All questions must be answered. If an item is not applicable, indicate "None" or "Not Applicable" ("N/A"). Do not use the term "Unknown" for dates, schooling, employment or residences. Forms must be printed in ink or typed and submitted in six legible copies. The original copy must not be part carbon copy.

Item 1. Give your full name, to include first, middle (maiden name if applicable), and last name, in that order. Names should agree with military or civilian employment records, if not, explain in item 20. If no middle name, use "NMN." If initial only, insert the appropriate initial followed by "(IO)." Check appropriate square for Mr., Mrs., or Miss.

Item 2. Complete only one status block. The civilian block will be completed by all civilians, including National Guard personnel, Reserve personnel not on active duty, and applicants for enlistment. The military block will be completed by military personnel on active duty at time of completing the form.

Item S. List all aliases, nicknames, or changes in name. This means all names under which you have been known to employers, associates, or others, i.e. "Joe" if your name is Joseph, "Bob" for Robert, etc. If you were known by your middle name, list it also. If none of the above apply to you, insert the word "None." If you have been known by any last name other than that which appears in item 1, give inclusive dates. If adopted, give date and place in item

20.

Item 4. This item reflects permanent mailing address. This is usually the permanent home address or legal address. Do not give military addresses. When a New York City address is given, borough must be shown.

Item 5. Give complete birth data and physical description to include any distinguishing marks, scars, tattoos, etc. Physical description must correspond with that entered on the fingerprint card, when a card is required. Spell month of birth; do not abbreviate. For example: 7 December 1929; do not use numbers such as 7-12-29.

Item 6. Read carefully and check appropriate blocks. If the answer to any of these questions is "Yes," include a complete explanation under item 20. If treatment was received from Veterans Administration, the VA case number and type of treatment must be shown in item 20.

Item 7. Citizenship status as reflected under this item must be complete. Aliens, naturalized citizens, and those with derivative citizenship

must furnish naturalization certificate numbers, alien registration numbers, or numbers of other pertinent documents as issued by the Immigration and Naturalization Service, Department of Justice, or competent court of record. If the required information is not readily available, it must be obtained from parents or other sources in possession of such information. An entry must be made in each block. Use the term "N/A" if appropriate.

Item 8. Indicate current status; include all requested data pertaining to military service, including all prior discharges and the following information pertaining thereto: day, month, and year; type of discharge; grade, and service number. Block indicating date current active service started should not include any period from which you were previously separated to civilian status, or discharged for re-enlistment or to accept a commission. It should reflect only the date of entry on current active duty following last separation or discharge. Under organization and station, give the current working location to include room and building number, if on a base. Use item 20, if necessary.

Item 9. List all schools attended, including military academy, if any, but not grammar schools or service schools. Indicate whether or not graduated from each school and college degree(s) received, if any. Location of school must be shown; if located in New York City, borough must be indicated. Location of schools shown in this item should agree with residences in item 15. Names of schools attended in foreign countries must be shown in language of that country. The specific, school, course or college of all universities attended must be shown.

Item 10. List full name of each close relative, as identified at the beginning of this item including step-brothers, step-sisters, and children by other marriages, preceded by appropriate identification, i.e., brother, sister, daughter, etc. For female relatives, give both maiden and married names in full. (Example: Alice May Jones, nee Smith, also known as ("aka") Mrs. James Robert Jones.) Give day, month, year, and city or county and State, if born in the United States. Complete addresses are required to include street and number. For each listed person born outside of the United States, use item 20 to show: date and port of entry into the United States, alien registration number, date of naturalization, place of naturalization, name under which naturalized, name and location of court of jurisdiction, and naturalization certificate number, when applicable. Indicate "None"

if not married, in spouse block. If any member of your family is deceased, list year of death.

Item 11. All information regarding each relative required to be listed under this item must be furnished with complete identifying data. If "none" so state. When relatives currently reside in any of the following countries, the method (mail, personal visits, etc.), regularity and recency of contact, if any, with such relatives must be shown in item 20: Albania, Bulgaria, Czechoslovakia, Cuba, Hungary, Poland, Rumania, Yugoslavia, Union of Soviet Socialist Republics, China (except for Taiwan (Formosa) and adjacent islands), Eastern Zone of Germany, Estonia, Korea north of the 38th Parallel, Kurile Islands and South Sakhalin (Karafuto), Latvia, Lithuania, Soviet Sector of Berlin, and those parts of Cambodia, Laos, and Vietnam now occupied by the Communists.

Item 12. List all periods of foreign travel not a result of U.S. military duties. This will include the duration of the visit, the countries visited, and the purpose of such travel.

Item 13. List each period of employment with complete names and addresses. Include selfemployment and unemployment. The month and the year of beginning and ending of each period must be shown. Do not list military service in this item. List it under item 8. Do not list any education under this item. List it under item 9. List employment in chronological order, beginning with your present employment. If selfemployed during any period, list in item 20 or an attached sheet, the complete name and address of the business and names and addresses of individuals who can verify periods of self-employment. If unemployed during any period, give names and addresses of individuals who can verify periods of unemployment. If any employment was in New York City, indicate the borough. If employed by Chrysler or General Motors Corporations in Detroit, Michigan, give the name of the specific plant. If presently employed by the Air Force, give current working location to include room and building number, if on a base.

Item 14. Three credit and five character references are required. All character references must be adult persons residing in the United States. If a rural route is given, location in relationship to nearest town should be shown. For example: Rural Route # 4, 3 miles south of Memphis, Tennessee, on Hwy #191. If the space provided for this information is insufficient, show the additional information under item 20. Do not list military references unless their military grade and current address are known. Persons listed as character references should be individu

als with whom a close and continuing relationship exists or has existed for at least five years, If any references are located in New York City, indicate the borough.

Item 15. List all places of residence during the last 15 years in chronological order to include instructions required to locate rural residences. (It is no longer necessary to list all residences from 1 January 1937.) Addresses while in military service, not permanent residence, must be furnished. When any New York City address is given, the borough in which located must be listed. If on base, give military organization; if off base, list street, number, city, and State.

Item 16. Give pertinent information including complete names and locations of each organization of which you are, or have been, a member. Labor unions, National Guard, and Reserve organizations (if not reflected in item 8) must be listed.

Item 17. Read carefully. Each question requires either a "Yes" or "No" answer. If a "Yes" has been checked in answer to any question, enter a complete and detailed explanation in either the space provided, item 20, or on attached sheets if necessary.

Item 18. Questions at the beginning of this item must be reviewed carefully and either "Yes" or "No" checked. If "Yes," list all information. List all courts-martial, to include current and prior enlistments. Give place, date, and charges. Also list any Articles 15 if they resulted in fines, restrictions, demotions, etc.

Item 19. Give details of any situation or incident which you feel might require some explanation. Include such items as failure or refusal to sign a loyalty oath, instances of pleading protection of the Fifth Amendment, United States Constitution, or of Article 31, Uniform Code of Military Justice.

Item 20. Use this space for continuation of other items where insufficient space was provided. If necessary, use attached sheets and indicate by stating "See attached sheet (s)" at the end of this space. Each copy of this Statement of Personal History and all attached sheets must be signed by both you and a witness in the presence of the witness. Each copy must be dated. The witnessing official must read the certification statement to you and assure himself that you understand the contents. You must understand that the certificate you sign must be accurate in every detail and understand the implications of certifying to false statements. Thereafter, you and the witnessing official must sign the forms in the presence of each other. Item 21. Do not use this space.

EXTRACT

From

DOD Directive 5210.8, Subject: "Policy on Investigation and Clearance of DOD Personnel for Access to Classified Defense Information."

V. CRITERIA FOR APPLICATION OF
POLICY

A. The ultimate determination of whether the granting of a clearance is clearly consistent with the interests of national security must be an over-all common sense determination based on all available information. The activities and associations listed below, whether current or past and while not all inclusive, are of varying degrees of seriousness and warrant initiation of action to effect such determination:

1. Commission of any act of sabotage, espionage, treason or sedition, or attempts thereat or preparation therefor, or conspiring with or aiding or abetting another to commit or attempt to commit any act of sabotage, espionage, treason or sedition.

2. Establishing or continuing a sympathetic association with a saboteur, spy, traitor, seditionist, anarchist, or revolutionist, or with an espionage or other secret agent or representative of a foreign nation, or any representative of a foreign nation whose interests are inimical to the interests of the United States, or with any person who advocates the use of force or violence to overthrow the government of the United States or the alteration of the form of government of the United States by unconstitutional means.

3. Advocacy of use of force or violence to overthrow the government of the United States, or of the alteration of the form of government of the United States by unconstitutional means.

4. Membership in, or affiliation or sympathetic association with, any foreign or domestic organization, association, movement, group or combination of persons which is totalitarian, Fascist, Communist, or subversive, or which has adopted or shows, a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights, under the Constitution of the United States, or which seeks to alter the form of government of the United States by unconstitutional means. (An organization, movement or group, officially designated by the Attorney General of the United States to be totalitarian, Fascist, Communist or subversive, to advocate or approve forcible or violent denial of Constitutional rights, or to seek alteration of the form of government of the United States by unconstitutional means, shall

be presumed to be of a character thus designated until the contrary be established.)

5. Performing or attempting to perform his duties, or otherwise acting, so as to serve the interests of another government in preference to the interests of the United States.

6. Failure or refusal to sign a loyalty certificate, or pleading protection of the Fifth Amendment or of Article 31, Uniform Code of Military Justice, in refusing to completely answer questions contained in required security forms or personal history statements; pleading protection of the Fifth Amendment or of Article 31, Uniform Code of Military Justice, or otherwise failing or refusing to answer any pertinent question propounded in the course of an official investigation, interrogation, or examination, conducted for the purpose of ascertaining the existence or extent, or both, of conduct of the nature described in 1 through 5 above and 7 through 13 below.

7. Participation in the activities of an organization established as a front for an organization referred to in 4 above, when his personal views were sympathetic to the subversive purposes of such organization.

8. Participation in the activities of an organization with knowledge that it had been infiltrated by members of subversive groups under circumstances indicating that the individual was a part of, or sympathetic to, the infiltrating element or sympathetic to its purposes.

9. Participation in the activities of an organization, referred to in 4 above, in a capacity where he should reasonably have had knowledge of the subversive aims or purposes of the organization.

10. Sympathetic association with a member or members of an organization referred to in 4 above, or sympathetic interest in totalitarian, Fascist, Communist, or similar subversive move

ments.

11. Currently maintaining a close continuing association with a person who has engaged in activities or associations of the type referred to in 1 through 9 above. A close continuing association may be considered to exist if the individual lives at the same premises as, frequently visits, or frequently communicates with such person.

12. Close continuing association of the type described in 11 above, even though later separated by distance, if the circumstances indicate that renewal of the association is probable.

13. Any facts, other than as set forth in 14

95-901 O-63 (App. vol. 1)–30

AFR 205-6

through 19 below, which furnish reason to believe that the individual may be subjected to coercion, influence, or pressure which may cause him to act contrary to the best interests of national security. Among matters which should be considered in this category would be the presence of a spouse, parent, brother, sister, or offspring in a nation, a satellite thereof, or an occupied area thereof, whose interests are inimical to the interests of the United States.

14. Willful violation or disregard of security regulations.

15. Intentional unauthorized disclosure to any person of classified information, or of other information disclosure of which is prohibited by law.

16. Any deliberate misrepresentation, falsification, or omission of material fact.

17. Any criminal, infamous, dishonest, im

moral or notoriously disgraceful conduct, habitual use of intoxicants to excess, drug addiction, or sexual perversion.

18. Acts of reckless, irresponsible or wanton nature which indicate such poor judgment and instability as to suggest that the individual might disclose security information to unauthorized persons or otherwise assist such persons, whether deliberately or inadvertently, in activities inimical to the security of the United States.

19. All other behavior, activities, or associations which tend to show that the person is not reliable or trustworthy.

20. Any illness, including any mental condition or hypnotic therapy, of a nature which in the opinion of competent medical authority may cause significant defect in the judgment or reliability of the individual, with due regard to the transient or continuing effect of the illness and the medical findings in such case.