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ALUIG-31-1994 14:46 FROM e WIN TT Ta @ WMFO P.ii need f b _ . Standard Form 86 QUESTIONNAIRE FOR Form approved: Revised December 1990 wo O.M.B. No, 2206-0007 U.S.Office of Personnel Management SENSITIVE POSITIONS erfeuaeneamelel FPM Chapter 732 (For National Security) 20 YOUR SELECTIVE SERVICE RECORD a. Are you a male born after December 31, 19597 If "No," go to 21. If "Yes," go to b. b. Have you registered with the Selactive Servica System? If "Yes,” provide your registration number, If “No,” show the reason for your lagat exernption below, Ragistration Number Legal Exemption Explanation 21 YOUR MILITARY RECORD a. Have you ever received other than an honorable discharge from the military? If “Yos,” provide: Date of Discharge (Month and Year): Type of Discharge: b. Have you ever been subject to court-martial or other disciplinary proceedings under the Uniform Code of Military Justice? lf "Yes," list any disciplinary proceedings in the last 8 years and all courts-martial, (Include nonjudicial and Captain's mast, etc.) . 22 YOUR EMPLOYMENT RECORD Has any of the following happened to you in the last 15 years? if “Yes,” begin with the most recent occurrence and go backward, providing date fired, quit, or left, and other information requested. Use the following codes and explain the reason your employment was anded: 1 - Fired from a job 3 - Left a job by mutual agreement following allegations of misconduct § - Left a job for other reasons 2 - Quit a job after being told 4 - Left a job by mutual agreement following allagations of under unfavorable Greumstances you'd be fired unsatisfactory perormenee ‘Montvy ear: Specify Reason mptoyers Name and Address ' 23 YOUR POLICE RECORD (De not include anything that happened before your 16th birthday.) . Have you ever been charged with or convicted of any felony offense? b. Have you ever been charged with or convicted of a firearms or explosives offense? — C. Are there currently any charges pending against you for any criminal offense? d. Have you evar been charged with or convicted of any offense(s) related to alcohol or drugs? € n the last 5 years, have you been arrested for, charged with, or convicted for any offense(s) not listed in response to a, b, c, ord above? (Leave out traffic fines of less than $100.) if you answered “Yes” to a, b, o, d, or @ above, explain your answar(s) in the space provided. Pf ea YOUR MEDICAL RECORD @. Have you experienced problems on or off the job because of any emotional or mental condition? b, Have you ever seen a health care professional for any of the types of probleme mentioned above? ¥ you answered "Yes" to questions a or b, explain below. “Mont eat, Month/Year. Expianation Enter your Social Security Number before going to the next page > Re v¥|-Vél-lepy Page 7 AUG G1 '9S4 19:19 @e@2 324 13979 £PAGE.@11