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Standard Form 86A Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

CONTINUATION SHEET FOR QUESTIONNAIRES SF 85, SF 85P, AND SF 86 For use with the SF 85, Questionnaire for Non-Sensitive Positions; SF 85P, Questionnaire for Public Trust Positions; and SF 86, Questionnaire for National Security Positions

Form approved: OMB No. 3206 0005 NSN 7540-01-268-4828 86-111

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

11 WHERE YOU HAVE LIVED (Continued) #5 Month/Year To Month/Year Status Own Rent Military housing Other (Explain) Street address Apt.#

APO/FPO address City (Country) Name of person who knows you at this address APO/FPO address (if currently applicable) City (Country) Telephone number Alternate contact number Own Rent Relationship Military housing Other (Explain) Neighbor Friend #6 Month/Year To Month/Year Status APO/FPO address City (Country) Name of person who knows you at this address APO/FPO address (if currently applicable) City (Country) Telephone number #7 Month/Year Alternate contact number Own Rent Relationship Military housing Other (Explain) Neighbor Friend To Month/Year Status Street address Landlord Business associate Apt.# State ZIP Code Current address State ZIP Code Apt.# Street address Landlord Business associate Apt.# State ZIP Code Current address State ZIP Code Apt.#

Other (Explain)

Other (Explain)

APO/FPO address City (Country) Name of person who knows you at this address APO/FPO address (if currently applicable) City (Country) Telephone number Alternate contact number Relationship Neighbor Friend Landlord Business associate State ZIP Code Current address State ZIP Code Apt.#

Other (Explain)

Enter your Social Security Number before going to the next page

Standard Form 86A Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

CONTINUATION SHEET FOR QUESTIONNAIRES SF 85, SF 85P, AND SF 86

Form approved: OMB No. 3206 0005 NSN 7540-01-268-4828 86-111

12 WHERE YOU WENT TO SCHOOL (Continued) #6 Month/Year To Month/Year Code Name of school Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. State Current address State To Month/Year Code Name of school ZIP Code Telephone number Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. State Current address State To Month/Year Code Name of school ZIP Code Telephone number Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. State Current address State To Month/Year Code Name of school ZIP Code Telephone number Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. State Current address State To Month/Year Code Name of school ZIP Code Telephone number Degree/diploma received? If "Yes," identify type of degree/diploma received and date awarded. State Current address State ZIP Code Telephone number ZIP Code Apt. # ZIP Code Apt. # ZIP Code Apt. # ZIP Code Apt. # ZIP Code Apt. # YES NO

Street address and City (Country) of school Name of person who knows you City (Country) #7 Month/Year

YES NO

Street address and City (Country) of school Name of person who knows you City (Country) #8 Month/Year

YES NO

Street address and City (Country) of school Name of person who knows you City (Country) #9 Month/Year

YES NO

Street address and City (Country) of school Name of person who knows you City (Country) #10 Month/Year

YES NO

Street address and City (Country) of school Name of person who knows you City (Country)

Enter your Social Security Number before going to the next page

Standard Form 86A Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

CONTINUATION SHEET FOR QUESTIONNAIRES SF 85, SF 85P, AND SF 86

Form approved: OMB No. 3206 0005 NSN 7540-01-268-4828 86-111

13 EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued) #5 Dates of Employment Month/Year To Month/Year Employer/Verifier Name of employer/verifier Address of employer/verifier City (Country) Physical Location Your actual work address (if different from employer address) City (Country) Supervisor (if different from employer) Name and title Work address of supervisor City (Country) Additional Periods of Activity with this Employer Month/Year To Month/Year Position title Month/Year Month/Year To Month/Year To Month/Year Position title Position title State ZIP Code State ZIP Code Type of Employment Employment code Position title/Military rank Work hours Full-Time Part-Time

Telephone number

Telephone number State ZIP Code

Telephone number

Supervisor Supervisor Supervisor

Explanation/Reason for leaving #6 Dates of Employment Month/Year To Month/Year Employer/Verifier Name of employer/verifier Address of employer/verifier City (Country) Physical Location Your actual work address (if different from employer address) City (Country) Supervisor (if different from employer) Name and title Work address of supervisor City (Country) State ZIP Code State ZIP Code Type of Employment Employment code Position title/Military rank

Work hours

Full-Time Part-Time

Telephone number

Telephone number State ZIP Code

Telephone number

Enter your Social Security Number before going to the next page

Standard Form 86A Revised July 2008 U.S. Office of Personnel Management 5 CFR Parts 731, 732, and 736

CONTINUATION SHEET FOR QUESTIONNAIRES SF 85, SF 85P, AND SF 86

Form approved: OMB No. 3206 0005 NSN 7540-01-268-4828 86-111

13 EMPLOYMENT/UNEMPLOYMENT INFORMATION (Continued) Additional Periods of Activity with this Employer Month/Year To Month/Year Position title Month/Year Month/Year To To Month/Year Position title Month/Year Position title

Supervisor Supervisor Supervisor

Explanation/Reason for leaving #7 Dates of Employment Month/Year To Month/Year Employer/Verifier Name of employer/verifier Address of employer/verifier City (Country) Physical Location Your actual work address (if different from employer address) City (Country) Supervisor (if different from employer) Name and title Work address of supervisor City (Country) Additional Periods of Activity with this Employer Month/Year To Month/Year Position title Month/Year Month/Year To Month/Year To Month/Year Position title Position title State ZIP Code State ZIP Code Type of Employment Employment code Position title/Military rank

Work hours

Full-Time Part-Time

Telephone number

Telephone number State ZIP Code

Telephone number

Supervisor Supervisor Supervisor

Explanation/Reason for leaving

PUBLIC BURDEN INFORMATION
Public burden reporting for this collection of information averages 20 minutes, 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 OPM Forms Officer, U.S. Office of Personnel Management, 1900 E Street NW, Washington, DC 20415. Do not send your completed form to this address, send it to the office that provided you the form. The OMB clearance number, 3206-0005, is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed. After completing this form and any attachments, you should review your answers to all questions to make sure the form is complete and accurate, and then sign and date the following certification and the attached release(s). My statements on this form, and on any attachments to it, are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I have carefully read the foregoing instructions to complete this form. I understand that a knowing and willful false statement on this form can be punished by fine or imprisonment or both (18 U.S.C. 1001). I understand that intentionally withholding, misrepresenting, or falsifying information may have a negative effect on my security clearance, employment prospects, or job status, up to and including denial or revocation of my security clearance, or my removal and debarment from Federal service. Signature Date (mm/dd/yyyy)

Certification

Enter your Social Security Number before going to the next page