Personnel Evaluation Form Page 2
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4Personnel Evaluation Form
Bailey
Nicholas
Last Name
First Name
Middle Initial
521-19-0303
303-892-1967 (home)
N/A
Social Security Number
Primary Phone #
Other Phone #s
Do you currently or have you ever held a security clearance?
Yes
X No
Polygraph Examinations:
Polygraph(s) Taken - Have you ever taken a polygraph examination?
Yes
X No
Polygraph(s) Anticipated - Do you anticipate taking a polygraph examination with
Yes
X No
another agency within the next 6 months?
Has any Agency ever conducted a single-scope background investigation (SSBI)
X Yes
No
or a periodic reinvestigation following an SSBI on you?
Sponsor
Year
CIA, NSA, FBI
2011
Have you ever received other than an honorable discharge from
X Not
Yes
No
the United States Armed Services?
Applicable
If you are a male born after December 1959, have you registered
X Not
Yes
No
with the Selective Service?
Applicable
Have you ever been subject to court martial or other disciplinary
X Not
Yes
No
proceedings under the Uniform Code of Military Justice?
Applicable
In the past seven years, have you left any employment for unfavorable reasons or
Yes
X No
without giving proper notice?
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