BACKGROUND INVESTIGATION QUESTIONNAIRE
THE CITY OF NEW YORK DEPARTMENT OF INVESTIGATION
80 MAIDEN LANE - 17TH FLOOR NEW YORK, NY 10038
(212) 825-5900
BACKGROUND INVESTIGATION QUESTIONNAIRE
DEPARTMENT OF INVESTIGATION (DOI) BACKGROUND INVESTIGATIONS ARE DETAILED AND THOROUGH. INFORMATION PROVIDED BY INDIVIDUALS IN THE BACKGROUND QUESTIONNAIRE IS VERIFIED BY THIS DEPARTMENT WITH OUTSIDE AGENCIES. FOR EXAMPLE, CRIMINAL CONVICTIONS ARE VERIFIED WITH THE FEDERAL BUREAU OF INVESTIGATION AND/OR THE NEW YORK STATE DIVISION OF CRIMINAL JUSTICE SERVICES; TAX FILING DATES ARE VERIFIED WITH THE INTERNAL REVENUE SERVICE AND THE NEW YORK STATE DEPARTMENT OF TAXATION AND FINANCE; EDUCATIONAL DEGREES ARE VERIFIED WITH SCHOOLS AND UNIVERSITIES; EMPLOYMENT HISTORY IS VERIFIED WITH PREVIOUS EMPLOYERS, ETC.
A FALSE STATEMENT OR INTENTIONAL OMISSION MADE IN THIS QUESTIONNAIRE OR IN CONNECTION WITH THIS BACKGROUND INVESTIGATION MAY RESULT IN THE IMPOSITION OF DISCIPLINARY PENALTIES, INCLUDING TERMINATION OF EMPLOYMENT, OR DISQUALIFICATION FROM FUTURE EMPLOYMENT AND, IN ADDITION, MAY SUBJECT YOU TO CRIMINAL PROSECUTION.
THIS DEPARTMENT WILL NOT APPROVE YOUR TERMS AND CONDITIONS OF APPOINTMENT IF YOU FAIL TO PROVIDE ALL INFORMATION REQUESTED OR OTHERWISE FAIL TO COOPERATE FULLY IN THIS INVESTIGATION.
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS FOR AT LEAST 10 YEARS
THIS BACKGROUND INVESTIGATION QUESTIONNAIRE (BIQ) IS NOT A PUBLIC DOCUMENT AND CANNOT BE ACCESSED BY THE
PUBLIC THROUGH THE FREEDOM OF INFORMATION LAW (FOIL)
For DOI Use Only
Candidate:
_________________________
Candidate Telephone #: _________________________
Investigator:
_________________________
Background Interview Date:
// /
DOI Review Date:
/ /
BIQ - 01/05
INDEX TO QUESTIONS
Instructions Personal Information Residence Family/Household Information Driving Record/Motor Vehicle Information Academic/Educational Record Professional Licenses and Certifications Employment History U.S. Military Service Criminal/Investigatory History Civil/Administrative Proceedings Organizational/Business Affiliations Sources of Income Net Worth Table Itemization of Assets Itemization of Liabilities Trusts/Beneficial Interests Tax Information Conflicts of Interest Political Party Positions Miscellaneous Certification and Signature Addendum to BIQ
Question(s) Page
1
1 - 6
1
7 - 9
3
10
5
11 - 12 7
13
9
14
10
15 - 18 11
19
16
20 - 27 17
28
19
29 - 30 20
31
24
32
26
33 - 39 27
40 - 47 31
48
35
49 - 51 36
52
37
53 - 55 37
56 - 59 38
40
41
INSTRUCTIONS
All questions must be answered completely and accurately. Type or print clearly in blue or black ink. If you need more space, attach an addendum (see page 41) and indicate the question number(s) to which the addendum pertains. Note in the space provided for your answer on the questionnaire that an addendum is attached. Indicate if a question is inapplicable to you by entering N/A.
Attach here passportsize photograph taken within the past twelve
(12) months.
This questionnaire must be signed and sworn to by you before a Notary Public or Commissioner of Deeds.
PERSONAL INFORMATION 1A. Full Name:
Last Name
First Name
Middle Name
1B. Have you ever used or been known by any other name, including a maiden name?
Yes9 No9
If Ayes,@ provide the information requested below:
Full Name
Dates Used
From
To
Month Year Month Year
/
/
/
/
Reason
2. Date of Birth: 3. Place of Birth:
_______/________/________
Month
Day
Year
City
State
Country
4. Marital Status: (Check one)
Single9 Divorced9
Married9 Widowed9
Domestic Partner9 Legally Separated9
Note: ADomestic Partner@ applies to persons who have a registered domestic partnership pursuant to New Yor k Cit y Adm inistrative Code '3-241, or a domestic partnership registered in accordance with Execu tive Order No. 123, dated Augus t 7, 1989, or Executive Order No. 48, dated January 7 , 1993.
If Married, provide the information requested below:
Date of Marriage
Month Day Year
/ /
Spouse=s Full Name, Including Maiden Name (Last, First)
Spouse=s Date of
Birth
Month
Day
Year
/ /
If you have a Registered Domestic Partnership, provide the information requested below:
Date of
Registration
Month
Day
Year
/ /
Domestic Partner=s Full Name (Last, First)
Domestic Partner=s
Date of Birth
Month
Day
Year
/ /
If Legally Separated, Divorced, or Widowed, provide the information requested below:
Date of
Separation,
Divorce, or Death
Month
Day
Year
/ /
/ /
Spouse=s Full Name, Including Maiden Name (Last, First)
Spouse=s Date of Birth
Month
Day
Year
/ /
/ /
(If Legally Separated or Divorced, attach to this questionnaire a copy of your separation agreement or divorce decree.)
5A. Social Security Number:
SELF SPOUSE DOMESTIC PARTNER
5B. Have you ever used, or been issued, a Social Security number other than the one listed above?
Yes9 No9
If Ayes,@ list the other Social Security number(s) used or issued, and provide details, including dates and reasons used or issued, below:
_________________________________________________________________________
_________________________________________________________________________
2
6A. Are you a citizen of the United States?
Yes9 No9
If you are not a U.S. citizen, state the country of your citizenship:
Country of citizenship ________________________________________________________
6B. Are you legally present in the United States?
Yes9 No9
IF YOU ARE NOT A UNITED STATES CITIZEN, BRING YOUR ORIGINAL IMMIGRATION DOCUMENT(S) AUTHORIZING YOUR ENTRY INTO, AND EMPLOYMENT IN, THE UNITED STATES WITH YOU TO YOUR BACKGROUND INTERVIEW.
6C. If you are a naturalized U.S. citizen, provide the following information:
Certificate #
Alien Registration #
Date of Issuance
Month
Day
Year
/ /
Court of Issuance
IF YOU ARE A NATURALIZED CITIZEN OF THE UNITED STATES, BRING YOUR ORIGINAL CERTIFICATE OF NATURALIZATION WITH YOU TO YOUR BACKGROUND INTERVIEW.
RESIDENCE
7A. State your present primary residence. Street address & apartment number City, State, Zip Code Dates of residence
7B. List your mailing address, if different than above. Street address & apartment number City, State, Zip Code Dates used and reason
7C. Home telephone number(s)
Business telephone number(s) Fax number(s) Cellular telephone number(s)
3
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