NCIS Form 5580/105 "Ncis Background Security Questionnaire for Interns"

What Is NCIS Form 5580/105?

This is a legal form that was released by the U.S. Department of the Navy - Naval Criminal Investigative Service on November 1, 2015 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2015;
  • The latest available edition released by the U.S. Department of the Navy - Naval Criminal Investigative Service;
  • 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 printable version of NCIS Form 5580/105 by clicking the link below or browse more documents and templates provided by the U.S. Department of the Navy - Naval Criminal Investigative Service.

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NCIS Background Security Questionnaire for Interns
PRIVACY ACT STATEMENT:
PURPOSE: The Naval Criminal Investigative Service (NCIS) is conducting a pre-internship
inquiry regarding you as the result of your application for an internship. The Privacy Act of
1974 requires that each individual asked to provide personal information be advised of the
following:
AUTHORITY: 5 U.S.C. 301.
ROUTINE USES: The information provided in this questionnaire will be analyzed by the NCIS.
The information provided by you will become a permanent part of your NCIS record if you are
offered and accept an NCIS internship position, or will be destroyed after one year if an
internship position is offered and declined, or if you are not accepted for an internship position
with NCIS. The information provided will not be divulged outside of the Department of
Defense without your written authorization other than to federal, state, and local law
enforcement bodies for their required official use, and to other authorized regulatory agencies.
PARTICIPATION: You are not required to provide this information; however, failure to do so
will result in your disqualification as an applicant.
IMPORTANT NOTE: The information provided below is used to screen potential interns. All
answers are verified through an extensive background suitability investigation, which involves
database queries, credit bureau reports and interviews of supervisors, co-workers, friends,
neighbors and other persons who know you and can provide information concerning your
suitability. Your willingness and ability to accurately and thoroughly answer the following
questions significantly affects the decision to continue processing your application. All
questions must be answered honestly and completely, regardless of whether you may have
been told that any of your records have been sealed or expunged. Attention to detail is critical.
Therefore, if you fail to fully answer all questions, to include providing explanations, your
questionnaire will be deemed to be incomplete. Incomplete questionnaires will result in
disqualification from further processing. Candor is a crucial character trait. Falsification of any
facts, through either omission or misrepresentation, on this questionnaire will, in most
circumstances, result in immediate disqualification from further processing. Any advice you may
have received concerning the withholding of requested and/or applicable information must be
disregarded. ____ Initial
Applicant’s Name (First MI Last):
Last 4 of Social Security Number:
Date of Birth:
RESPOND TO THE FOLLOWING QUESTIONS BY CHECKING THE APPROPRIATE BOX.
1. Are you a U.S. citizen?
Yes
No
2a. Do you hold dual citizenship?
Yes
No
b. If yes, list the country or countries
Yes
No
3. Are there any members of your immediate family who are not U.S. citizens?
Yes
No
4. Would your past actions result in others characterizing you as indiscreet,
Yes
No
unstable, or of questionable character?
NCIS Form 5580/105 (11/15)
Initials_______/Date________
1
NCIS Background Security Questionnaire for Interns
PRIVACY ACT STATEMENT:
PURPOSE: The Naval Criminal Investigative Service (NCIS) is conducting a pre-internship
inquiry regarding you as the result of your application for an internship. The Privacy Act of
1974 requires that each individual asked to provide personal information be advised of the
following:
AUTHORITY: 5 U.S.C. 301.
ROUTINE USES: The information provided in this questionnaire will be analyzed by the NCIS.
The information provided by you will become a permanent part of your NCIS record if you are
offered and accept an NCIS internship position, or will be destroyed after one year if an
internship position is offered and declined, or if you are not accepted for an internship position
with NCIS. The information provided will not be divulged outside of the Department of
Defense without your written authorization other than to federal, state, and local law
enforcement bodies for their required official use, and to other authorized regulatory agencies.
PARTICIPATION: You are not required to provide this information; however, failure to do so
will result in your disqualification as an applicant.
IMPORTANT NOTE: The information provided below is used to screen potential interns. All
answers are verified through an extensive background suitability investigation, which involves
database queries, credit bureau reports and interviews of supervisors, co-workers, friends,
neighbors and other persons who know you and can provide information concerning your
suitability. Your willingness and ability to accurately and thoroughly answer the following
questions significantly affects the decision to continue processing your application. All
questions must be answered honestly and completely, regardless of whether you may have
been told that any of your records have been sealed or expunged. Attention to detail is critical.
Therefore, if you fail to fully answer all questions, to include providing explanations, your
questionnaire will be deemed to be incomplete. Incomplete questionnaires will result in
disqualification from further processing. Candor is a crucial character trait. Falsification of any
facts, through either omission or misrepresentation, on this questionnaire will, in most
circumstances, result in immediate disqualification from further processing. Any advice you may
have received concerning the withholding of requested and/or applicable information must be
disregarded. ____ Initial
Applicant’s Name (First MI Last):
Last 4 of Social Security Number:
Date of Birth:
RESPOND TO THE FOLLOWING QUESTIONS BY CHECKING THE APPROPRIATE BOX.
1. Are you a U.S. citizen?
Yes
No
2a. Do you hold dual citizenship?
Yes
No
b. If yes, list the country or countries
Yes
No
3. Are there any members of your immediate family who are not U.S. citizens?
Yes
No
4. Would your past actions result in others characterizing you as indiscreet,
Yes
No
unstable, or of questionable character?
NCIS Form 5580/105 (11/15)
Initials_______/Date________
1
NCIS Background Security Questionnaire (continued)
5. Do you have any reason to think that anyone would believe you to be disloyal
Yes
No
to the U.S.?
6. Have you ever been convicted of any criminal offense, other than a traffic
infraction? If yes, state the offense charged, the offense convicted of, the date of
Yes
No
conviction, the punishment imposed and location of the Court.
7. Have you ever been arrested or detained or charged with any criminal offense
regardless of the disposition? If yes, state the specific conduct for which you
Yes
No
were arrested/detained/charged. Explain how the matter was resolved. Include
the date, location and entity that made the arrest/detention/charge.
8. Have you ever been convicted of any offense by a military court? If yes, state
Yes
No
the offense charged, the date of conviction and the punishment imposed.
9. Have you ever been the subject of a criminal investigation conducted by any
local, state, federal and/or military law enforcement agency? If yes, state the
Yes
No
nature of the investigation and your involvement.
10. Have you ever been punished under Article 15 of the UCMJ? If yes, state the
Yes
No
circumstances, offense charged, date and punishment.
11. Have you ever experienced any financial difficulties in your lifetime? This
includes, but is not limited to declaring bankruptcy; having liens against your
property; writing checks not covered by sufficient funds; being late on regularly
scheduled payments; had any bills that are more than 30 days delinquent; had
your wages garnished; failed to pay child and/or spousal support; been sued by
Yes
No
creditors; had an account closed at the request of the credit grantor; failed to pay
court ordered judgments, moved, changed your address or taken other steps to
avoid creditors; had a loan modified, had a debt forgiven and/or defaulted on a
loan or consumer debt.
12. Do you know of, or have any reason to believe, that there is any unfavorable
credit information about you on record with any credit bureau, business or court?
Unfavorable credit information includes, but is not limited to late payments (i.e.
Yes
No
30, 60 or 90 days) for loans and/or consumer credit, accounts which have been
closed at the request of the credit grantor, accounts which have been turned over
to a debt collection agency, and tax liens
13. Have you reviewed your credit reports (e.g. Transunion, Experian and
Yes
No
Equifax) within the past 12 months?
14. Have you used marijuana at all within the last three years?
Yes
No
15. Have you ever used marijuana in your lifetime?
Yes
No
16. Have you used anabolic steroids at all within the last three years?
Yes
No
17. Have you ever used anabolic steroids in your lifetime?
Yes
No
Last Name: ____________________ SSN (Last 4): _________
Initials: _________
Date: ________
2
NCIS Background Security Questionnaire (continued)
18. Have you used any other illegal drugs within the last 10 years?
Yes
No
19. Have you ever used any other illegal drugs in your lifetime?
Yes
No
20. Have you used any prescription drug and/or a legally obtainable substance in a
Yes
No
manner for which it was not intended within the last three years?
21. Have you ever used any prescription drug and/or a legally obtainable substance
Yes
No
in a manner for which it was not intended in your lifetime?
22. Have you ever been involved in the illegal possession, purchase,
manufacture, trafficking, production, transfer, shipping, receiving, handling, or
Yes
No
sale of any controlled substance (including prescription drugs) for profit?
23. Have you ever used an illegal drug and/or misused a prescription drug while
in the military, a law enforcement or prosecutorial position, or while employed in a
Yes
No
position requiring a U.S. Government security clearance and/or a position
designated for drug testing?
24. Have you ever been punished, expelled, received a failing grade or no credit,
or received any other type of sanction as a result of cheating since graduating
Yes
No
high school?
25. Has your use of alcohol resulted in intervention by law enforcement?
Yes
No
26. Are there any incidents in your life which could subject you to blackmail, such
Yes
No
as extramarital affairs, undetected theft, fraud or embezzlement?
27. Are you now or have you ever been a member of any organization,
association, movement, group, or combination of persons advocating the
overthrow of the American constitutional form of government, or which has
Yes
No
adopted the policy of advocating or approving the commission of acts of force or
violence to deny other persons their rights under the Constitution of the U.S.?
28. Are you now or have you ever been affiliated or associated with any
Yes
No
organization listed or described in item 27 as an agent, official or employee?
29. Have you ever contributed to any organization listed or described in item 27?
Yes
No
30. Have you ever been approached to engage in espionage or sabotage against
Yes
No
the U.S.?
31. Have you ever had any unauthorized contact with a representative of a
Yes
No
foreign government?
32. Have you ever been approached to give or sell any classified information?
Yes
No
Last Name: ____________________ SSN (Last 4): _________
Initials: _________
Date: ________
3
NCIS Background Security Questionnaire (continued)
33. Have you ever been approached to give or sell any national defense
information and/or controlled unclassified information to a person or an
Yes
No
organization you knew to be an unauthorized recipient?
34. Have you ever been involved in a violation of security rules or loss or possible
Yes
No
compromise of classified information?
35. Have you ever deliberately provided and/or leaked classified information,
national defense information and/or controlled unclassified information (e.g. SBU,
Yes
No
FOUO, LES) to a person or an organization you knew to be an unauthorized
recipient?
36. Have you been fired or left a job under unfavorable circumstances?
Yes
No
37. Have you ever resigned in lieu of termination?
Yes
No
38. Have you ever been told you would be fired before resigning from a job?
Yes
No
39. Did you ever resign, by mutual agreement, following allegations of misconduct
Yes
No
or unsatisfactory performance?
40. Have you ever received a written warning, been officially reprimanded,
Yes
No
suspended, or disciplined for misconduct in the workplace?
41. Have you ever received a written warning, been officially reprimanded,
Yes
No
suspended, or disciplined for violating a security rule or policy?
42. I understand that if I receive a conditional offer of employment, I am required
to disclose any and all prior personal, government, military and/or VA medical and
Yes
No
psychological treatment histories.
Use the space below to explain any “yes” answers (with the exception of 1, 13 & 42). Annotate
the question # for each response. A complete answer is one which addresses all the basic
interrogatives (i.e. who, what, when, where, how & why). Your answers need to describe the
situation, your actions and the outcome. IMPORTANT NOTE: It is important you consider how
your answers and/or non-answers potentially reflect on your candor. If you are in doubt as to
whether or not you should provide information, it is STRONGLY recommended that you include
the information to ensure NCIS can consider the both the context and the totality of the
circumstances. Attach additional sheets if necessary.
I certify the entries made by me are true, complete and accurate to the best of my knowledge
and belief. I understand that an intentional false statement and/or omission on this form can
lead to immediate disqualification from the internship process.
Signature: _________________________________________
Date: __________________
Last Name: ____________________ SSN (Last 4): _________
Initials: _________
Date: ________
4
NCIS Background Security Questionnaire (continued)
Continuation
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Continuation
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(Use additional sheets if more space is required)
Last Name: ____________________ SSN (Last 4): _________
Initials: _________
Date: ________
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