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Fill and Sign the Western Reserve Policy Reinstatement Fee Form

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Standard Form 86A (EG) Revised September 1995 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736 Form approved: OMB No. 3206-0007 NSN 7540-01-268-4828 86-203 CONTINUATION SHEET FOR QUESTIONNAIRES SF 86, SF 85P, AND SF 85 For use with the SF 86, Questionnaire for National Security Positions; SF 85P, Questionnaire for Public Trust Positions; and SF 85, Questionnaire for Non-Sensitive Positions INSTRUCTIONS: Use this form to continue your answers to "Where You Have Lived," "Where You Went to School," and/or "Your Employment Activities." Follow the instructions on the form for the particular questions you are answering and give information in the same sequence. Use as many continuation sheets as needed. Your Name Your Social Security Number WHERE YOU HAVE LIVED (Continued) Month/Year Month/Year Street Address To Name of Person Who Knew You Street Address Apt. # City (Country) State ZIP Code #1 Apt. # City (Country) State ZIP Code Telephone Number ( Month/Year Month/Year Street Address To Name of Person Who Knew You Street Address Apt. # ) State City (Country) ZIP Code #2 Apt. # City (Country) State ZIP Code Telephone Number ( Month/Year Month/Year Street Address To Name of Person Who Knew You Street Address Apt. # ) State City (Country) ZIP Code #3 Apt. # City (Country) State ZIP Code Telephone Number ( Month/Year Month/Year Street Address To Name of Person Who Knew You Street Address Apt. # ) State City (Country) ZIP Code #4 Apt. # City (Country) State ZIP Code Telephone Number ( Month/Year Month/Year Street Address To Name of Person Who Knew You Street Address Apt. # ) State City (Country) ZIP Code #5 Apt. # City (Country) State ZIP Code Telephone Number ( ) WHERE YOU WENT TO SCHOOL (Continued) Month/Year Month/Year Code Name of School Degree/Diploma/Other Month/Year Awarded #1 To Street Address and City (Country) of School Name of Person Who Knew You State Street Address Apt. # City (Country) State ZIP Code ZIP Code Telephone Number ( Month/Year Month/Year Code Name of School Degree/Diploma/Other #2 To Street Address and City (Country) of School Name of Person Who Knew You State Street Address Apt. # City (Country) State ZIP Code ZIP Code Telephone Number ( Month/Year Month/Year Code Name of School Degree/Diploma/Other #3 To Street Address and City (Country) of School Name of Person Who Knew You Street Address City (Country) State ZIP Code ZIP Code Telephone Number ( Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995. Designed using Perform Pro, WHS/DIOR, Sep 95 ) Month/Year Awarded State Apt. # ) Month/Year Awarded ) YOUR EMPLOYMENT ACTIVITIES (Continued) Month/Year 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 Street Address of Job Location (If different than Employer’s Address) City (Country) State ZIP Code Supervisor’s Name & Street Address (If different than Job Location) City (Country) State ZIP Code Telephone Number ( ( PREVIOUS PERIODS OF ACTIVITY Month/Year Position Title Position Title Supervisor Month/Year Position Title ) Supervisor Month/Year ) Telephone Number ( Month/Year ) Telephone Number Supervisor To Month/Year To Month/Year To Month/Year 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 Street Address of Job Location (If different than Employer’s Address) City (Country) State ZIP Code Supervisor’s Name & Street Address (If different than Job Location) City (Country) State ZIP Code Telephone Number ( ( PREVIOUS PERIODS OF ACTIVITY Month/Year Position Title Position Title Supervisor Month/Year Position Title ) Supervisor Month/Year ) Telephone Number ( Month/Year ) Telephone Number Supervisor To Month/Year To Month/Year To Month/Year 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 Street Address of Job Location (If different than Employer’s Address) City (Country) State ZIP Code Supervisor’s Name & Street Address (If different than Job Location) City (Country) State ZIP Code Telephone Number ( ( PREVIOUS PERIODS OF ACTIVITY Month/Year Position Title Position Title Supervisor Month/Year Position Title ) Supervisor Month/Year ) Telephone Number ( Month/Year ) Telephone Number Supervisor To Month/Year To Month/Year To Month/Year 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 Street Address of Job Location (If different than Employer’s Address) City (Country) State ZIP Code Supervisor’s Name & Street Address (If different than Job Location) City (Country) State ZIP Code Telephone Number ( ( PREVIOUS PERIODS OF ACTIVITY Month/Year Position Title Position Title Supervisor Month/Year Position Title ) Supervisor Month/Year ) Telephone Number ( Month/Year ) Telephone Number Supervisor To Month/Year To Month/Year To Enter your Social Security Number before going to the next page Standard Form 86A (Back) September 1995

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