Standart Form 85 - Questionnaire For Non-Sensitive Positions Page 6
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8YOUR EMPLOYMENT ACTIVITIES (CONTINUED)
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#4
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 #4)
To
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#5
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 #5)
To
Month/Year
Month/Year
Code
Employer/Verifier Name/Military Duty Location
Your Position Title/Military Rank
#6
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 #6)
To
11
PEOPLE WHO KNOW YOU WELL
List three people who know you well and live in the United States. They should be good friends, peers, colleagues, college roommates, etc., whose combined
association with you covers as well as possible the last 5 years. Do not list your spouse, former spouses, or other relatives, and try not to list anyone who is listed
elsewhere on this form.
Name
Dates Known
Telephone Number
Month/Year
Month/Year
Day
#1
(
)
Night
To
Home or Work Address
City (Country)
State
ZIP Code
Name
Dates Known
Telephone Number
Month/Year
Month/Year
Day
#2
(
)
Night
To
Home or Work Address
City (Country)
State
ZIP Code
Name
Dates Known
Telephone Number
Month/Year
Month/Year
Day
#3
(
)
Night
To
Home or Work Address
City (Country)
State
ZIP Code
Enter your Social Security Number before going to the next page
Page 4
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