◆ SpookStack

AUG-31-1994 14:41 FROM r UMIT TO @ LIMFO Pile ™~ “a 25 ILLEGAL DRUGS AND ALCOHOL : . a, (nm the last 5 yoars, have you used, possessed, supplied, of manufactured any illegal drugs? When used without a prescription, tlegal drugs include marijuana, cocaine, hashish, narcotics (opium, morphing, codeine, hergin, ett.), stimulants (cocaine, amphetamines, etc.), depressants (barbiturates, methaquatons, tranquilizers, etc.), hallucinegenies (LSD, PCP, ote.). (NOTE: The information you provide in response to this queston will not be provided for use in any etiminal proceedings against you.) b,. Have you experienced problems (disciplinary actions, evictions, formal complaints, etc.) on or off a job from your use of iNegal drugs or aleohal? Ht you answered “Yas” to question a or b above, provide information relating to the types of substance(s), the nature of the actvity, and any other details relating te your involvement with illegal drugs or alcohol. Include any treatment ot counseling received. “MontvYear Month/Year | Type of Substance Explanaton ST ee i ooo 26 YOUR INVESTIGATIONS RECORD ' g, Was the United States Government ever investigated your background?’ It “Yea,” use the codes that follow to provide the enter “Other” agency code or clearance code, as appropriate, and “Don’t know” or “Don’t recall” under the “Other Agency” heading, below. ff your response js "No," or you don’t know of can't recall if you were investigated and cleared, check the "No” box, 3 for Invesigaung Agency 1 - Defense Depanment To Be PRE ‘ 9 - Not Required 3- Top Secrat 6 - ONonsensitive 2+ State Department 5. Treasury Deparynent + - Confidential 4 - Sensitive Companmenied Iniermation 7-4 3 - Office of Personnel Management 6. Otter (Specity) 2 - Secret 5 - OSensitive 8 Other . Month/Year. Ageney | Other Agency ~ ear: Clearance : : Code D. To your knowledge, have you ever had a clearance or access authorization denied, suspended, of revoked, or have you | Yes | No | ~ ever been debarred from government employment? If “Yes,” give date of action and agency. Baia , Departmen: or Agesey Taking Action ar. Desartnent or Agency Taking Acton 27 YOUR FINANCIAL RECORD a. inthe last 5 years, have you, or a company over which you exercised some control, filed for bankruptcy, been declared bankrupt, been subject to a tax lien, or had legal judgment rendered against you for a debt? If you answered “Yes,” provide date of las action and other information requested below, aes ” — “ . — = ™ bal . Are you now over 180 days delinquent on any loan or finanial obligation? Include loans of obligations funded of | Yes | No | guaranteed by the Federal Government. (/f an SF 177, Application for Federal Employment, will be attached, you do xx not Tom?) repeat Federal Government celinquencies. See the instructions headed, “How is the SF 171 used with | | | is form If you answored “Yes.” provide the information requested below: part Type of Loan or Obligation lame/Address of Creditor or Optiges if Gado and Account # ft fotd enter your Social Security Number before going to the next page > Page & a i 1373 PAGE.Gle a] Gl ion) ral re to AUG 31 *94 13:26