Security Clearance Form Fillable Template

United States Secret Service Security Clearance Forms 08/2013 Instructions You are being considered for a position with the United States Secret Service. In addition Federal agencies generally fire do not grant a security clearance or disqualify individuals who have materially and deliberately falsified these forms and this remains a part of the permanent record for future placements. If necessary and usually in conjunction with another form or forms this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance and it may be disclosed to authorized officials making similar subsequent determinations. Since all Secret Service employees are required to have a Top Secret Security Clearance the enclosed background investigation forms are being provided for your immediate completion. Once you have been asked by a Secret Service representative to complete this package please note the following instructions. Do not sign or initial any of the forms unless otherwise indicated. Your signatures must be witnessed by Secret Service representatives. DEPARTMENT OF HOMELAND SECURITY ACKNOWLEDGMENT OF SECURITY CLEARANCE REQUIREMENTS NAME OF CANDIDATE THIS FORM MUST BE SIGNED BY ALL CANDIDATES WHO ARE TO BE APPOINTED ON A CONTINGENCY BASIS. I understand that I am being considered for appointment with the U.S. Secret Service based on a contingent security investigation. employment with the U.S. Secret Service is contingent on the satisfactory completion of a special security background investigation and if the position is considered critical-sensitive the granting of a Top Secret clearance. SIGNATURE OF CANDIDATE DATE SIGNED SIGNATURE OF WITNESS DISTRIBUTION ORIGINAL - OFFICIAL PERSONNEL FILE SSF 1871 2/2003 CC - SECURITY CLEARANCE DIVISION CC - CANDIDATE Page 1 of 1 Form Approved OMB No. 3206-0182 Declaration for Federal Employment This form may also be used to assess fitness for federal contract employment enrollment status in the Government s Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. If you are selected before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true. All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you or for firing you after you begin work. Follow Your Name 11 WHERE YOU HAVE LIVED Continued 5 Month/Year Own Rent Other Explain Apt. APO/FPO address Name of person who knows you at this address ZIP Code Current address Alternate contact number 6 Month/Year To Month/Year Status To Month/Year Status 12 WHERE YOU WENT TO SCHOOL Continued To Month/Year Code of degree/diploma received and date awarded. Name of school Street address and City Country of school 13 EMPLOYMENT/UNEMPLOYMENT INFORMATION Continued 5 Dates of Employment Type of Employment Work hours Employer/Verifier Name of employer/verifier Address of employer/verifier Physical Location Your actual work address if different from employer address Supervisor if different from employer Name and title Work address of supervisor To Month/Year Position title gathering and maintaining the data needed and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to OPM Forms Of cer U.S. Of ce of Personnel Management 1900 E Street NW Washington DC 20415. Do not send your completed form to this address send it to the of ce that provided you the form. The OMB clearance number 3206-0005 is currently valid. OPM may not collect this information and you are not required to respond unless this number is displayed. or imprisonment or both 18 U.S.C. This system allows disclosure of information to training facilities organizations deciding claims for retirement insurance unemployment or health benefits officials in litigation or administrative proceedings where the Government is a party law enforcement agencies concerning a violation of law or regulation Federal agencies for statistical reports and studies officials of labor organizations recognized by law in connection with representation of employees Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining security clearance security or suitability investigations classifying jobs contracting or issuing licenses grants or other benefits public and private organizations including news media which grant or publicize employee recognitions and awards the Merit Systems Protection Board the Office of Special Counsel the Equal Employment Opportunity Commission the Federal Labor Relations Authority the National Archives and Records Administration and Congressional offices in connection with their official functions prospective non-Federal employers concerning tenure of employment civil service status length of service and the date and nature of action for separation as shown on the SF 50 or authorized exception of a specifically identified individual requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard authorized Federal and non-Federal agencies for use in computer matching spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment individuals working on a contract service grant cooperative agreement or job for the Federal government non-agency members of an agency s performance or other panel and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures. Public Burden Statement ---Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response including time for reviewing instructions searching existing data sources gathering the data needed and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information including suggestions for reducing this burden to the U.S. Office of Personnel Management Reports and Forms Manager 3206-0182 Washington DC 20415-7900.