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While the requirements for some items on this form are self-explanatory, there are areas not fully explained as to the exact information or format that is required. Ensure each block is completed. If a particular block doesn’t apply to you, enter N/A. Leaving blocks unanswered (blank) will result in the form being returned for corrections. This form may be either typed (The GSA Official can provide an electronic copy of the form) or handwritten. If handwritten, ensure entire form is completed using black ink and that all items are legible. Illegible items may result in form being returned for corrections. Any corrections, changes, cross-outs, stray marks, use of a different pen, must be initialed and dated as near to these actions as possible.
Those items where your answer is to mark a box, you may use either an “X” or a check mark. 1. Social Security Number: Enter your social security number.
2. Telephone Number: Either home, work or cell, must include the area code. 3. Date of birth: Enter using the Month/Day/4 digit year format.
4. Name Data:
-Enter your full last, first, and middle names. If it is an initial only, signify by writing “(IO)” next to the initial.
-Other Names Used: List all other names you ever used, to include maiden name, other names by former marriages, nicknames, etc. You need to specify which type of name it is, and also list the inclusive dates you have used this name. In the case of nicknames, if you still use it, have the end date listed as “Present”.
-If none, write N/A
5. Place of Birth: City, State and Country 6. Sex: Mark the appropriate box.
7, 8, 9, and 10. Height, Weight, Hair and Eyes: Write height in feet and inches, your weight in pounds, hair and eye color.
11. Marital Status: Mark the box that currently pertains to you.
12. Provide full first, middle and last names for current spouse and any previous spouses. -Ensure maiden name is provided
-For each: Provide place (city, state) and date of birth -For each: Provide place (city, state) and date of marriage -If never married, write N/A
13. Check the box pertaining to you
14. List your residences from your current address going back 10 years, to the month. -List dates in Month/Year format.
-If you are unsure of the month, enter a month; then write EST (short for estimate) -Ensure you provide complete information in each block for each address.
-For your current residence, in the “To” block, write Present. -Zip codes can be located at www.usps.com
-There can be no time gaps in this section 15. Check either US citizen or Alien, as applicable.
-If US citizen, check either By Birth, Naturalized of Derived. -If by birth, go to item 16.
-If naturalized, provide information in boxes 15a through 15e. -If derived, provide information in box 15f.
-If Alien is checked, provide your registration number, expiration date, date of entry and U.S. port of entry.
General Services Administration
R10 Security Clearance Desk Guide (External use)
External Version 1.0 10/15/2009
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16. Provide all education you have attended above elementary school, whether or not you received a diploma or degree.
-Provide complete address for all educational institutions. -Addresses can be obtained from phone books and the internet. -Zip codes can be found atwww.usps.com.
-You need to provide the four digit year for the dates you attended these schools.
17. The section must cover the last 10 years. Start with your current position (the job you require this investigation for). For this job enter Present in the “To” block.
-You must list any periods of unemployment. -There can be no time gaps in this section.
-Ensure you provide both the name of the company you worked for and the name of your supervisor.
-Each block must be completed for each entry.
-Under “Reason for Leaving”, for your current job and periods of unemployment, you may leave this blank. For all other jobs, acceptable entries include; quit; moved to state name, more money, fired, laid off, etc.
18. Check the appropriate box. If you check “yes” provide detailed information of the circumstances in Item 22. Dismissed from a job includes being fired.
18a. Check yes or no, as appropriate. If yes, complete serial number, branch of service, year from and year to blocks.
19. Check the appropriate box. Traffic violations for which you received only a fine of $25 or less do not need to be listed.
-The timeframe for this item covers your entire life.
-You must list any other charges, whether or not the charges were later dismissed. -If you check “No”, write N/A in the “Reason Charged or Held” block.
-If you answered yes, provide complete information for all blocks.
-For “Place where charged or held”, enter the location, i.e., Sioux Falls, SD; Smithy County, MO, etc.
-Under “Disposition”, enter the final outcome. For example, paid $550 fine, 30 days jail, 3 years supervised or unsupervised probation, dismissed, dismissed, etc.
19a. Check either the Yes or No box for all 3 items. If yes to any, provide details in the space below this question, completing in the same manner as item 19. If you answered “No” to all 3, write N/A in the “Reason charged or held” block.
20. Provide information on parents, spouse, former spouse, children, brothers and sisters. -Enter their information whether alive or deceased.
-Ensure each block is completed for every individual.
-For deceased relatives, write deceased in the “address” block, ensuring all other information which was current at the time of death is provided.
21. These individuals cannot be relatives or employers. Provide a complete physical address (can be home or business) and the total number of years you have know them.
22. Use this space for any comments, clarifying information or continuation of answers from anywhere else on the form.
23, 24 and 25. Ensure you read and understand these statements.
26. Sign and date in this block. This certifies that all statements you made on the form are true, correct and complete. The date you sign this must be less than 120 days old.