Form Uga Hr - Security Questionnaire -University System Of Georgia
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1
2Board of Regents
Employment
University System of Georgia
Clear this form
Security Questionnaire
Please type this form online, then print.
NOTICE TO EMPLOYEES: The Sedition and Subversive Activities Act of 1953 (Ga. Laws, 1953), as amended, requires each employee to complete
and sign, prior to his/her employment by the State of Georgia, a questionnaire which is designed to establish that there are no reasonable grounds to
believe that he/she is a subversive person. A subversive person is defined as one who commits acts, advocates, or teaches the overthrow of the
government of the United States or government of the State of Georgia by force or violence or who is a knowing member of a subversive organization.
INSTRUCTIONS: Prepare in original only. Fill in all items. If more space is needed for any item, or explanation, continue under Item 5. Please type
or print in ink.
1. Name ________________________________________________________________Social Security No. ________________________________
First name
M I
Last name
Other Names Used: (Maiden name, names by former marriages, former names changed legally or otherwise: Aliases, nicknames, etc. Specify which,
and show dates used.)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
2.
Address ______________________________________________________________________________________________________________
Street and No.
City
State
County
Phone No.
3.
Are you now or have you been within the last ten (10) years a member of any organization which to your knowledge at the time of membership
advocates or has as one of its objectives, the overthrow of the government of the United States or the government of the State of Georgia by force or
violence? Yes ______ No _____ If “Yes,” state the name of the organization and your past and present membership status including any offices
held therein. ________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
NOTE:
If the answer to Question 3 is “yes” and the employing authority deems further inquiry is necessary, you will be notified of such
determination. No action adverse to your applicaton will be taken because of an affirmative answer until after such an inquiry, with notice
to you and an opportunity for you to present evidence, and only if the results of such inquiry bring your application within the
prohibition within the Sedition and Subversive Activities Act of 1953, as amended.
4. (A)
Have you ever been convicted or are any charges now pending against you by Federal, State, or other law-enforcement authorities, for any
violation of any federal law, state law, county or municipal law, regulation, or ordinance? (Do not include anything that happened before
your sixteenth birthday. Do not include minor traffic violations for which a fine of $35.00 or less was imposed. All other convictions must
be included even if they were pardoned.)
Yes _____
No _____
(B)
If the answer to 4 (A) is “yes,” state the reason convicted, the date convicted, and the place where convicted.
REASON CONVICTED
DATE
PLACE WHERE CONVICTED
5. SPACE FOR CONTINUING ANSWERS OR EXPLANATIONS: (Show item numbers to which answers or explanations apply. Attach a separate
sheet if more space is needed.)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
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