Section 11, Residences:
Entry #
Dates (from – to)(MM/YYYY):
Status:
Address:
City, State, Zip Code:
APO/FPO:
Verifying Person:
Name:
Address:
City, State, Zip Code:
APO/FPO:
Phone #:
Relationship:
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Section 13A, Employment:
Entry #
Dates (from – to)(MM/YYYY):
Employer/Verifier:
Phone #:
Address:
City, State, Zip Code:
Physical location (if different form employers address)
Address:
Phone #:
City, State, Zip Code:
Supervisor (if different form employers address)
Name and title:
Phone #:
Address:
City, State, Zip Code:
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Section 18, Relatives:
Entry #
Code:
Full Name:
Date of Birth(MM/DD/YYYY):
Place of Birth (City, State):
Country(ies) of Citizenship:
Current Address:
City, State, Zip Code:
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Section 19, Foreign Contacts:
Entry #
Full Name:
Date of First Contact:
Date of Last Contact:
Method of Contact:
Frequency of Contact:
Nature of Relationship:
Country(ies) of Citizenship:
Contact’s Date of Birth:
Contact’s Street Address:
Contact’s Employer/Employer’s Address:
Is Foreign National affiliated with a foreign government, military, security, defense industry, or intelligence service:
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Section 20C, Foreign Travel:
Entry #
Country Visited:
Dates of Travel:
Total Number of Days Involved in Visit:
Purpose of Travel:
While traveling to, or in this country, were you questioned, searched, or otherwise detained by local customs or security service officials when entering or leaving this country?:
While traveling to or in this country, were you involved in any encounter with the police?:
While traveling to, or in this country, were you contacted by, or in contact with any person known or suspected of being involved or associated with foreign intelligence, terrorist, security, or military organizations?:
While traveling to, or in this country, were you involved in any counterintelligence or security issues not reported?:
While traveling to, or in this country, were you contacted by, or in contact with anyone exhibiting excessive knowledge of or undue interest in your or your job?:
While traveling to, or in this country, were you contacted by, or in contact with anyone attempting to obtain classified information or unclassified, sensitive information?:
While traveling to, or in this country, were you threatened, coerced, or pressured in any way to cooperate with a foreign government official or foreign intelligence or security service?:
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Section 26, Financial Record:
Entry #
Date Satisfied:
Amount:
Type of Loan:
Name of Institution:
Address:
City, State, Zip Code:
Status:
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Continuation Space:
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