Standart Form 85 - Questionnaire For Non-Sensitive Positions Page 5
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810
YOUR EMPLOYMENT ACTIVITIES
List your employment activities, beginning with the present (#1) and working back 5 years. You should list all full-time work, part-time work, military service, temporary
military duty locations over 90 days, self-employment, other paid work, and all periods of unemployment. The entire 5-year period must be accounted for without breaks,
but you need not list employments before your 16th birthday.
Code. Use one of the codes listed below to identify the type of employment:
1 - Active military duty stations
5 - State Government (Non-Federal
7 - Unemployment (Include name of
9 - Other
2 - National Guard/Reserve
employment)
person who can verify)
3 - U.S.P.H.S. Commissioned Corps
6 - Self-employment (Include business name
8 - Federal Contractor (List Contractor,
4 - Other Federal employment
and/or name of person who can verify)
not Federal agency)
Employer/Verifier Name. List the business name of your employer or the name of the person who can verify your self-employment or unemployment in this block. If
military service is being listed, include your duty location or home port here as well as your branch of service. You should provide separate listings to reflect changes in
your military duty locations or home ports.
Previous Periods of Activity. Complete these lines if you worked for an employer on more than one occasion at the same location. After entering the most recent
period of employment in the initial numbered block, provide previous periods of employment at the same location on the additional lines provided. For example, if you
worked at XY Plumbing in Denver, CO, during 3 separate periods of time, you would enter dates and information concerning the most recent period of employment first,
and provide dates, position titles, and supervisors for the two previous periods of employment on the lines below that information.
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#1
Present
To
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Position Title
Supervisor
PREVIOUS
To
PERIODS
Month/Year
Month/Year
Position Title
Supervisor
OF
To
ACTIVITY
Month/Year
Month/Year
Position Title
Supervisor
(Block #1)
To
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#2
To
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Position Title
Supervisor
To
PREVIOUS
PERIODS
Month/Year
Month/Year
Position Title
Supervisor
OF
To
ACTIVITY
Month/Year
Month/Year
Position Title
Supervisor
(Block #2)
To
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#3
To
Employer’s/Verifier’s Street Address
City (Country)
State
ZIP Code
Telephone Number
(
)
Street Address of Job Location (if different than Employer’s Address)
City (Country)
State
ZIP Code
Telephone Number
(
)
Supervisor’s Name & Street Address (if different than Job Location)
City (Country)
State
ZIP Code
Telephone Number
(
)
Month/Year
Month/Year
Position Title
Supervisor
PREVIOUS
To
PERIODS
Month/Year
Month/Year
Position Title
Supervisor
OF
To
ACTIVITY
Month/Year
Month/Year
Position Title
Supervisor
(Block #3)
To
Enter your Social Security Number before going to the next page
Page 3
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