history record information.
I Understand that, for some sources of information, a separate specific release will be needed, and I may be contacted for such
a release at a later date.
I Authorize custodians of records and sources of information pertaining to me to release such information upon request of the
investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any
previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official use by the Federal
Government only for the purposes provided in this Standard Form 85, and may be redisclosed by the Government only as
authorized by law.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid
for two (2) years from the date signed.
Signature (Sign in ink)
Date Signed
Full Name (Type or Print Legibly)
Other Names Used
Social Security Number
Current Address (Street, City)
State
ZIP Code
Home Telephone Number
(Include Area Code)
(
)
Page 6
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