PERSONNEL SECURITY WORKSHEET - Marines



PERSONNEL SECURITY WORKSHEET

 

This is a draft worksheet to help you assemble your personal information for your clearance. The items from this worksheet are then input into the Security Officer program for validation and the printing of a hard copy for your signature. The security program is on all OSO Denver's office computers. When you have assembled all the required information you can schedule a time to come in the office and enter the information. If you are not in the Denver commuting area we will enter the information you provide. When the information is validated and printed, fingerprint cards and a cover sheet are attached, all are signed and the package is then submitted for investigation.

ALL ITEMS ARE REQUIRED

• Indicate Unk (Unknown) or FNU (First Name Unknown), MNU (Middle Name Unknown) or LNU (Last Name Unknown) if names are ABSOLUTELY irretrievable.

• PLEASE do not use family members as verifiers.

• Dates should be formatted as YYYY/MM/DD (e.g., 1995/03/28), and it is your responsibility to account for all time periods. The Security Officer Program will sort dates automatically but any date gaps of more than 1-2 days will prevent validation.

• AVOID CONFLICTING INFO. Verify time periods between residences, colleges and employment. Example: listing a residence in Wisconsin, college in New York and employment in Japan during the same time period.

**click mouse in First Name field, then use TAB key to move from field to field

PERSONAL INFORMATION:

|First Name |Middle Name |Last Name |Jr/Sr/III, etc? |SSN |

|      |      |      |      |      |

|Date of Birth |City/State of Birth |County of Birth |Country of Birth |Gender (M/F) |

|      |      |      |      |      |

|Birth Name (if different) |Dates used (to/from) |Height |Weight |Hair Color |Eye Color |

|      |      |      |      |      |      |

|Country of Citizenship |Dual Citizen Country? |If Foreign Born, what is your source of citizenship? |

|      |      |      |

|Naturalization Number, Date, Court Name, City/State |Citizen Certificate #, Date, Court Name, City/State |

|      |      |

|U. S. Passport # (if applicable) |Foreign Passport # (if applicable) |

|      |      |

|Your Mother's Full Maiden Name |Your Mother's citizenship status |

|      |      |

RESIDENCES for the past FULL 7 years, no gaps - more fields for this info are at the end of this form

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

Residences continued on next page

Residences, continued:

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

Additional Residences can be provided at the end of this form

SCHOOL ATTENDANCE: List all schools/degrees in the past 7 full years

|From Date |To Date |School |Degree? |School Address |

|      |      |      |      |      |

|Verifier Name |Verifier's Mailing Address |Verifier Phone# |

|      |      |      |

|From Date |To Date |School |Degree? |School Address |

|      |      |      |      |      |

|Verifier Name |Verifier's Mailing Address |Verifier Phone# |

|      |      |      |

|From Date |To Date |School |Degree? |School Address |

|      |      |      |      |      |

|Verifier Name |Verifier's Mailing Address |Verifier Phone# |

|      |      |      |

|From Date |To Date |School |Degree? |School Address |

|      |      |      |      |      |

|Verifier Name |Verifier's Mailing Address |Verifier Phone# |

|      |      |      |

EMPLOYMENT/UNEMPLOYMENT Periods- the past FULL 7 years-no gaps - Unemployment periods must be listed individually with a Verifier, just insert the verifier's name/address/phone in the Supervisor fields.

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

| | | | | | |

|EMPLOYMENT, CONTINUED | |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

ADDITIONAL FIELDS FOR EMPLOYMENT/UNEMPLOYMENT CAN BE FOUND AT THE END OF THIS FORM

CIVIL SERVICE

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Service |Unit |Grade |RE Code |

|      |      |      |      |      |      |

|Supervisor's Name |Unit Address |Unit Ph# |

|      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Service |Unit |Grade |RE Code |

|      |      |      |      |      |      |

|Supervisor's Name |Unit Address |Unit Ph# |

|      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Service |Unit |Grade |RE Code |

|      |      |      |      |      |      |

|Supervisor's Name |Unit Address |Unit Ph# |

|      |      |      |

3 PEOPLE WHO KNOW YOU WELL - All or a combination of these 3 must cover the entire past 7 years.

|1.Known From Date |Known To Date |First Name |Middle Name |Last Name |Jr/Sr/III, etc.|

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |

|      |      |

|Date of Separation |City/State/County where separated |

|      |      |

|Citizenship of Spouse |Alien#/Naturalization#, City/State/Court where Naturalized |

|      |      |

|2. Date of Marriage |Current Marital Status |Spouse First Name |Middle Name |Current Last Name |Jr/Sr/III, etc.|

|      |      |      |      |      |      |

|      |      |

|      |      |

|Date of Separation |City/State/County where separated |

|      |      |

|Citizenship of Spouse |Alien#/Naturalization#, City/State/Court where Naturalized |

|      |      |

RELATIVES - List all immediate family, stepfamily, adoptive family, foster family and in-laws only.

|Relationship |First Name |Middle Name |Last Name |Jr/Sr/III, etc.|Date of Birth |

|      |      |      |

|      |      |      |

|Still Living? |Current Address |

|      |      |

|Relationship |First Name |Middle Name |Last Name |Jr/Sr/III, etc.|Date of Birth |

|      |      |      |

|      |      |      |

|Still Living? |Current Address |

|      |      |

|Relationship |First Name |Middle Name |Last Name |Jr/Sr/III, etc.|Date of Birth |

|      |      |      |

|      |      |      |

|Still Living? |Current Address |

|      |      |

|Relationship |First Name |Middle Name |Last Name |Jr/Sr/III, etc.|Date of Birth |

|      |      |      |

|      |      |      |

|Still Living? |Current Address |

|      |      |

|Relationship |First Name |Middle Name |Last Name |Jr/Sr/III, etc.|Date of Birth |

|      |      |      |

|      |      |      |

|Still Living? |Current Address |

|      |      |

| |

|Relatives continued on next page |

| |

|Relationship |First Name |Middle Name |Last Name |Jr/Sr/III, etc.|Date of Birth |

|      |      |      |

|      |      |      |

|Still Living? |Current Address |

|      |      |

|Relationship |First Name |Middle Name |Last Name |Jr/Sr/III, etc.|Date of Birth |

|      |      |      |

|      |      |      |

|Still Living? |Current Address |

|      |      |

SPOUSE-LIKE RELATIONSHIP - list any person of this relationship IF he/she was not born in the U.S.

|First Name |Middle Name |Last Name |Jr/Sr/III, etc.|Date of Birth |

|      |      |      |      |      |

|Country of Birth |Citizenship |Citizenship Document Type, Registration #, Date/Court Name/City/State where issued |

|      |      |      |

| |Current Address |

|      |

MILITARY SERVICE

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Service |Unit |Grade |RE Code |

|      |      |      |      |      |      |

|OIC's Name |Unit Address |Unit Ph# |

|      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Service |Unit |Grade |RE Code |

|      |      |      |      |      |      |

|OICs Name |Unit Address |Unit Ph# |

|      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Service |Unit |Grade |RE Code |

|      |      |      |      |      |      |

|OIC's Name |Unit Address |Unit Ph# |

|      |      |      |

YOUR MILITARY RECORD

|Yes |No | |

| | |Have you ever received other than an Honorable Discharge from the Military? |

| | |Explain if "Yes":       |

| | |Have you registered with the Selective Service? (To find your # call 1-847-688-6888. |

| | |Enter your SSS #       |

YOUR EMPLOYMENT RECORD

|Yes |No | |

| | |Have you ever been fired, quit, or left a job under unfavorable circumstances? |

| | |Explain if "Yes":       |

| |

|YOUR MEDICAL RECORD |

|Yes |No | |

| | |Have you ever consulted a mental health professional or visited a health care provider for a mental related question? |

| | |Explain if "Yes":       |

| | |Did this treatment involve only marital, family or grief counseling and not related to any violence by you? |

| | |If Yes, please insert the dates, name of the therapist, and the address of the clinic/office. |

| | |      |

FOREIGN ACTIVITIES - use "Space" key to click on answer. Area at bottom of page is for explanation.

|Yes |No | |

| | |Do you have any foreign property, business connections or financial interests? |

| | |Are you now or have you ever been employed by or acted as a consultant for a foreign government? |

| | |Have you ever had any contact with a foreign government or it's representatives, inside or outside the US? |

| | |Have you ever had an active passport that was issued by a foreign government? |

| | | |

|Explanation for any "Yes" answers, above.      |

FOREIGN TRAVEL - list any travel outside the US in the past 7 years, EXCEPT travel done on official government orders issued to you.

| | | Reason for Trip | |

|From Date |To Date |(Business/Pleasure/Education, etc.) |List all country(ies) visited on this trip |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

POLICE RECORD- offenses must be listed, regardless of age at time of offense or whether record is

|Yes |No | sealed, stricken, expunged, et. al |

| | |Have you ever been charged or convicted of a felony? |

| | |Have you ever been charged or convicted of a firearms or explosives offense? |

| | |Are there currently any charges pending against you for any offense? |

| | |Have you ever been charged or convicted of any offense related to alcohol or drugs? |

| | |Has your use of alcohol resulted in your treatment or counseling? |

| | |Are you currently under deferment or probation for any offence? |

| | |Have you ever been subject to court martial or other military discipline? |

|Explain all "Yes" answers to above |

|Date of Offense |Charged With |Action of Court |Court/Clinic Name |Court/Clinic Address City/State/Zip |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

MINOR OFFENSES- all citations/tickets/violations, etc. regardless of age at time of offense

| |

|Date Charged |Charge |Pled to/Convicted of |Issuing Agency |Agency or Court City/State/Zip |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

DRUG ACTIVITY/USE - list all use of controlled substances (unless prescribed for you by a physician) -

regardless of age at the time of use.

|Date(s) Used |Times Used |Reason for Use |Method of Use |Substance Used |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

| | | | | |

| | |Have you ever used a controlled substance while employed in a position of public trust?: |

| | |(law enforcement/court official/while possessing a clearance, etc?) |

| | |Explanation:      |

| | | |

| | |Have you ever been involved in the purchase/trafficking/manufacture/transfer/shipping or sale of any narcotic, depressant, stimulant, |

| | |hallucinogen, or cannabis for your or another's profit? |

| | |Explanation:      |

| | | |

INVESTIGATION/CLEARANCE RECORD

|Yes |No | |

| | |Has the U.S. Government every investigated your background or granted you a clearance? |

| | |Explain:      |

| | |Have you ever had a clearance or access denied, suspended or revoked or have you been barred |

| | |from government employment? |

| | |Explain:      |

YOUR FINANCIAL RECORD

|Yes |No | |

| | |Have you ever filed for any type of bankruptcy? |

| | |Have you ever had your wages garnished? |

| | |Have you ever had any property repossessed? |

| | |Have you ever had a lien placed against your property? |

| | |Have you ever had any judgments against you which have not been paid? |

| | |Have you ever been over 180 delinquent on any debts? |

| | |Are you currently over 90 days delinquent on any debts? |

| | |Have you ever been a party to any civil court actions? |

|Explain all "Yes" answers to above |

|Date Incurred |Date Satisfied |Amount&Type of Debt |Account/Court Name & #'s |Mailing Address of Creditor/Court |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

|      |      |      |      |      |

YOUR ASSOCIATION AND MEMBERSHIPS

|Yes |No | |

| | |Have you ever been a member or made a contribution to an organization which advocates the violent |

| | |overthrow of the U.S. and which engages in illegal activities to achieve that goal? |

| | |Have you ever knowingly engaged in any acts or activities designed to overthrow the U.S. government |

| | |by force? |

| | |Explain any "yes" answers to the above questions:      |

| | | |

ADDITIONAL AND CONTINUATION INPUT SHEET

MISCELLANEOUS INPUT OR COMMENTS 4/16/2007

|      |

RESIDENCES, CONTINUED:

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Street Address |Unit/Apt |City |State |ZIP |

| | | | | |(or Country) | |

|      |      |      |      |      |      |      |

|Person who knew you there |Their Street Address |Unit/Apt |City/State |ZIP |Phone# |

|      |      |      |      |      |      |

|EMPLOYMENT, CONTINUED | |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

|From (Yr/Mo/Dt) |To (Yr/Mo/Dt) |Name of Company |Street Address, Suite |ZIP |Phone# |

|      |      |      |      |      |      |

|Your job title |Supervisor's Name |Supervisor's Location (if other than company) |Supervisor Ph# |

|      |      |      |      |

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