Please do not sign this document until you attend the Benefits Orientation.
This document must be printed on one page (2 sided, front and back).
Complete part 1 only.
Reflect information in every field.
Reflect "N/A" if a field does not apply to you.
Reflect your address for at least the last 10 years.
Reflect a "?" if you do not know the answer to a field.
Answer all questions completely and accurately by printing clearly in black ink or typing your answers. Failure to complete or print clearly may delay or deny your request. Given the nature of the form and the actions to be taken when received, the Office of Background Investigations shall not accept forms that have been altered in any fashion. Forms that contain correction tape or white-out will be returned.
If a middle name is an initial, indicate "initial only" otherwise, enter a full middle name given at birth.
For "other names used" list all previous names; nicknames, all previous married names, legal name changes, changes due to adoption, etc. Circle appropriate title description on the form.
If additional space is needed to complete the form (i.e. providing information on addresses, spouses, and children) attach an 8 inch by 11-inch sheet of paper along with your form.