PERSONAL HISTORY STATEMENT

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP90-00530R000701680023-0
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 24
• Document Creation Date: December 27, 2016
• Document Release Date: March 13, 2013
• Sequence Number: 23
• Content Type: MISC

Declassified and Approved For Release 2013/03/13: CIA-RDP90-00530R000701680023-0
PERSONAL
HISTORY
STATEMENT
FORM-
( 444
OBSOLETE PREVIOUS
EDITIONS
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INSTRUCTION SHEET
READ THIS FIRST
PLEASE REVIEW THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE ATTEMPTING TO
COMPLETE THE ENCLOSED APPLICATION FORM.
GENERAL
I. TYPE OR PRINT LEGIBLY. Use black or blue typewriter ribbon or black or blue ink.
2. Answer all questions completely or check (X) the box which applies. If the question is not applicable, write
"NA". If you do not know the answer and it cannot be obtained from personal records, write "UNKNOWN".
Use a separate sheet of paper for extra details on individual questions if necessary. Be sure to SIGN EACH
SEPARATE SHEET. ALSO, INCLUDE YOUR SOCIAL SECURITY NUMBER ON EACH.
3. Consider each of your answers carefully. Verification of the data furnished will be accomplished during the
course of the background investigation. Your signature at the end of the forms will certify their correctness.
4. You are encouraged to make and retain a copy of this application for future reference.
5. Transcripts:
Include one (1) copy of your college or business school transcripts (including graduate work, if appropriate). If
an official transcript is not immediately available, DO NOT DELAY SUBMISSION OF PHS. Submit either
an unofficial transcript or a list of course titles and grades by semester, that you have completed. Forward an
official transcript as soon as it is available. If you are currently enrolled in courses, please list these courses
and attach to your transcript or list of completed courses.
NOTE
Upon initiation of the security clearance you will be provided with a point of contact within the Office of
Personnel who will keep you appraised of the status of your application. The processing is necessarily time
consuming and its length varies with each applicant. No firm offer of employment can be made until such
time as all required clearances have been satisfactorily completed.
The authority for soliciting your Social Security Number (SSN) is Executive Order 9397. Disclosure by you of
your SSN on the enclosed Personal History Statement form is mandatory. Failure to disclose your SSN will
result in no further action being taken on your application. Your SSN will be used to identify you precisely dur-
ing your Federal career. This is necessary because of the large number of persons who have identical names and
birth dates.
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Type or print Declassified and Approved For Release 2013/03/13: CIA-RDP90-00530R000701680023-0
....
SUMMARY SHEET PERSONAL HISTORY STATEMENT
-DO NOT ATTEMPT TO COMPLETE THIS FORM UNTIL YOU HAVE READ THE ENCLOSED INSTRUCTION SHEET-
NOTE: The Agency may disseminate the information which you provide on this form only in accordance with the Privacy Act and Agency regulatory issuances promulgated pursuant thereto and
published in the Federal Register. Pursuant to the Privacy Act and Executive Order 12333, the Agency will report possible violations of Federal criminal law by United States Government employees
to appropriate governmental authorities. Pursuant to the Privacy Act and Executive Order 12333 and as specified by the Attorney General, the Agency will also report to appropriate governmental
authorities possible violations of Federal criminal law by persons who are not employees of the United States Government.
SECTION I GENERAL PERSONAL AND PHYSICAL DATA
1. Full name (Last-First-Middle) D Mr. El Mrs. El Miss El Ms.
,
'
2. Date of birth (Mo/Do/Yr)
3. Place of birth (City, State, Country)
4. Social security number
5. Other names used (including maiden name) (Last-First-Middle)
6. Nicknames
7. Indicate circumstances (including length of time) under which you have used the names noted in item 5 above
8. If legal change of name, give particulars (Where and by what authority)
9. Citizenship (if naturalized, indicate date 8 place of naturalization 8, '
certificate no.)
10. Current address (No., Street, City, State .4 Zip Code?country if not U.S.)
11. Current phone
(
numbe-
)
Area code
Number
12. Permanent Address (No., Street, City, State & Zip Code?country if not U.S.) ,
13. Permanent phone
(
number
)
Area code
Number
14. Office phone number
( )
Area code
Number
Extension(s)
15. Height
16. Weight
17. Color of eyes
18. Color of hair
19. Build
SECTION II EDUCATION
COLLEGE OR UNIVERSITY STUDY
(LIST LATEST STUDIES FIRST)
Do not claim any degree not yet conferred. Do indicate status of study and degree) now in progress.
Name and location of college or university
Subject
Date attended
From-To-
(Mo/Yr)
Degree
Received
Date
Received
(Mo/Yr)
Grade or
Point
Average
Number of
Sem./Qtr.
Hours (Specify)
Major
Minor
1.
2.
3.
4. If a graduate degree has been noted above which required submission of a written thesis indicate the title of the thesis and briefly describe its content.
HIGH SCHOOLS
Name of high school(s)
Address (City, State, Country)
Years attended (From-To-)
Graduate
El Yes
El No
TRADE, COMMERCIAL, SPECIALIZED SCHOOLS AND MILITARY TRAINING IN SPECIALIZED SCHOOLS SUCH AS TELECOMMUNICATIONS, ETC.
Name and address of school
Study or specialization
From
To
No. of months
1.
2.
3.
4. Other education or training not indicated above
FORM A A 4
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SUMMAR1 arucc
SECTION III MILITARY SERVICE
Complete the following items for current and/or past active military service with the Army, Navy, Air Force, Marine Corps, Coast Guard, Merchant Marine, National
Guard, Air National Guard, or foreign (non-U.S.) military organizations. For foreign military organizations, specify both nationality and organization in item 1 below.
1. Military organization (Army, Navy, etc-specify)
2. Branch or Corps
3. Dates of service (extended active duty)
From - To-
4. Status (Regular, Reserve etc-specify)
5. Rank, grade or rate (at separation
if past service)
6. Serial, service or file number
7. Type of separation from active duty
* (insert number for type which applies-see list below)
8. Brief description of military duties (record the duties and skills which best describe your work or function in the military service)
9. If you are currently affiliated with a Reserve, National Guard or ROTC unit, identify the unit and
its address
10. Current rank, grade or rating
11. Expiration of reserve obligations
Types of separation from
1-Honorable discharge 4-Retirement for age 7 Retirement for physical disability
active duty. Record
2-General discharge 5-Retirement for service 8 Undue hardships
applicable number in *
. 3-Release to inactive duty 6-Retirement for combat disability Other -specify in item 7 in lieu of number
item 7 above
SECTION IV ACTUAL PLACES -OF RESIDENCE FOR THE PAST 15 YEARS
(LIST ONLY RESIDENCE AFTER YOUR 17TH BIRTHDAY)
Include address while at school and in military. For college on-campus residences, give dorm name & room number, city & state. If residences in military service cannot be shown as street address, in-
dicate complete military unit designation and location by city, state, and country. If post office box, give location of post office. Please indicate if you own, rent or sublet property.
Record below last two places of residence or places of residence for past two years only-begin with most recent or current address (continue on page 5)
Address-current residence first (number, street, city, state, country) If apartment, list apartment name and number.
Apt. It
Complete inclusive dates ( mo. & yr.)
From-
To-
SECTION V MARITAL STATUS (continued on page 7)
1. Name of spouse ( Last-First-Middle)
2. Social Security Number
3. Date of birth
4. Place of birth (spouse) ?
5. Date and place of marriage
6. Citizenship of spouse (If naturalized, indicate date & place of naturalization & certificate no.)
7. Former spouse(s)-full name(s)
8. If divorced, date & place of divorce
SECTION VI PARENTS (continued on page 8)
1. Father's full name (Last-First-Middle)
2. Date of birth
3. Place of birth (Father)
4. Father's current address (Number, Street, City, State)(last address if deceased)
5. Father's citizenship (If naturalized, indicate date & place of naturalization & certificate no.)
6. Mother's full name (Last-First-Middle-Maiden)
7. Date of birth
8. Place of birth (Mother)
9. Mother's current address (Number, Street, City, State) (last address if deceased)
10. Mother's citizenship (If naturalized, indicate date & place of naturalization & certificate no.)
SECTION VII EMPLOYMENT HISTORY
Complete below for last two employment positions or last two years only-begin with most recent or current position (continued on page 3)
1
1. Inclusive dates (From-to-by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
Telephone #
4. Indicate specific area or place of employment if other than address noted in item 3.
5. Kind of business
6. Title of job
7. Name of supervisor 0 Male
0 Female
B. Reason for leaving
9. Salary or earnings
$ per
10. Class, grade if Federal Service
11. Description of duties
If list
0 Full time
0 Part time; no. of hours per
week
applicable, number of persons you supervised
2
1. Inclusive dates (From-to-by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
Telephone It
4. Indicate specific area or place of employment if other than address noted in item 3.
5. Kind of business
6. Title of job
7. Name of supervisor 0 Male
0 Female
8. Reason for leaving
9. Salary or earnings
$ per
10. Class, grade if Federal Service
11. Description of duties
0 Full time
If list 0 Part time; no. of hours per week
applicable, number of persons you supervised
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SECTION VII ?, I
EMPLOYMENT HISTORY
(con44,__d trom page
2)
3
1. Inclusive dates (From-to-by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
Telephone #
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Title of job
7. Name of supervisor 0 Male
0 Female
8. Reason for leaving
9. Salary or earning
$
10. Class, grade if Federal Service
Per
11. Description of duties
If applicable, list number of persons you supervised.
0 Full
0 Part
time
time; no. hours per week
4
1. Inclusive dates (From-to-by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
Telephone #.
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Title of job
7. Name of supervisor 0 Male
0 Female
8. Reason for leaving
9. Salary or earning
$
10. Class, grade if Federal Service
Per
11. Description of duties
If applicable, list number of persons you supervised.
0 Full
0 Part
time
time; no. hours per week
5
1. Inclusive dates (From-to-by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
Telephone #
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Title of job
7. Name of supervisor 0 Male
, 0 Female
8. Reason for leaving
9. Salary or earning
$
10. Class, grade if Federal Service
Per
11. Description of duties
If applicable, list number of persons you supervised.
0 Full
0 Part
time
time; no. hours per week
6
1. Inclusive dates (From-to-by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
Telephone #
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Title of job
7. Name of supervisor 0 Male
0 Female
8. Reason for leaving
.
9. Salary or earning
$
10. Class, grade if Federal Service
Per
11. Description of duties
If applicable, list number of persons you supervised.
0 Full
- 0 Part
time
time; no. hours per week
7
1. Inclusive dates (From-to-by month & year)
2. Name of employing firm or agency
3. Address (Number, Street, City, State, Country)
Telephone #
4. Indicate specific area or place of employment if other than address noted in item 3
5. Kind of business
6. Title of job
'
7. Name of supervisor 0 Male
0 Female
8. Reason for leaving
{Salary or earnings
$ ?Per
10. Class, grade if Federal Service
11. Description of duties
If applicable, list number of persons you supervised.
0 Full
0 Part
time
time; no. hours per week
PRINT NAME: SOCIAL SECURITY NUMBER:
FORM 444 OBSOLETE PREVIOUS PLEASE TURN PAGE AND COMPLETE BACK.
EDITIONS
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1. Type of position desired
-c..?
2. Lowest annual salary acceptable
$
3. Availability
Earliest
Latest
dates
4. I are applying for
work which is
5. Indicate your willingness to travel
6. Indicate your willingness to accept assignment in the following
locations?check (X) each item applicable
Occasionally
Other (Specify)
Washington, D.C. area
Outside continental U.S.
full time
Frequently
Anywhere in U.S.
Certain locations only
(Specify where)
part time
As Required
7. Indicate any restrictions you would place on assignments outside the Washington, D.C. area
SECTION IX TYPING AND STENOGRAPHIC SKILLS
1. Typing (WPM)
2. Shorthand (WPM)
3. Indicate shorthand system used?check (X) appropriate item
p Gregg El Speedwriting El Stenotype El Other-Specify
4. Indicate other business machines with which you have had operating experience or training (calculator, computer terminal, MAG cord typewriter, Xerox, word-processing equipment, etc.).
SECTION X FOREIGN LANGUAGE ABILITIES
I. List below the foreign language or languages in which
you possess any degree of competence. Indicate your
proficiency in each of the five skill factors shown.
If your proficiency relates to a particular dialect of a
major language, identify this dialect by noting it in
parentheses after the language on the same line.
If you have no profi ciency in any foreign language, ?
check (X) box at right and leave other items blank.
If you have noted a proficiency in a language, would you be willing to use
this ability in any position for which you might be selected? 0 Yes 0 No
Level of Skill
(Slight) (Notice)
B C D E F
A = No proficiency in a skill factor
sq
1 4
it of
SKILL FACTORS
,
.z? e?
c,
HOW ACQUIRED
Check (X) Box(es)
which apply
-..
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2. If you have had experience as a translator, interpreter or instructor?explain and specify in which language(s) you have had such experience.
3. Describe your ability to do specialized language work involving vocabularies and terminology in the scientific, engineering, telecommunications, military and other specialized fields.
SECTION XI ? SPECIAL QUALIFICATIONS
1. List all hobbies and sports in which you are active or have actively participated. Indicate your proficiency in each.
2. Indicate any special qualifications resulting from experience or training which may fit you for a particular position or type of work.
3. Excluding business equipment or machines, list any special skills you possess relating to equipment and machines such as operation of an offset press, turret lathe, ADP and other scientific 8 professional devices; indicate CW speed;
sending and receiving speed; proficiency in use of telecommunications equipment.
(I
4. Do you have a valid driver's license? El Yes
0 No
5. Are you now or have you ever been a licensed or certified member of any trade or profession such as pilot, electrician, radio 0 yes
operator, teacher, lawyer, CPA, medical technician, psychologist, physician, etc.?
El No
6. If you have answered Yes to item 5 above, indicate kind of license or certification and the issuing State, municipality, etc. (Provide license registry number, if known, and year of isssue)
7. List any significant published materials of which you are the author (DO NOT submit copies unless requested). Indicate the title, publication dote, and type of writing (non-fiction or subjects, novels, short stories, etc.).
8. Indicate any devices which you have invented and state whether or not they are patented.
9. List any honorary associations or societies of which you are now or were formerly a member. List academic honors you have received.
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SECTION XII FUN ,/ UtIJCSKArrIlL. AKCA KINIVWLCIJVC APIL014......AVCL
List below any foreign regions or countries in which you have traveled or gained knowledge as a result of residence, study or work assignment. Indicate type of knowledge such as geography, industries, utilities, political parties,
economic, history, etc.
Name of Region
or Country
Type of Specialized
Knowledge
Dates of Travel
or Residence
Purpose of Visit
Residence or Travel
Dates 8 Place
of Study
Knowledge acquired by?
Check (X)
Residence
Travel
Study
AssWi;rnmkent
SECTION XIII CLUBS, SOCIETIES, AND OTHER ORGANIZATIONS
.NOTE: List names and addresses of all clubs, societies, professional societies, employee groups or organizations of any kind to which you belong or have belonged (include membership M, or support of, any organization having
headquarters or branch in a foreign country).
Name and chapter
Address (Number, City, State, Country)
Date of membership
From-
To-
SECTION IV ACTUAL PLACES OF RESIDENCE FOR THE PAST 15 YEARS
(continued from page 2) (LIST ONLY RESIDENCE AFTER YOUR 17th BIRTHDAY)
Include address while at school and in military. Fa college on-campus residences, give dorm name 8 room number, city 8 state. If residences in military service cannot be shown as street address, indicate complete military unit
designation and location by city, state, and country. If post office box, give location of post office. Please indicate if you own, rent, or sublet property.
Address-current residence first (number, street, city, state, country), if apartment, list apartment name & number.
Apt. #
Complete Inclusive dates (month 8 year)
From-
To'
PRINT NAME: SOCIAL SECURITY NUMBER:
FORM A 44 OBSOLETE PREVIOUS
(7-87) ?1. EDITIONS
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1?,G,,,IG4J.0111G,..1 G41 is-i r
SECTION Al If
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References must be individuals (not relatives) who have known you well for at least 2 years-up to 15 years if possible. They must now be U.S. citizens and residing in the U.S.
1. List three character references (not relatives) in the U.S. who know you well.
Name (Last-First-Middle)
Sex
Complete Business Address
(Business Name, Number, Street, City, State)
Complete Residence Address
(Number, Street, City, State)
No. of
Years
Known
OM
OF
Address:
Area Code: Phone Na.,
Address:
-
C
Area Code: Phone No.:
CI m
OF
Address:
Area Code: Phone No.:
Address: .
Area Code: Phone No.:
0 M
OF
Address:
Area Code: Phone No.:
Address:
Area Code: Phone No.:
2. List three social references in the U.S. Social references are friends (not relatives) of your own age group who know you well.
Name (Last-First-Middle)
Sex
Complete Business Address
(Business Name, Number, Street, City, State)
Complete Residence Address
(Number, Street, City, State)
No. of
Years
Known
OM
0 F
Address:
Area Code: Phone No.:
Address:
Area Code: Phone No.:
OM
OF
Address:
Area Code: Phone No.:
Address:
Area Code: Phone No.:
0 m
OF
Address:
Area Code: Phone No.:
Address:
Area Code: Phone No.:
3. List two neighbors at your current location who know you.
Name (Lost-First-Middle)
Sex
Complete Business Address
(Business Nome, Number, Street, City, State)
Complete Residence Address
(Number, Street, City, State)
-
No. of
Years
Known
OM
OF
Address:
Area Code: Phone No.:
Address:
Area Code: Phone No.:
OM
OF
Address:
Area Code: Phone No.:
Address:
Area Code: Phone No.:
Use the following space for extra detail. Reference each continued item by section and item number to which it relates and sign your name at the end of
the material. If additional space is required use extra pages the same size as this page and sign each such page.
6
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2. Court Issuing Naturalization. Certificate and Petition Numbers
1. Citizenship acquired by 0 Birth
0 Other (Specify)
3. Alien Registration Number
4. Date and place of arrival in U.S.
5. Have you held previous nationalities (if yes, show dates)
0 Yes 0 No
6. If yes, give name of country or countries
7. Last U.S. visa (number, type, place of issue)
8. Date visa issued
9. United States Passport number & expiration date, if issued
SECTION V (continued from page 2) MARITAL STATUS
1. Present status (Single, engaged, married, widowed, separated, divorced, annulled, remarried) specify
2. State date, place and reason for all separations, divorces or annulments
Spouse, Fiance(e); Other
If Other, please provide background information on any individual with
whom you have a close and continuing personal relationship and with
whom you are bound by close ties of affection,
If you have been married more than once (including annulments) use page
11 for former wife or husband giving information required below for all
previous marriages. If marriage contemplated, fill in appropriate informa-
tion for fiance(e).
3. Name (Last) (First) (Middle) (Maiden)
4. Living
0 Yes 0 No
5. State any other names ever used by spouse
Indicate circumstances (including length of time) under which any names noted in item 5 above were used. If legally changed, give particulars (where and by what authority). Use extra space pro-
vided on page 11 of this form to record this information.
6. Former citizenship(s) icountry(ies)]
7. Alien Registration Number
8. Date and place of arrival in U.S.
9. If deceased, date, place and cause of death
10. Current address (Give last address, if deceased)
11. Address of spouse before marriage
12. Occupation
13. Present employer (Also give former employer, or if spouse deceased or unemployed, give last two employers.)
14. Employer(s) or business address (Number, Street, City, State, Country)
15. Dates of military service
(From-to-by month & year)
16. Branch of military service
17. Country with which military service affiliated
18. Details of other governmental service, U.S. or foreign
SECTION XVI CHILDREN AND OTHER DEPENDENTS
1. Provide the following information for all dependents (include step-children and adopted children)
Name
Relationship
Date & Place of Birth
Citizenship
Address
PRINT NAME: SOCIAL SECURITY NUMBER:
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1. Are you now or have you ever been a member of any forLd domestic organization, association, movement, group, or combinati.,,, 1?persons which is totalitarian, fascist,
Communist, or subversive or which has adopted, or shows, a policy advocating the commission of acts of force or violence to deny other persons their rights under the Constitu-
tion of the United States, or which seeks to alter the form of government of the United States by unconstitutional mewls. If you have answered YES to the question above, ex-
plain on a separate signed sheet. 0 Yes 0 No
2 Do you associate with anyone not related to you who is associated with a foreign government? If yes, please provide the following
information on each individual on a separate sheet. Include your name and SSN on each sheet.
(A) FULL NAME (INCLUDE ALIASES AND MAIDEN NAMES IF APPROPRIATE)
(B) DATE OF BIRTH (OR APPROXIMATE AGE)
(C) PLACE OF BIRTH (CITY, COUNTRY)
(D) CITIZENSHIPS (CURRENT AND PAST)
(E) CURRENT ADDRESS
(F) OCCUPATION AND EMPLOYER
(G) KNOWN SINCE, HOW MET, LAST CONTACT, PLANS FOR FUTURE CONTACT
(H) SHORT DESCRIPTION OF RELATIONSHIP/DEGREE OF ASSOCIATION
(I) ANY KNOWN POLITICAL, MILITARY OR INTELLIGENCE ACTIVITIES?
(J) WITTING OF PROPOSED EMPLOYMENT? HOW AND WHY?
3. Have you ever been a member of, or supported, or had any connection with a foreign intelligence organization or its activities. If answer is Yes, give complete details. , 0 Yes 0 No
4. Do you use or have you ever used alcoholic beverages? If so, to what extent?
0 Yes
0 No
5. Have you ever been treated for alcohol abuse, or ever been enrolled in an alcohol abuse program? If so, please explain including dates of treatment. 0 Yes 0 No
6 Have you ever tried or
Have you ever tried or
Have you ever tried or
Have you ever tried or
("Mushroom"), PCP (Angel
Tranquilizer"), or other
Have you ever used barbiturates,
steroids or other medications
without a doctors prescription?
If you have answered
a. Substance:
b. Substance:
c. Substance:
d. Substance:
e. Substance:
f. Substance:
used a marijuana product? 0 Yes 0 No
used cocaine? 0 Yes 0 No
used heroin or other narcotic drugs? 0 Yes 0 No
used LSD, mescaline, Psilocybin
dust, "KW,? "Animal 0 Yes 0 No
such substances?
amphetamines, tranquilizers,
0 Yes 0 No
for non-medicinal purposes or
YES to any of the above, please describe below:
First tried Last tried # Occasions Circumstances
First tried Last tried # Occasions Circumstances
First tried Last tried # Occasions Circumstances
First tried Last tried # Occasions Circumstances
First tried Last tried # Occasions Circumstances
.
First tried Last tried # Occasions Circumstances
7. Have you ever taken a polygraph test? If so, please state circumstances.
0 Yes 0 No
8. List the names of Government departments, agencies, or offices to which you have applied for employment (show dotes of application).
9. If to your knowledge any of the above have conducted an investigation of you, indicate the name of the agency and the approximate date of the investigation.
Note Special
Instructions
If your answer is "Yes" to the following questions 10, 11, 12, 13, 14, 15 or 16, provide the information requested for each question on a separate, signed sheet and
attach the sheet to this form in a sealed envelope.
10. Have you ever been g anted or denied a security clearance, a Sensitive Compartmented Information access approval or access authorization? If answer is Yes, give
complete details. 0 Yes 0 No
11. Have you ever had a security clearance withdrawn for cause (Sensitive Compartmented Information access approval). If answer is Yes, give complete details.
0 Yes 0 No
12. Have you ever been arrested or convicted in the U.S. or abroad of an offense against the law or forfeited collateral, or are you now under charges for any offense
against the law? (You may omit traffic violations for which you paid a fine of $100 or less). If so, state name of court, date, nature of offense, and disposition of case El Yes 0 No
in accordance with special instructions above.
13. While in the military service were you ever convicted by special or general court martial? If so, describe incident(s) and provide date(s) of occurrence on separate
sheet in accordance with special instructions above. 0 Yes 0 No
14. Are there any incidents in your life (not mentioned above) which may come to light in subsequent investigation, whether you were directly involved or not, which you
desire to explain? If so, describe incident(s) and provide date(s) of occurrence(s) on separate sheet in accordance with special instructions above. 0 Yes 0 No
15 Have you ever been dismissed or asked to resign from any position? , Have you left a position under circumstances which you desire to explain?
0 Yes 0 No 0 Yes 0 No
1,6. If your answer to either or both questions in Item 15 above is Yes, give details on a separate sheet of paper.
10
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?I 1IA_I-'I_ _
?.-- ?... ?. . ? .rr? _
SECTION XXII Li FINANCIAL STATUS ?..--i
1. Are you entirely dependent on your salarY? p Yes- 0 No
2. If your answer is NO to the above, state sources of other income:
3. Have you ever been in or petitioned for bankruptcy? 0 Yes 0 No
4. If your answer is YES to the above, give particulars, including court and date(s) on a separate sheet.
5. Do you receive an annuity from the United States or District of Columbia Government under any retirement act, pension, or compensation for military service?
0 Yes 0 No
6. If your answer is YES to the above, give complete details. .
7. Do you have any financial interest in, or official connection with non-U.S. corporations or business having substantial foreign interests?
0 Yes 0 No (If answer is "YES", furnish details in space below?Continue on separate sheet, if necessary)
,
Use the following space for extra details. Reference each continued item by section and item number to which it relates and sign your name at the end of
the material. If additional space is required use extra pages the same size as this page and sign each such page.
SECTION XXIII CERTIFICATION AND ACCEPTANCE OF EMPLOYMENT CONSIDERATION
YOU ARE INFORMED THAT THE ACCURACY OF ANY STATEMENT MADE IN THIS APPLICATION MAY BE INVESTIGATED
I have read and understand the instructions. I certify that the foregoing answers are true and correct to the best of my knowledge and belief. I understand that any misstatement or omission as to
material fact will constitute grounds for rejection of my application or for immediate dismissal, if employed. I also understand that any false statement made herein may be punishable by law
(U.S. Code, Title 18, Section 1001).
My signature hereon acknowledges my acceptance of the conditions for consideration of my application for employment with the Agency, and further,
that I understand that should I be denied employment, the Agency is not required to provide a specific reason for such denial.
1. Date of signature
3. SOCIAL SECURITY NUMBER
2. Signature of applicant
4. PRINT NAME
FORM AAA OBSOLETE PREVIOUS
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1.1
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OFFICE OF MEDICAL SERVICES
PRIVILEGED MEDICAL INFORMATION
THIS ENVELOPE NOT TO BE USED FOR MAILING PURPOSES
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REPORT OF MEDICAL HISTORY
(THIS INFORMATION IS FOR OFFICIAL AND MEDICALLY-CONFIDENTIAL USE ONLY AND WILL NOT BE RELEASED TO UNAUTHORIZED PERSONS)
1. LAST NAME?FIRST NAME?MIDDLE NAME
2. HOME ADDRESS (No street or RFD, city or town, State, and ZIP CODE)
3. HEIGHT (inches)
4. WEIGHT
5. BUILD (S,M,L)
6. DOB (DDMMYY)
7. PLACE OF BIRTH
8. SEX
9. HOME PHONE
10. OFFICE PHONE
11. FAMILY HISTORY DATA:
12. HAS ANY BLOOD RELATIVE HAD:
Relation
Age
State of
Health
Cause of
Death
Age at
Death
YES
NO
Check each item
Relationship _
Allergy
Father
Glaucoma
Mother
Diabetes
Heart Disease
Lung Disease
Kidney Disease
Emotional Disorders
Cancer
Alcohol Abuse
13. HAVE YOU EVER (Please check each item)
14. DO YOU (Please check each item)
YES
NO
(Check each item)
YES
NO
(Check each item)
Lived with anyone who had tuberculosis
Wear glasses or contact lenses
Coughed up blood
Have vision in both eyes
Bled excessively after injury or tooth extraction
Wear a hearing aid
Attempted suicide
Stutter or stammer habitually
Been a sleepwalker
Wear a brace or back support
15. HAVE YOU EVER (Please check at left of each item -explain on reverse)(Use Extra sheet If needed)
YES
NO
Vi.(381w1
(Check each item)
YES
NO
DON'T
KNOW
(Check each item)
YES
NO
DON'T
KNOW
(Check each item)
Scarlet fever, erysipelas
Cramps in your legs
"Trick" or locked knee
Rheumatic fever
Frequent indigestion
Foot trouble
Swollen or painful joints
Stomach, liver or intestinal trouble
Neuritis
Frequent or severe headache
Gallbladder trouble or gallstones
Paralysis (include infantile)
Dizziness or fainting spells
Jaundice or hepatitis
Epilepsy or fits
Eye trouble
Adverse reaction to serum, drug, or medicine
Car, train, sea or air sickness
Ear, nose, or throat trouble
Broken bones
Frequent trouble sleeping
Hearing loss
Tumor, growth,cyst, cancer
Depression or excessive worry
Chronic or frequent colds
Rupture/hernia
Loss of memory or amnesia
Severe tooth or gum trouble
Piles or rectal disease
Nervous trouble of any sort
Sinusitis
Frequent or painful urination
Periods of unconsciousness
Hay Fever
Bed wetting since age 12
Speech Impediment
Head injury
Kidney stone or blood in urine
Used Illegal Drugs (LSD, Marijuana, etc.)
Skin diseases
Sugar or albumin in urine
Alcohol (to what extent)
Thyroid trouble
VD?Syphillis, gonorrhea, etc.
Do you Smoke (how much)
Tuberculosis
Recent gain or loss of weight
Asthma
Arthritis, Rheumatism, or Bursitis
Shortness of breath
Bone, joint or other deformity
Pain or pressure in chest
Lameness
Chronic cough
Loss of finger or toe
Palpitation or pounding heart
Painful or "trick"shoulder or elbow
16. FEMALES ONLY: HAVE YOU EVER
Heart trouble
Recurrent back pain
Been treated for a female disorder
High or low blood pressure
Bloody or tarry stools
Had a change in menstrual pattern
Malaria
Diabetes or other endocrine disease
17. WHAT IS YOUR USUAL OCCUPATION?
18. ARE YOU Check
I I Right handed
one)
Left handed
:ran o4 OBSOLETE
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SELF-IDENTIFICATION SHEET
General Instructions
The information from this survey is used to help insure
that Agency personnel practices meet the requirements of Federal
law. Providing this information is voluntary. Solicitation of
your Social Security Number is authorized under provision of
Executive Order 9397, dated November 22, 1943. No individual
personnel selections are made based on this information. Please
answer each of the questions.
1. Name
2. Year of birth
3. Social Security Number
4. Sex Male Female
5. Ethnicity and Race (Please categorize yourself as follows:)
Hispanic (A person of Mexican, Puerto Rican,
Cuban, Central or South American, or other Spanish
culture or origin, regardless of race.)
Black (A person having origins in any of the black
racial groups of Africa.)
Asian or Pacific Islander (A person having origins
in any of the original peoples of the Far East,
Southeast Asia, the Indian sub-continent, or the
Pacific Islands. This area includes, for example,
China, India, Japan, Korea, the Philippine Islands,
and Samoa.)
American Indian or Alaskan Native (A person having
origins in any of the original peoples of North
America, and who maintains cultural identification
through tribal affiliation or community recognition.)
White (A person having origins in any of the original
peoples of Europe, North Africa, or the Middle East.)
6. Do you have any physical disability? Yes No
FORM 444T
5-80
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GENERAL CONSIDERATIONS
1. The Agency's responsibilities require it to maintain special employment criteria which may be
different from those of other Government departments and agencies. The investigation of applicants,
which is a prerequisite to employment, is a time consuming process. It includes an initial
determination that a suitable position exists, followed by loyalty and security checks and an evaluation
of the applicant's competence and physical and emotional fitness.
2. Appointments are highly competitive, and thousands of applications are received for the
limited number of postions available each year. All applicants are judged on their competitiveness
with other candidates possessing similar qualifications. Employment by the Agency is not a right upon
which an applicant can insist. Any offer of employment is subject to full security and medical
clearance and does not constitute a commitment of employment on the Agency's part.
3. This comprehensive review may result in a determination that an applicant is not to be offered
employment. Frequently, such determination would not be the result of any single event or element in
the applicant's personal background or qualifications but would reflect the composite results of the
several evaluations involved. In any event, determinations by the Agency are conclusive and final, and
no statement of specific reasons will be provided to the applicant.
CERTIFICATION
I have read and I understand and agree to the General Considerations. I further
understand that if the Agency conducts an investigation on me, and that if I am
employed, I will be subject to periodic reinvestigations and polygraph interviews. Should
I not be employed, I fully understand that no statement of specific reasons for that de-
termination will be provided to me.
Date Signature of Applicant
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GENERAL CONSIDERATIONS
1. The Agency's responsibilities require it to maintain special employment criteria which may be
different from those of other Government departments and agencies. The investigation of applicants,
which is a prerequisite to employment, is a time consuming process. It includes an initial
determination that a suitable position exists, followed by loyalty and security checks and an evaluation
of the applicant's competence and physical and emotional fitness.
2. Appointments are highly competitive, and thousands of applications are received for the
limited number of postions available each year. All applicants are judged on their competitiveness
with other candidates possessing similar qualifications. Employment by the Agency is not a right upon
which an applicant can insist. Any offer of employment is subject to full security and medical
clearance and does not constitute a commitment of employment on the Agency's part.
3. This comprehensive review may result in a determination that an applicant is not to be offered
employment. Frequently, such determination would not be the result of any single event or element in
the applicant's personal background or qualifications but would reflect the composite results of the
several evaluations involved. In any event, determinations by the Agency are conclusive and final, and
no statement of specific reasons will be provided to the applicant.
CERTIFICATION
I have read and I understand and agree to the General Considerations. I further
understand that if the Agency conducts an investigation on me, and that if I am
employed, I will be subject to periodic reinvestigations and polygraph interviews. Should
I not be employed, I fully understand that no statement of specific reasons for that de-
termination will be provided to me.
Date Signature of Applicant
FORM
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.86
EDITIONS
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AUTHORIZATION TO RELEASE INFORMATION
To Whom It May Concern:
I hereby authorize any Investigator or duly accredited representative of the United States
Government bearing this release, or a copy thereof, within one year of its date, to obtain any
information from schools, residential management agents, employers, criminal justice agencies,
or individuals, relating to my activities. This information may include, but is not limited to, ac-
ademic achievement, performance, attendance, personal history, disciplinary, residential,
credit, medical, birth and other vital records, criminal, civil and domestic court records, and
conviction and arrest records. I hereby authorize and request your release of such information
upon request of the bearer. I understand that the information released is for official use only by
authorized agencies of the U.S. Government as necessary in the fulfillment of official
responsibilities.
I hereby release any individual, including record custodians, from any and all liability for
damages of whatever kind or nature which may at any time result to me on account of compli-
ance, or any attempts to comply, with this authorization. Should there be any question as to the
validity of this release, you may contact me as indicated below.
Signature (Full Name):
Full Name (Printed):
Other Names Used:
Date:
Current Address:
Telephone Number:
Parent or Guardian (If Required):
PRIVACY ACT NOTICE
Authority for Collecting Information
E. 0. 10450 and E. 0. 12356
Purposes and Uses
Information provided on this form will be furnished to individuals in order to obtain information regarding your activities in connection with an
investigation for security clearances or access. The information obtained may be furnished to authorized agencies of the U.S. Government as
necessary in the fulfillment of official responsibilities.
Effects of Nondisclosures
Furnishing the requested information is voluntary, but failure to provide all or part of the information may result in a lack of further consider-
ation for clearances or access.
FORM
6-83 JZY/ (USE PREVIOUS EDITIONS)
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SECURITY PROCESSING
The Agency is obliged to judge carefully the suitability of each applicant who is offered a
position. To assist in this determination, an extensive investigation is conducted of which there are
two parts. One part is a background investigation, designed to validate information in the
applicant's Personal History Statement and to determine that he or she is of excellent character,
sound judgment, and unquestionable loyalty. The investigation involves, but is not limited to,
inquiries concerning.
a. professional competence;
b. any behavior, activities, or associations which tend to show that the individual is of
questionable character, discretion, integrity, or trustworthiness;
c. any deliberate misrepresentations, falsifications. or omissions of material facts;
d. any criminal, infamous, dishonest, immoral, or notoriously disgraceful conduct, habitual
use of intoxcants, illegal drug use or abuse, or sexual perversion;
e. past or pending business activities or involvements in a legal suit or litigation that could be
used to discredit the applicant or the U.S. Government;
f. physical fitness;
g. insanity, serious mental illness, neurological disorders, or emotional instability;
h. any facts which furnish reason to believe that the applicant may be subjected to coercion,
influence, or pressure which may cause him or her to act contrary to the best interests of
the national security;
i. commission of any act of sabotage, espionage, treason, or sedition, or attempts thereat or
preparation therefor, or conspiring with, or aiding or abetting another to commit or
attempt to commit any act of sabotage, espionage, treason, or sedition;
j. establishment or continuation of a sympathetic association with a saboteur, spy, traitor,
seditionist, anarchist, or revolutionist or with an espionage or other secret agent or
representative of a foreign nation, or any representative of a foreign nation whose interests
may be inimical to the interests of the United States, or with any person who advocates the
use of force or violence to overthrow the government of the United States or the alteration
of the form of government of the United States by unconstitutional means;
k. advocacy or use of force of violence to overthrow the government of the United States, or
of the alteration of the form of government of the United States by unconstitutional
means;
1. membership in, or affiliation or sympathetic association with, any foreign or domestic
organization, movement, group, or combination of persons which is totalitarian, Fascist,
Communist or subversive, or which has adopted or shows a policy of advocating or
approving the commission of acts of force or violence to deny other persons their rights
under the Constitution of the United States or which seeks to alter the form of government
of the United States by unconstitutional means;
m. intentional, unauthorized disclosure to any person of security or other information,
disclosure of which is prohibited by law or willful violation or disregard of security
regulations;
n. performing or attempting to perform his or her duties, or otherwise acting, so as to serve
the interests of another government in preference to the interests of the United States.
The Agency's standards require strict interpretation of the above and other relevant factors
in considering applications for employment. Should you be in doubt as to whether anything in
your background may disqualify you, you are at liberty to describe the matter in writing, place it
in an envelope bearing only your name and marked -CONFIDENTIAL DISCLOSURE-, and
forward it with your application.
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FBI files are checked on the applicant and spouse as well as on the applicant's parents if the
applicant is under 21 years of age. Files of the Office of Personnel Management (formerly the
Civil Service Commission) are also checked along with those of appropriate national agencies such
as the Department of Defense Central Index of Investigation and the Immigration and
Naturalization Service. Certain aspects of the investigation may be curtailed if the applicant has
been the subject of an investigation by another agency.
The investigation covers the most recent 15 years of the applican's life or from age 17,
whichever is shorter. The applicant must be a U.S. citizen and should have no relative or person to
whom they are bound by close ties of affection or obligation who is subject to a foreign power. All
education, employments, and neighborhoods are covered, and neighbors are interviewed to the
extent possible as are a minimum of five character references, including peers. Police records are
checked in all areas where the applicant has lived, worked, or attended school. Credit reputation
is established through interviews and credit reporting agencies.
The other part of the security screening is a polygraph examination. The polygraph
instrument records changes in certain physiological responses of the individual being examined. In
the hands of our trained and skilled examiners, the polygraph instrument is invaluable in
validating investigative information and exploring with the applicant issues of security relevance.
The polygraph questions, like the background investigation, focus on the issues of loyalty,
character integrity, judgment, discretion, reliability, and trustworthiness. All questions are
reviewed in advance with the applicant, and any areas of uncertainty are explored. At the
conclusion of the polygraph, the examiner prepares a report to the interview, including an
analysis of the polygraph charts and a summary of any pertinent security information orally
disclosed during the interview.
In analyzing personnel security information developed through investigation and polygraph
examination, special attention is given to the potential vulnerability of the individual to
exploitation, including blackmail. For example, sexual perversion, dishonesty, infamous, immoral,
or notoriously disgraceful conduct, and conviction of felonious or serious misdemeanor criminal
acts are considered highly significant. An individual's use of illegal drugs in examined in light of
the frequency, recency, and types of drugs used. Agency policy precludes any involvement by an
employee or assignee with illegal drugs or chemical compounds identified in the Controlled
Substance Act of 1970. Infractions can result in serious administrative action and may be reported
to the Department of Justice for prosecution.
The decision to grant or deny a security clearance is adjudicated by appropriate Office of
Security personnel based on a thorough appraisal of the entire security profile of the applicant,
including the results of the background investigation and the report of the polygraph examination.
The recommendation to approve or disapprove must pass several significant levels of supervisory
review and challenge before the matter is presented to the Director of Security for final decision.
MEDICAL PROCESSING
Medical qualification for employment with the Agency is based on an extensive medical
evaluation to determine that the prospective employee has the physical and mental capability to
perform the duties of a particular position. This evaluation consists of a comprehensive review of
the medical history and record provided by the applicant, a complete physical examination
including X-ray and laboratory studies, and a psychological/psychiatric assessment. The physical
examination and interviews are completed at Agency facilities in Washington, D.C. at no expense
to the applicant. The applicant may be required to provide information from his or her personal
physician concerning a previous or current medical condition.
In accordance with affirmative action requirements of Federal statutes, applicants with
handicaps are evaluated in the same manner as non-handicapped individuals with the realization
that some conditions may require an accommodation of the work environment. This
determination usually is made during the processing phase in consultation with the Selective
Placement Coordinator and the prospective supervisor with the applicant's consent.
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Nu,
SECRECY AGREEMENT
1. I, (print full name), hereby agree to accept is a prior condition of my
being employed by, or otherwise retained to perform services for, the Central Intelligence Agency, or for staff elements of
the Director of Central Intelligence (hereinafter collectively referred to as the "Central Intelligence Agency"), the
obligations contained in this agreement.
2. I understand that in the course of my employment or other service with the Central Intelligence Agency I may be
given access to information which is classified in accordance with the standards set forth in Executive Order 12356 as
amended or superseded, or other applicable Executive Order, and other information which, if disclosed in an unauthorized
manner, would jeopardize intelligence activities of the United States Government. I accept that by being granted access to
such information I will be placed in a position of special confidence and trust and become obiiga ed to protect the informa-
tion from unauthorized disclosure.
3. In consideration for being employed or otherwise retained to provide services to the Central Intelligence Agency, L
hereby agree that I will never disclose in any form or any manner any of the following categories of information or
materials, to any person not authorized by the Central Intelligence Agency to receive them:
a. information which is classified pursuant to Executive Order and which I have obtained during the course of my
employment or other service with the Central Intelligence Agency;
b. information, or materials which reveal information, classifiabkjursuant to Executive Order and obtained by me
in the course of my employment or other service with the CentM7itelligence Agency.
4. I understand that the burden will be upon me to learn whether 'nformation or materials within my control are
considered by the Central Intelligence Agency to fit the descriptions set or, in paragraph 3, and whom the Agency has
authorized to receive it.
5. As a further condition of the special confidence and trust reposed in me by the Central Intelligence Agency, I
hereby agree to submit for review by the Central Intelligence Agency all information or materials including works of fiction
which contain any mention of intelligence data or activities, or contain data which may be based upon information
classified pursuant to Executive Order, which I contemplate disclosing publicly or which I have actually prepared for public
disclosure, either during my employment or other service with the Central Intelligence Agency or at any time thereafter,
prior to discussing it with or showing it to anyone who is not authorized to have access to it. I further agree that I will not
take any steps toward public disclosure until 1 ceived written permission to do so from the Central Intelligence
Agency.
6. I understand that the purpose of theiewdscribed in paragraph 5 is to give the Central Intelligence Agency an
opportunity to determine whether the inforion or materials which I contemplate disclosing publicly contain any
information which I have agreed not to disclose.Mrther understand that the Agency will act upon the materials I submit
and make a response to me within a reasonable time. I further understand that if I dispute the Agency's initial classification
determinations on the basis that the information in question derives from public sources, I may be called upon to
specifically identify such sources. My failure or refusal to do so may by itself result in denial of permission to publish or
otherwise disclose the information in dispute.
7. I understand that all information or materials which I may acquire in the course of my employment or other service
with the Central Intelligence Agency which fit the descriptions set forth in paragraph 3 of this agreement are and will re-
main the property of the United States Government. I agree to surrender all materials reflecting such information which
may have come into my ssession or for which I am responsible because of my employment or other service with the Cen-
tral Intelligence Agen y u e en e emand by an appropriate official of the Central Intelligence Agency, or upon the conclusion
of my employment or .thr service with the Central Intelligence Agency.
8. I agree to notify t e Central Intelligence Agency immediately in the event that I am called upon by judicial or
congressional authorities to testify about, or provide, information which I have agreed herein not to disclose.
9. I understand that nothing contained in this agreement prohibits me from reporting intelligence activities which I
consider to be unlawful or improper directly to the Intelligence Oversight Board established by the President or to any
successor body which the President may establish. I recognize that there are also established procedures for bringing such
matters to the attention of the Agency's Inspector General or to the Director of Central Intelligence. I further understand
that any information which I may report to the Intelligence Oversight Board continues to be subject to this agreement for all
ther purposes and that such reporting does not constitute public disclosure or declassification of that information.
FORM girSiII:g.tS
EiTE PREVIOUS
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Nta %or
10. I understand that any breach of this agreement by me may result in the Central Intelligence Agenc
administrative action against me, which can include temporary loss of pay or termination of my employment or other
service with the Central- Intelligence Agency. I also understand that if I violate the terms of this agreement, the United
States Government may institute a civil proceeding to seek compensatory damages or other appropriate relief. Further, I
understand that the disclosure of information which I have agreed herein not to disclose can, in some circumstances,
constitute a criminal offense.
11. I understand that the United States Government may, prior to any unauthorized disclosure which is threatened by
me, choose to apply to any appropriate court for an order enforcing this agreement. Nothing in this agreement constitutes a
waiver on the part of the United States to institute a civil or criminal proceeding for any breach of this agreement by me.
Nothing in this agreement constitutes a waiver on my part of any possible defenses I may have in connection with either
civil or criminal proceedings which may be brought against me.
12. In addition to any other remedy to which the United States Government may become en I hereby assign to
the United States Government all rights, title, and interest in any and all royalties, remunerations, and emoluments that
have resulted or will result or may result from any divulgence, publication or revelation of information by me which is
carried out in breach of paragraph 5 of this agreement or which involves information prohibited from disclosure by the
terms of this agreement.
13. I understand and accept that, unless I am provided a written release from this agreement or any portion of it by the
Director of Central Intelligence or the Director's representative, all the conditions and obligations accepted by me in this
agreement apply both during my employment or other service with the Central Intelligence Agency, and at all times
thereafter.
14. I understand that the purpose of this agreement is to implemen4k responsibilities of the Director of Central
Intelligence, particularly the responsibility to protect intelligence sources andgpethods, as specified in the National Security
Act of 1947, as amended.
15. I understand that nothing in this agreement limits or otherwise affects provisions of criminal or other laws
protecting classified or intelligence information, including provisions of the espionage laws (sections 793, 794 and 798 of
Title 18, United States Code) and provisions of the Intelligence Identities Protection Act of 1982 (P. L. 97-200; 50 U. S. C.,
421 et seq).
16. Each of the numbered paragraphs and lettered subparagraphs of this agreement is severable. If a court should find
any of the paragraphs or subparagraphs of this ateement to be unenforceable. I understand that all remaining provisions
will continue in full force.
17. I make this agreement in good faith and with no purpose of evasion.
Signature
Date
The execution of this agreement was witnessed by the undersigned, who accepted it on behalf of the Central Intelligence
Agency as a prior cotillion of the employment or other service of the person whose signature appears above.
WITNESS AND AC EPTANCE:
Signature
rinted Name
Date
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WARNING NOTICE
Many employees of the Agency?particularly those who spend a significant
portion of their careers abroad?work under cover and may not acknowledge
their Agency affiliation publicly. If you are accepted for such covert employ-
ment, the fact of your employment will be classified at the secret level.
Therefore, for your own security and the security of any Agency activities in
which you may become engaged after employment, knowledge of your applica-
tion to the Agency should be limited to the smallest possible number of persons.
Telling friends and casual acquaintances, work or school colleagues of your plans
to join the Agency makes it difficult for you to establish sound cover after
employment.
Spouses and relatives most directly affected (normally parents and adult
siblings) may be told of your application for Agency employment if, in your judg-
ment, they can be trusted to be discreet. They should be told to keep the
information confidential. These precautions protect national security interests
and will help assure your personal safety and security should you be employed
under cover. Widespread public knowledge of Agency affiliation could adversely
affect the desirability to this Agency of an applicant and may restrict an
employee's mobility and the types of positions available.
My signature below certifies that I have read and understood this warning
notice on the security implications of covert employment with the Agency.
Signature: Date:
Name:
(type or print)
Declassified and Approved For Release 2013/03/13: CIA-RDP90-00530R000701680023-0
Declassified and Approved For Release 2013/03/13: CIA-RDP90-00530R000701680023-0
FACTS ABOUT SECURITY PROCESSING
? Staff employment with the Agency allows access to very sensitive national
security information which is classified, and must be protected from unauthorized or
uncontrolled disclosure.
? The Agency's Office of Security conducts a thorough screening procedure to
insure that all applicants meet the required security criteria established by the Central
Intelligence Agency. This screening procedure is comprised of the following:
(a) A national agency name trace is conducted at other U.S. government
departments and agencies to determine if relevant information is held that
will assist in establishing and verifying the character, integrity, and loyalty
of the applicant.
(b) A background investigation is conducted to verify the information on the
application for employment; during this process the listed references, other
referrals, and employers are interviewed to verify and establish the
character, integrity, and loyalty of the applicant.
(c) A polygraph examination is conducted which relies on the applicant's own
physiological response to relevant questions regarding the applicant's
character, integrity, and loyalty. The questions asked concern counter
intelligence and life style issues. The counter intelligence questions verify
and determine the extent of the applicant's involvement with individuals
or nations that are considered to be a threat to United States national
security. The life style questions determine the suitability of the applicant
to handle classified information. This examination verifies the non-
involvement or the extent of the applicant's involvement with drugs, illegal
substances, dishonest behavior, criminal activity, deviant sexual behavior,
and personal financial stability. The best approach the applicant can take
toward the polygraph examination is to engage in open, frank discussion
and disclosure to all questions posed. Only through such discussions can
issues be clarified and resolved, so that the examination can be successfully
completed. This open discussion is a necessary part of the polygraph
process and helps to verify the applicant's character, integrity, and loyalty.
? The above procedure has proven to be a reliable security screening process, and the
information developed is confidential and not shared outside the Agency's Office of
Security, unless properly authorized under U.S. law.
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IMPORTANT NOTICE
On 8 November 1985, the President signed into law the Defense Authorization Act of 1986. Section 1622 of the Act adds a new
section to the United States Code which prohibits any male born after 31 December 1959 from being appointed to a position in an
executive agency if he is required to register with the Selective Service System but has knowingly and willfully not complied.
Since you are currently under consideration for employment with this Agency and may be within the age group required to
register with the Selective Service System, we are asking you to complete the attached certification document to confirm your
registration status. If you are required to register and have not done so, and you have not reached your 26th birthday, you are
encouraged to fulfill this obligation at once. While your processing for employment will continue, we will not be able to confirm
your appointment until such time as confirmation of your registration has been received.
If you are required to register but refuse to do so, or have reached your 26th birthday and have not registered, you will need to
provide information concerning the reasons for your nonregistration so as to enable the appropriate authority to make the neces-
sary determination on your eligibility for executive agency appointment.
In order to avoid any unnecessary delays in your appointment following completion of the required processing, please complete
the enclosed -Pre-Appointment Certification Statement Regarding Selective Service Registration- and return it in the self-
addressed envelope as soon as possible.
PRE-APPOINTMENT CERTIFICATION STATEMENT FOR
SELECTIVE SERVICE REGISTRATION
Important If you are a male born after 31 December 1959, and you want to be employed by the Federal Government, you
Notice must (subject to certain exemptions) be registered with the Selective Service System.
Privacy Act We need information on your registration with the Selective Service System to see whether you are affected by
Statement the laws we must follow in deciding who may be employed by the Federal Government.
Criminal A false statement by you may be grounds for not hiring you, or for firing you after you begin work. Also, you
Penalty may be punished by fine or imprisonment (U.S. Code, Title 18, Section 1001).
Review If your employing agency has informed you that you cannot be appointed to a position in an executive agency
because of your failure to register, and you wish to establish that your non-compliance with the law was neither
knowing or willful, you may write to:
Office of Personnel
Department S, Room 4N05
P.O. Box 1925
Washington, D.C. 20013
CERTIFICATION OF REGISTRATION STATUS
( ) I certify that I am registered with the Selective Service System.
( ) I certify that I am not required to be registered with the Selective Service System.
Legal signature (please use ink) Date Signed
Name (please print) Date of Birth
Social Security Number
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