OPM Form SF-85P "Questionnaire for Public Trust Positions"

What Is OPM Form SF-85P?

This is a legal form that was released by the U.S. Office of Personnel Management on September 1, 1995 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 1995;
  • The latest available edition released by the U.S. Office of Personnel Management;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of OPM Form SF-85P by clicking the link below or browse more documents and templates provided by the U.S. Office of Personnel Management.

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Standard Form 85P
Form approved:
Revised September 1995
OMB No. 3206-0191
U.S. Office of Personnel Management
NSN 7540-01-317-7372
5 CFR Parts 731, 732, and 736
85-1602
Questionnaire for Public Trust Positions
Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 7 and the release on
Page 8. If you have any questions, call the office that gave you the form.
Purpose of this Form
The U.S. Government conducts background investigations and
These include documentation of any legal name change, Social Security
reinvestigations to establish that applicants or incumbents either
card, and/or birth certificate.
employed by the Government or working for the Government under
contract, are suitable for the job and/or eligible for a public trust or
You may also be asked to bring documents about information you
sensitive position. Information from this form is used primarily as the
provided on the form or other matters requiring specific attention.
basis for this investigation. Complete this form only after a conditional
These matters include alien registration, delinquent loans or taxes,
offer of employment has been made.
bankruptcy, judgments, liens, or other financial obligations, agreements
involving child custody or support, alimony or property settlements,
Giving us the information we ask for is voluntary. However, we may
arrests, convictions, probation, and/or parole.
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
Instructions for Completing this Form
may affect your placement or employment prospects.
1. Follow the instructions given to you by the person who gave you the
Authority to Request this Information
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
The U.S. Government is authorized to ask for this information under
form you are to turn in. You must sign and date, in black ink, the
Executive Orders 10450 and 10577, sections 3301 and 3302 of title 5,
original and each copy you submit.
U.S. Code; and parts 5, 731, 732, and 736 of Title 5, Code of Federal
Regulations.
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
Your Social Security number is needed to keep records accurate,
form in an approved electronic format.
because other people may have the same name and birth date. Executive
Order 9397 also asks Federal agencies to use this number to help
3. All questions on this form must be answered. If no response is
identify individuals in agency records.
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,
The Investigative Process
approximate or estimate the date to the best of your ability and indicate
this by marking "APPROX." or "EST."
Background investigations are conducted using your responses on this
form and on your Declaration for Federal Employment (OF 306) to
4. Any changes that you make to this form after you sign it must be
develop information to show whether you are reliable, trustworthy, of
initialed and dated by you.
Under certain limited circumstances,
good conduct and character, and loyal to the United States.
The
agencies may modify the form consistent with your intent.
information that you provide on this form is confirmed during the
investigation. Your current employer must be contacted as part of the
5. You must use the State codes (abbreviations) listed on the back of
investigation, even if you have previously indicated on applications or
this page when you fill out this form. Do not abbreviate the names of
other forms that you do not want this.
cities or foreign countries.
In addition to the questions on this form, inquiry also is made about a
6. The 5-digit postal ZIP codes are needed to speed the processing of
person’s adherence to security requirements, honesty and integrity,
your investigation. The office that provided the form will assist you in
vulnerability
to
exploitation
or
coercion,
falsification,
mis-
completing the ZIP codes.
representation, and any other behavior, activities, or associations that
tend to show the person is not reliable, trustworthy, or loyal.
7. All telephone numbers must include area codes.
Your Personal Interview
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
Some investigations will include an interview with you as a normal part
example, June 10, 1978, should be shown as 6/10/78.
of the investigative process. This provides you the opportunity to
update, clarify, and explain information on your form more completely,
9. Whenever "City (Country)" is shown in an address block, also
which often helps to complete your investigation faster. It is important
provide in that block the name of the country when the address is
that the interview be conducted as soon as possible after you are
outside the United States.
contacted.
Postponements will delay the processing of your
investigation, and declining to be interviewed may result in your
10.
If you need additional space to list your residences or
investigation being delayed or canceled.
employments/self-employments/unemployments or education, you
should use a continuation sheet, SF 86A. If additional space is needed
You will be asked to bring identification with your picture on it, such as
to answer other items, use a blank piece of paper. Each blank piece of
a valid State driver’s license, to the interview.
There are other
paper you use must contain your name and Social Security Number
documents you may be asked to bring to verify your identity as well.
at the top of the page.
Standard Form 85P
Form approved:
Revised September 1995
OMB No. 3206-0191
U.S. Office of Personnel Management
NSN 7540-01-317-7372
5 CFR Parts 731, 732, and 736
85-1602
Questionnaire for Public Trust Positions
Follow instructions fully or we cannot process your form. Be sure to sign and date the certification statement on Page 7 and the release on
Page 8. If you have any questions, call the office that gave you the form.
Purpose of this Form
The U.S. Government conducts background investigations and
These include documentation of any legal name change, Social Security
reinvestigations to establish that applicants or incumbents either
card, and/or birth certificate.
employed by the Government or working for the Government under
contract, are suitable for the job and/or eligible for a public trust or
You may also be asked to bring documents about information you
sensitive position. Information from this form is used primarily as the
provided on the form or other matters requiring specific attention.
basis for this investigation. Complete this form only after a conditional
These matters include alien registration, delinquent loans or taxes,
offer of employment has been made.
bankruptcy, judgments, liens, or other financial obligations, agreements
involving child custody or support, alimony or property settlements,
Giving us the information we ask for is voluntary. However, we may
arrests, convictions, probation, and/or parole.
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
Instructions for Completing this Form
may affect your placement or employment prospects.
1. Follow the instructions given to you by the person who gave you the
Authority to Request this Information
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
The U.S. Government is authorized to ask for this information under
form you are to turn in. You must sign and date, in black ink, the
Executive Orders 10450 and 10577, sections 3301 and 3302 of title 5,
original and each copy you submit.
U.S. Code; and parts 5, 731, 732, and 736 of Title 5, Code of Federal
Regulations.
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
Your Social Security number is needed to keep records accurate,
form in an approved electronic format.
because other people may have the same name and birth date. Executive
Order 9397 also asks Federal agencies to use this number to help
3. All questions on this form must be answered. If no response is
identify individuals in agency records.
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,
The Investigative Process
approximate or estimate the date to the best of your ability and indicate
this by marking "APPROX." or "EST."
Background investigations are conducted using your responses on this
form and on your Declaration for Federal Employment (OF 306) to
4. Any changes that you make to this form after you sign it must be
develop information to show whether you are reliable, trustworthy, of
initialed and dated by you.
Under certain limited circumstances,
good conduct and character, and loyal to the United States.
The
agencies may modify the form consistent with your intent.
information that you provide on this form is confirmed during the
investigation. Your current employer must be contacted as part of the
5. You must use the State codes (abbreviations) listed on the back of
investigation, even if you have previously indicated on applications or
this page when you fill out this form. Do not abbreviate the names of
other forms that you do not want this.
cities or foreign countries.
In addition to the questions on this form, inquiry also is made about a
6. The 5-digit postal ZIP codes are needed to speed the processing of
person’s adherence to security requirements, honesty and integrity,
your investigation. The office that provided the form will assist you in
vulnerability
to
exploitation
or
coercion,
falsification,
mis-
completing the ZIP codes.
representation, and any other behavior, activities, or associations that
tend to show the person is not reliable, trustworthy, or loyal.
7. All telephone numbers must include area codes.
Your Personal Interview
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
Some investigations will include an interview with you as a normal part
example, June 10, 1978, should be shown as 6/10/78.
of the investigative process. This provides you the opportunity to
update, clarify, and explain information on your form more completely,
9. Whenever "City (Country)" is shown in an address block, also
which often helps to complete your investigation faster. It is important
provide in that block the name of the country when the address is
that the interview be conducted as soon as possible after you are
outside the United States.
contacted.
Postponements will delay the processing of your
investigation, and declining to be interviewed may result in your
10.
If you need additional space to list your residences or
investigation being delayed or canceled.
employments/self-employments/unemployments or education, you
should use a continuation sheet, SF 86A. If additional space is needed
You will be asked to bring identification with your picture on it, such as
to answer other items, use a blank piece of paper. Each blank piece of
a valid State driver’s license, to the interview.
There are other
paper you use must contain your name and Social Security Number
documents you may be asked to bring to verify your identity as well.
at the top of the page.
Final Determination on Your Eligibility
Your prospects of placement are better if you answer all questions
truthfully and completely.
You will have adequate opportunity to
Final determination on your eligibility for a public trust or sensitive
explain any information you give us on the form and to make your
position and your being granted a security clearance is the responsibility
comments part of the record.
of the Office of Personnel Management or the Federal agency that
requested your investigation. You may be provided the opportunity
Disclosure of Information
personally to explain, refute, or clarify any information before a final
decision is made.
The information you give us is for the purpose of investigating you for a
position; we will protect it from unauthorized disclosure.
The
Penalties for Inaccurate or False Statements
collection, maintenance, and disclosure of background investigative
The U.S. Criminal Code (title 18, section 1001) provides that knowingly
information is governed by the Privacy Act.
The agency which
falsifying or concealing a material fact is a felony which may result in
requested the investigation and the agency which conducted the
fines of up to $10,000, and/or 5 years imprisonment, or both. In
investigation have published notices in the Federal Register describing
addition, Federal agencies generally fire, do not grant a security
the system of records in which your records will be maintained. You
clearance, or disqualify individuals who have materially and
may obtain copies of the relevant notices from the person who gave you
deliberately falsified these forms, and this remains a part of the
this form. The information on this form, and information we collect
permanent record for future placements. Because the position for which
during an investigation may be disclosed without your consent as
you are being considered is one of public trust or is sensitive, your
permitted by the Privacy Act (5 USC 552a(b)) and as follows:
trustworthiness is a very important consideration in deciding your
suitability for placement or retention in the position.
PRIVACY ACT ROUTINE USES
1. To the Department of Justice when: (a) the agency or any component thereof; or
5. To a Federal, State, local, foreign, tribal, or other public authority the fact that this
(b) any employee of the agency in his or her official capacity; or (c) any employee of
system of records contains information relevant to the retention of an employee, or
the agency in his or her individual capacity where the Department of Justice has
the retention of a security clearance, contract, license, grant, or other benefit. The
agreed to represent the employee; or (d) the United States Government, is a party to
other agency or licensing organization may then make a request supported by
litigation or has interest in such litigation, and by careful review, the agency
written consent of the individual for the entire record if it so chooses. No disclosure
determines that the records are both relevant and necessary to the litigation and the
will be made unless the information has been determined to be sufficiently reliable to
use of such records by the Department of Justice is therefore deemed by the agency
support a referral to another office within the agency or to another Federal agency for
to be for a purpose that is compatible with the purpose for which the agency
criminal, civil, administrative, personnel, or regulatory action.
collected the records.
6. To contractors, grantees, experts, consultants, or volunteers when necessary to
2. To a court or adjudicative body in a proceeding when: (a) the agency or any
perform a function or service related to this record for which they have been
component thereof; or (b) any employee of the agency in his or her official capacity;
engaged. Such recipients shall be required to comply with the Privacy Act of 1974,
or (c) any employee of the agency in his or her individual capacity where the
as amended.
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
7. To the news media or the general public, factual information the disclosure of
careful review, the agency determines that the records are both relevant and
which would be in the public interest and which would not constitute an unwarranted
necessary to the litigation and the use of such records is therefore deemed by the
invasion of personal privacy.
agency to be for a purpose that is compatible with the purpose for which the agency
collected the records.
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
3. Except as noted in Question 21, when a record on its face, or in conjunction with
enable an intelligence agency to carry out its responsibilities under the National
other records, indicates a violation or potential violation of law, whether civil, criminal,
Security Act of 1947 as amended, the CIA Act of 1949 as amended, Executive Order
or regulatory in nature, and whether arising by general statute, particular program
12333 or any successor order, applicable national security directives, or classified
statute, regulation, rule, or order issued pursuant thereto, the relevant records may
implementing procedures approved by the Attorney General and promulgated
be disclosed to the appropriate Federal, foreign, State, local, tribal, or other public
pursuant to such statutes, orders or directives.
authority responsible for enforcing, investigating or prosecuting such violation or
charged with enforcing or implementing the statute, rule, regulation, or order.
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
4. To any source or potential source from which information is requested in the
about whom the record is maintained.
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,
10. To the National Archives and Records Administration for records management
license, or other benefit, to the extent necessary to identify the individual, inform the
inspections conducted under 44 USC 2904 and 2906.
source of the nature and purpose of the investigation, and to identify the type of
information requested.
11. To the Office of Management and Budget when necessary to the review of
private relief legislation.
STATE CODES (ABBREVIATIONS)
Alabama
AL
Hawaii
HI
Massachusetts
MA
New Mexico
NM
South Dakota
SD
Alaska
AK
Idaho
ID
Michigan
MI
New York
NY
Tennessee
TN
Arizona
AZ
Illinois
IL
Minnesota
MN
North Carolina
NC
Texas
TX
Arkansas
AR
Indiana
IN
Mississippi
MS
North Dakota
ND
Utah
UT
MO
Ohio
OH
Vermont
VT
California
CA
Iowa
IA
Missouri
Colorado
CO
Kansas
KS
Montana
MT
Oklahoma
OK
Virginia
VA
Connecticut
CT
Kentucky
KY
Nebraska
NE
Oregon
OR
Washington
WA
Delaware
DE
Louisiana
LA
Nevada
NV
Pennsylvania
PA
West Virginia
WV
Florida
FL
Maine
ME
New Hampshire
NH
Rhode Island
RI
Wisconsin
WI
Georgia
GA
Maryland
MD
New Jersey
NJ
South Carolina
SC
Wyoming
WY
Puerto Rico
PR
American Samoa
AS
District of Columbia
DC
Guam
GU
Northern Marianas
CM
VI
Trust Territory
TT
Virgin Islands
PUBLIC BURDEN INFORMATION
Public burden reporting for this collection of information is estimated to average 60 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 85P (EG)
Form approved:
QUESTIONNAIRE FOR
Revised September 1995
OMB No. 3206-0191
U.S. Office of Personnel Management
PUBLIC TRUST POSITIONS
NSN 7540-01-317-7372
5 CFR Parts 731, 732, and 736
85-1602
OPM
Codes
Case Number
USE
ONLY
Agency Use Only (Complete items A through P using instructions provided by USOPM)
Month
Day
Year
A
Type of
B
Extra
C
Sensitivity/
D
Compu/
E
Nature of
F
Date of
Investigation
Coverage
Risk Level
ADP
Action Code
Action
G
Geographic
H
Position
I
Position
Location
Code
Title
Location
J
K
None
Other Address
ZIP Code
of Official
SON
NPRC
Personnel
Folder
At SON
Location
L
M
Other Address
ZIP Code
None
of Security
SOI
At SOI
Folder
NPI
N
OPAC-ALC
O
Accounting Data and/or
Number
Agency Case Number
Requesting Name and Title
Signature
Telephone Number
Date
P
Official
(
)
Persons completing this form should begin with the questions below.
2
1
FULL
If you have only initials in your name, use them and state (IO).
- If you are a "Jr.," "Sr.," "II," etc., enter this in the
DATE OF
NAME
If you have no middle name, enter "NMN".
box after your middle name.
BIRTH
Last Name
First Name
Middle Name
Jr., II, etc.
Month
Day
Year
4
3
PLACE OF BIRTH - Use the two letter code for the State.
SOCIAL SECURITY NUMBER
Country (if not in the United States)
City
County
State
5
OTHER NAMES USED
Name
Month/Year
Month/Year
Name
Month/Year
Month/Year
#1
#3
To
To
Name
Month/Year
Month/Year
Name
Month/Year
Month/Year
#2
#4
To
To
OTHER
Height (feet and inches)
Weight (pounds)
6
Hair Color
Eye Color
Sex (Mark one box)
IDENTIFYING
Female
Male
INFORMATION
Work (include Area Code and extension)
Home (include Area Code)
7
TELEPHONE
Day
Day
(
)
(
)
NUMBERS
Night
Night
Your Mother’s Maiden Name
8
CITIZENSHIP
b
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. Answer
items b and d.
a
Mark the box at the right that
reflects your current citizenship
I am a U.S. citizen, but I was NOT born in the U.S. Answer items b, c and d.
status, and follow its instructions.
I am not a U.S. citizen. Answer items b and e.
c
UNITED STATES CITIZENSHIP 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
Country
d
DUAL CITIZENSHIP
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.
e
ALIEN If you are an alien, provide the following information:
City
State
Date You Entered U.S.
Alien Registration Number
Country(ies) of Citizenship
Place You
Month
Day
Year
Entered the
United States:
Exception to SF85, SF85P, SF85P-S, SF86, and SF86A approved by GSA September, 1995.
Page 1
Designed using Perform Pro, WHS/DIOR, Sep 95
9
WHERE YOU HAVE LIVED
List the places where you have lived, beginning with the most recent (#1) and working back 7 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 5 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 5-year period, and do not list your spouse, former spouses, or other relatives). Also for addresses in the last 5 years, if the address is "General Delivery," a
Rural or Star Route, or may be difficult to locate, provide directions for locating the residence on an attached continuation sheet.
Month/Year
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
#1
Present
To
Name of Person Who Knows You
Street Address
Apt. #
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
#2
To
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
#3
To
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
#4
To
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Street Address
Apt. #
City (Country)
State
ZIP Code
#5
To
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Telephone Number
(
)
10
WHERE YOU WENT TO SCHOOL
List the schools you have attended, beyond Junior High School, beginning with the most recent (#1) and working back 7 years. List all 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 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 schools you attended in the past 3 years, list a person who knew you at school (an instructor, student, etc.). Do not list people for education
completely outside this 3-year period.
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
State
ZIP Code
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Code
Name of School
Degree/Diploma/Other
Month/Year Awarded
#2
To
Street Address and City (Country) of School
State
ZIP Code
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Code
Name of School
Degree/Diploma/Other
Month/Year Awarded
#3
To
Street Address and City (Country) of School
State
ZIP Code
Name of Person Who Knew You
Street Address
Apt. #
City (Country)
State
ZIP Code
Telephone Number
(
)
Enter your Social Security Number before going to the next page
Page 2
11
YOUR EMPLOYMENT ACTIVITIES
List your employment activities, beginning with the present (#1) and working back 7 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 7-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:
1 - Active military duty stations
5 - State Government (Non-Federal
7 - Unemployment (Include name of
9 - Other
2 - National Guard/Reserve
employment)
person who can verify)
3 - U.S.P.H.S. Commissioned Corps
6 - Self-employment (Include business
8 - Federal Contractor (List Contractor,
4 - Other Federal employment
and/or name of person who can verify)
not Federal agency)
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
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#1
Present
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
Month/Year
Position Title
Supervisor
PREVIOUS
To
PERIODS
Month/Year
Month/Year
Position Title
Supervisor
OF
To
ACTIVITY
Month/Year
Month/Year
Position Title
Supervisor
(Block #1)
To
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#2
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
Month/Year
Position Title
Supervisor
To
PREVIOUS
PERIODS
Month/Year
Month/Year
Position Title
Supervisor
OF
To
ACTIVITY
Month/Year
Month/Year
Position Title
Supervisor
(Block #2)
To
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#3
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
Month/Year
Position Title
Supervisor
PREVIOUS
To
PERIODS
Month/Year
Month/Year
Position Title
Supervisor
OF
To
ACTIVITY
Month/Year
Month/Year
Position Title
Supervisor
(Block #3)
To
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