La Borrachera Seca

8/20/2019 La Borrachera Seca

1/48

PRIVACY ACT INFORMATION

Electronic Questionnaires for Investigations

Processing (e-QIPInvestigation Re!uest "#$%%&'

REVIE) COPY - *O NOT RETAIN

This copy is for review purposes only. An official copy for archival is generated upon formcertification.

Note: To conserve paper only the first entry in multiple-entry lists displays completioninstructions. The completion instructions for the first entry also applies to each additional entryunless otherwise noted.

For+ Co+,letion Instructions

Questionnaire for National ecurit. Positions (F$/ For+at

OMB No. 3!"-!!!#

$ollow instructions fully or we cannot process your form. If you have any questions, call theoffice that gave you the form.

Pur,ose of t0is For+

The %nited &tates 'overnment conducts (ac)ground investigations and reinvestigations toesta(lish that military personnel* applicants for or incum(ents in national security positions*either employed (y the 'overnment or wor)ing for 'overnment contractors* licensees*certificate holders* and grantees* are eligi(le for a re+uired security clearance. ,nformation fromthis form is used primarily as the (asis for investigation for access to classified information orspecial nuclear information or material. omplete this form only after a conditional offer ofemployment has (een made for a position re+uiring a security clearance.


2/48

'iving us the information we as) for is voluntary. owever* we may not (e a(le to completeyour investigation* or complete it in a timely manner* if you don/t give us each item ofinformation we re+uest. This may affect your placement or security clearance prospects.

Aut0orit. to Re!uest t0is Infor+ation

0epending upon the purpose of your investigation* the %nited &tates 'overnment is authori1edto as) for this information under 2ecutive Orders 4!5#!* 4!6"#* 4333* and 43#"7 sections33!4 and 84!4 of title #* %nited &tates ode7 sections 4"# and !4 of title 5* %nited &tatesode7 sections 964 to 669 of title #!* %nited &tates ode7 and parts #* 93* and 93" of Title #*ode of $ederal egulations.

;our &ocial &ecurity num(er is needed to )eep records accurate* (ecause other people may havethe same name and (irth date. April "* 488"?* as amended in title 34*section 99!4* also as)s $ederal agencies to use this num(er to help identify individuals in agencyrecords.

T0e Investigative Process

Bac)ground investigations for national security positions are conducted to develop informationto show whether you are relia(le* trustworthy* of good conduct and character* and loyal to the%nited &tates. The information that you provide on this form is confirmed during theinvestigation. ,nvestigation may etend (eyond the time covered (y this form when necessary toresolve issues. ;our current employer must (e contacted as part of the investigation* even if youhave previously indicated on applications or other forms that you do not want this.

,n addition to the +uestions on this form* in+uiry also is made a(out a person/s adherence to

security re+uirements* honesty and integrity* vulnera(ility to eploitation or coercion*falsification* mis-representation* and any other (ehavior* activities* or associations that tend toshow the person is not relia(le* trustworthy* or loyal.

Your Personal Intervie1

&ome investigations will include an interview with you as a normal part of the investigative process. This provides you the opportunity to update* clarify* and eplain information on yourform more completely* which often helps to complete your investigation faster. ,t is importantthat the interview (e conducted as soon as possi(le after you are contacted.


3/48

;ou may also (e as)ed to (ring documents a(out information you provided on the form or othermatters re+uiring specific attention. These matters include alien registration* delin+uent loans ortaes* (an)ruptcy* udgments* liens* or other financial o(ligations* agreements involving childcustody or support* alimony or property settlements* arrests* convictions* pro(ation* and@or parole.

Organi2ation of t0is For+

This form has two parts.


4/48

". All dates provided on this form must (e in Month@0ay@;ear or Month@;ear format. %se the pull down lists to select the month and day. The year should (e entered as all four num(ers* i.e.*4896 or !!4. ,f you find that you cannot report an eact date* approimate or estimate the dateto the (est of your a(ility and indicate this (y chec)ing the 2st. (o.

Final *eter+ination on Your Eligi3ilit.

$inal determination on your eligi(ility for access to classified information is the responsi(ility ofthe $ederal agency that re+uested your investigation. ;ou may (e provided the opportunity personally to eplain* refute* or clarify any information (efore a final decision is made.

Penalties for Inaccurate or False tate+ents

The %nited &tates riminal ode >title 46* section 4!!4? provides that )nowingly falsifying orconcealing a material fact is a felony which may result in fines of up to E4!*!!!* and@or # yearsimprisonment* or (oth. ,n addition* $ederal agencies generally fire* do not grant a security

clearance* or dis+ualify individuals who have materially and deli(erately falsified these forms*and this remains a part of the permanent record for future placements. Because the position forwhich you are (eing considered is a sensitive one* your trustworthiness is a very importantconsideration in deciding your eligi(ility for a security clearance. ;our prospects of placement or security clearance are (etter if you answer all +uestions truthfully and completely. ;ou will haveade+uate opportunity to eplain any information you give us on the form and to ma)e yourcomments part of the record.

*isclosure of Infor+ation

The information you give us is for the purpose of investigating you for a national security

position7 we will protect it from unauthori1ed disclosure. The collection* maintenance* anddisclosure of (ac)ground investigative information is governed (y the (?? and asfollows (elow.

PRIVACY ACT RO4TINE 4E

4. To the 0epartment of Fustice when: >a? the agency or any component thereof7 or >(? anyemployee of the agency in his or her official capacity7 or >c? any employee of the agency in his or her individual capacity where the 0epartment of Fustice has agreed to represent the employee7 or >d? the %nited &tates 'overnment* is a party to litigation or has interest in such litigation* and (ycareful review* the agency determines that the records are (oth relevant and necessary to thelitigation and the use of such records (y the 0epartment of Fustice is therefore deemed (y theagency to (e for a purpose that is compati(le with the purpose for which the agency collected therecords.


5/48

. To a court or adudicative (ody in a proceeding when: >a? the agency or any componentthereof7 or >(? any employee of the agency in his or her official capacity7 or >c? any employee ofthe agency in his or her individual capacity where the 0epartment of Fustice has agreed torepresent the employee7 or >d? the %nited &tates 'overnment* is a party to litigation or hasinterest in such litigation* and (y careful review* the agency determines that the records are (oth

relevant and necessary to the litigation and the use of such records is therefore deemed (y theagency to (e for a purpose that is compati(le with the purpose for which the agency collected therecords.

3. 2cept as noted in Guestion 5* when a record on its face* or in conunction with otherrecords* indicates a violation or potential violation of law* whether civil* criminal* or regulatoryin nature* and whether arising (y general statute* particular program statute* regulation* rule* ororder issued pursuant thereto* the relevant records may (e disclosed to the appropriate $ederal*foreign* &tate* local* tri(al* or other pu(lic authority responsi(le for enforcing* investigating or prosecuting such violation or charged with enforcing or implementing the statute* rule*regulation* or order.

5. To any source or potential source from which information is re+uested in the course of aninvestigation concerning the hiring or retention of an employee or other personnel action* or theissuing or retention of a security clearance* contract* grant* license* or other (enefit* to the etentnecessary to identify the individual* inform the source of the nature and purpose of theinvestigation* and to identify the type of information re+uested.

#. To a $ederal* &tate* local* foreign* tri(al* or other pu(lic authority the fact that this system ofrecords contains information relevant to the retention of an employee* or the retention of asecurity clearance* contract* license* grant* or other (enefit. The other agency or licensingorgani1ation may then ma)e a re+uest supported (y written consent of the individual for the

entire record if it so chooses. No disclosure will (e made unless the information has (eendetermined to (e sufficiently relia(le to support a referral to another office within the agency orto another $ederal agency for criminal* civil* administrative* personnel* or regulatory action.

". To contractors* grantees* eperts* consultants* or volunteers when necessary to perform afunction or service related to this record for which they have (een engaged. &uch recipients shall (e re+uired to comply with the


6/48

8. To a Mem(er of ongress or to a ongressional staff mem(er in response to an in+uiry of theongressional office made at the written re+uest of the constituent a(out whom the record ismaintained.

4!. To the National Archives and ecords Administration for records management inspections

conducted under 55 %& 8!5 and 8!".

44. To the Office of Management and Budget when necessary to the review of private relieflegislation.

P456IC 54R*EN INFORMATION

4!? year time frame for the case to meet the new standard:

&ection 8: Chere ;ou ave =ived&ection 4!: Chere ;ou Cent to &chool&ection 44: ;our 2mployment Activities&ection : ;our 2mployment ecord&ection 3* +uestions e and f: ;our


7/48

,f you have no first name or middle name* select No $irst Name >N$N? or No Middle Name>NMN?* as appropriate. ,f you have only initials in your name* enter the initial>s? >without the period? and select ,nitial Only >,O?. ,f you are a Fr.* &r.* ,,* etc.* enter this under &uffi.

$ull Name

=ast: Brennan. $irst: Fohn. Middle: Owen. &uffi: $ield is (lan)H

ection &< *ate of 5irt0

0ate of BirthMonth@0ay@;ear: !8@@48##.

ection '< Place of 5irt0


8/48

Num(er: 9!3-53#-699. Time: Night.

ection $< Citi2ens0i,

Ite+ a

Mar) the (o that reflects your current citi1enship status* and follow its instructions.

iti1enship &tatus, am a %.&. citi1en or national (y (irth in the %.&. or %.&. territory@possession. >Answer items (and d?: I Bo ,& hec)edHJ ., am a %.&. citi1en* (ut , was NOT (orn in the %.&. >Answer items (* c and d?: I Bo NOThec)edH J ., am not a %.&. citi1en. >Answer items ( and e?: I Bo NOT hec)edH J .

Ite+ 3

;our Mother/s Maiden Name: 0unn.

Ite+ c> 4nite: tates Citi2ens0i,

,f you are a %.&. citi1en* (ut were not (orn in the %.&.* provide information a(out one or more of the following proofs of your citi1enship.

Naturali1ation ertificate >Chere were you naturali1edK?ourt: $ield is (lan)H=ocationity: $ield is (lan)H &tate: $ield is (lan)Hertificate Num(er: $ield is (lan)H0ate ,ssuedMonth@0ay@;ear: L @ L @ L .iti1enship ertificate >Chere was the certificate issuedK?


9/48

%.&.


10/48

$or addresses in the last five years* if this address is 'eneral 0elivery* a ural or &taroute* or may (e difficult to locate* provide directions for locating the residence underAdditional omments (elow.

0ates of Activity

$rom >Month@;ear?: !9@4888. To >Month@;ear?:


11/48

&treet Address

&treet: $ield is (lan)H

ity: $ield is (lan)H &tate: $ield is (lan)H ountry: $ield is (lan)H Dip ode: $ield is

(lan)H

Telephone Num(er

Num(er: $ield is (lan)H

3. 0ates of Activity

$rom >Month@;ear?: !5@4868. To >Month@;ear?: 44@488".

&treet Address

&treet: 433#4 Month@;ear?: 4@4865. To >Month@;ear?: !5@4868.

&treet Address

&treet: "6#9 =afayette


12/48

Person )0o @ne1 You

Name: $ield is (lan)H

&treet Address


ity: $ield is (lan)H &tate: $ield is (lan)H ountry: $ield is (lan)H Dip ode: $ield is (lan)H

Telephone Num(er


#. 0ates of Activity

$rom >Month@;ear?: !6@486. To >Month@;ear?: 44@4865.

&treet Address

&treet: 2m(assy esidence.

ity: Feddah. &tate: $ield is (lan)H ountry: &audi Ara(ia. Dip ode: $ield is (lan)H

Person )0o @ne1 You


&treet Address



Telephone Num(er


". 0ates of Activity

$rom >Month@;ear?: !4@4864. To >Month@;ear?: !@486.

&treet Address


13/48

&treet: "459 =ees(urg Month@;ear?: !6@486!. To >Month@;ear?: 4@486!.

&treet Address

&treet: #!4 N. oosevelt oad.

ity: $alls hurch. &tate: A. ountry: $ield is (lan)H Dip ode: !5.

Person )0o @ne1 You


&treet Address



(lan)H

Telephone Num(er




14/48

$rom >Month@;ear?: !6@4896. To >Month@;ear?: !6@486!.

&treet Address

&treet: #9!! ameron oad Apt. 4!.

ity: Austin. &tate: T. ountry: $ield is (lan)H Dip ode: 9694!.

Person )0o @ne1 You


&treet Address



Telephone Num(er



$rom >Month@;ear?: !4@489". To >Month@;ear?: !6@4896.

&treet Address

&treet: 53# 95th &treet.

ity: North Bergen. &tate: NF. ountry: $ield is (lan)H Dip ode: !9!59.

Person )0o @ne1 You


&treet Address



Telephone Num(er


15/48


4!. 0ates of Activity

$rom >Month@;ear?: !6@489#. To >Month@;ear?: !4@489".

&treet Address

&treet: American %niversity in airo 0ormitory.

ity: airo. &tate: $ield is (lan)H ountry: 2gypt. Dip ode: $ield is (lan)H

Person )0o @ne1 You


&treet Address



Telephone Num(er



$rom >Month@;ear?: !@48"3. To >Month@;ear?: !6@489#.

&treet Address

&treet: 53# 95th &treet.

ity: North Bergen. &tate: NF. ountry: $ield is (lan)H Dip ode: !9!59.

Person )0o @ne1 You


&treet Address



16/48


Telephone Num(er


>2nd of =ist?

ection 8%< )0ere You )ent To c0ool

=ist the schools you have attended* (eyond Funior igh &chool* in the last 9 years. ,f all of youreducation occurred more than 9 years ago* list your most recent education (eyond high school*no matter when that education occurred.

&chools Attended > Not Applica(le: I Bo NOT hec)edH J . ?

4. Month@;ear?: !6@4899. To >Month@;ear?: !#@486!.

&chool Type

igh &chool: I Bo NOT hec)edH J .

ollege@%niversity@Military ollege: I Bo ,& hec)edHJ .

ocational@Technical@Trade &chool: I Bo NOT hec)edH J .

&chool Name: %niversity of Teas at Austin.

&treet Address

&treet: %niversity Boulevard.

ity: Austin. &tate: T. ountry: $ield is (lan)H Dip ode: 96943.


17/48

Month@;ear: !#@486!.

0egree@0iploma@Other: M.A..

>2nd of 0egree@0iploma@Other =ist?

Person )0o @ne1 You

$or schools you attended in the last 3 years* list a person who )new you at school >aninstructor* student* etc.?. 0o not list people for education completely outside this 3-year period.


&treet Address



Telephone Num(er


. 0ates of Activity

$rom >Month@;ear?: !8@4893. To >Month@;ear?: !#@4899.

&chool Type




&chool Name: $ordham %niversity.

&treet Address

&treet: $ordham oad.

ity: Bron* New ;or) ity. &tate: N;. ountry: $ield is (lan)H Dip ode: 4!5#6.

0egree@0iploma@Other


18/48

4. 0ate Awarded

Month@;ear: !#@4899.

0egree@0iploma@Other: B.A..

>2nd of 0egree@0iploma@Other =ist?

Person )0o @ne1 You


&treet Address



Telephone Num(er




&chool Type




&chool Name: American %niversity in airo.

&treet Address

&treet: A%.

ity: airo. &tate: $ield is (lan)H ountry: 2gypt. Dip ode: $ield is (lan)H

0egree@0iploma@Other

>No 2ntry


19/48

Person )0o @ne1 You


&treet Address



Telephone Num(er


>2nd of =ist?

ection 88< Your E+,lo.+ent Activities


20/48

%nemployment: I Bo NOT hec)edH J .

$ederal ontractor: I Bo NOT hec)edH J .

Other: I Bo ,& hec)edHJ .

2mployer Name: The Analysis orporation.

;our if different than o( location?



(lan)H

&upervisor/s Telephone Num(er

Num(er: 9!3-936-669.


21/48

a(ove* provide previous periods of employment at the same location on the additionallines provided. $or eample* if you wor)ed at ; Month@;ear?: 44@!!6.

Type of 2mployment

Active military duty stations: I Bo NOT hec)edH J .

National 'uard@eserve: I Bo NOT hec)edH J .

%.&.


22/48

Num(er: 9!3-5-5"9.

Fo( =ocation &treet Address >if different than employer address?



Fo( =ocation Telephone Num(er


&upervisor/s Name: None.

&upervisor/s &treet Address >if different than o( location?






23/48

National 'uard@eserve: I Bo NOT hec)edH J .

%.&.if different than o( location?



24/48



Num(er: 9!3-56-"5!!.

Non-$ederal employment?: I Bo NOT hec)edH J .

&elf-employment: I Bo NOT hec)edH J .

%nemployment: I Bo NOT hec)edH J .

$ederal ontractor: I Bo NOT hec)edH J .

Other: I Bo ,& hec)edHJ .

2mployer Name: %niversity of Teas at Austin.

;our


25/48

2mployer/s &treet Address

&treet: %niversity Boulevard.

ity: Austin. &tate: T. ountry: $ield is (lan)H Dip ode: 9694.

2mployer/s Telephone Num(er


Fo( =ocation &treet Address >if different than employer address?



Fo( =ocation Telephone Num(er


&upervisor/s Name: 'overnment 0epartment.

&upervisor/s &treet Address >if different than o( location?






26/48

>2nd of =ist?

ection 8&< Peo,le )0o @no1 You )ell

=ist three people who )now you well and live in the %nited &tates. They should (e good friends*

peers* colleagues* college roommates* etc.* whose com(ined association with you covers as wellas possi(le the last 9 years. 0o not list your spouse* former spouses* or other relatives* and trynot to list anyone who is listed elsewhere on this form.

4. 0ates nown

$rom >Month@;ear?: !6@4885. To >Month@;ear?:


27/48

ome or Cor) Address

&treet: 4!!4 'rovewood Cay.

ity: $airfa. &tate: A. ountry: $ield is (lan)H Dip ode: !3.

Telephone Num(er

Num(er: 9!3-9"5-!"89. Time: Night.

>2nd of =ist?

ection 8'8=< Your ,ouse

Mar) one item to show your current marital status.

Marital &tatus Never Married: I Bo NOT hec)edH J .Married: I Bo ,& hec)edHJ .&eparated: I Bo NOT hec)edH J .=egally &eparated: I Bo NOT hec)edH J .0ivorced: I Bo NOT hec)edH J .Cidowed: I Bo NOT hec)edH J .Other: I Bo NOT hec)edH J .urrent &pouse > Not Applica(le: I Bo NOT hec)edH J . ?

• omplete the following a(out your current spouse only.

,f no first name or middle name is used* select No $irst Name >N$N? or No Middle Name>NMN?* as appropriate. ,f only an initial is used as the first name or middle name* enterthe initial >without the period? and select ,nitial Only >,O?. ,f this person is a Fr.* &r.*,,* etc.* enter this under &uffi.

$ull Name

=ast: Brennan. $irst: atherine. Middle: >NMN?. &uffi: $ield is (lan)H

0ate of Birth

Month@0ay@;ear: !5@!9@48#".

&ocial &ecurity Num(er > Not Applica(le: I Bo NOT hec)edH J . ?

456 - # - 4"58.


28/48

ity: Fersey ity. &tate: NF. ountry: $ield is (lan)H

%se My urrent Address: I Bo ,& hec)edHJ . ?



2nd of ountry>ies? of iti1enship =ist?

&pecify maiden name* names (y other marriages* etc.* and show dates used for eachname. hec) the nee (o to denote maiden name.

Other Names %sed > Not Applica(le: I Bo NOT hec)edH J . ?


29/48

. Name

=ast: NMN?. &uffi: $ield is (lan)H

nee: I Bo NOT hec)edH J .

0ates %sed

$rom >Month@;ear?: !5@48#". To >Month@;ear?: !6@4896.

>2nd of Other Names %sed =ist?

ection 8=< Citi2ens0i, of Your Relatives an: Associates

,f your current spouse is a %.&. citi1en (y other than (irth* or an alien residing in the %.&.* provide a Not Applica(le: I Bo ,& hec)edHJ . ?>No 2ntry


30/48

#. $oster


31/48

Month@0ay@;ear: !8@!4@484.

ountry of Birth

ountry: %&.

ountry>ies? of iti1enship

4. ountry: %&.

>2nd of ountry>ies? of iti1enship =ist?


32/48

ountry: ,reland.


4. ountry: %&.


urrent Address

&treet: 63 0orset oad.

ity: Manchester. &tate: NF. ountry: $ield is (lan)H


No 2ntry Adopted and $oster hild also?.

$ull Name

=ast: Brennan. $irst: Faclyn. Middle: Ann. &uffi: $ield is (lan)H

0eceased

;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

0ate of Birth

Month@0ay@;ear: !5@!#@4866.

ountry of Birth

ountry: %&.


4. ountry: %&.


urrent Address


33/48

&treet: 433#4


34/48

#. elationship Type: hild >Adopted and $oster hild also?.

$ull Name

=ast: Brennan. $irst: elly. Middle: Marie. &uffi: $ield is (lan)H

0eceased


0ate of Birth

Month@0ay@;ear: !5@!#@4866.

ountry of Birth

ountry: %&.


4. ountry: %&.


urrent Address

&treet: 433#4


35/48

0ate of Birth

Month@0ay@;ear: !@43@48#8.

ountry of Birth

ountry: %&.


4. ountry: %&.


urrent Address

&treet: 45!! udson &treet.

ity: o(o)en. &tate: NF. ountry: $ield is (lan)H


No 2ntry ies? of iti1enship


36/48

4. ountry: %&.


urrent Address

&treet: 8"4 Oa)wood


37/48


No 2ntry 2nd of ountry>ies? of iti1enship =ist?

urrent Address


ity: $ield is (lan)H &tate: $ield is (lan)H ountry: $ield is (lan)H


No 2ntry 2nd of =ist?

ection 8/< Your Militar. ?istor.


38/48

Answer the following +uestions.

a. ave you served in the %nited &tates militaryK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

(. ave you served in the %nited &tates Merchant MarineK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

=ist all of your military service (elow* including service in eserve* National 'uard* and %.&.Merchant Marine. ,f you had a (rea) in service* each separate period should (e listed. ,f yourservice was with other than the %.&. Armed $orces* identify the country for which you served.

Military istory > Not Applica(le: I Bo ,& hec)edHJ . ?>No 2ntry em(assies orconsulates?* or its representatives* whether inside or outside the %.&.* other than on official %.&.'overnment (usinessK >0oes not include routine visa applications and (order crossing contacts.?;es: I Bo ,& hec)edHJ . No: I Bo NOT hec)edH J .

d. ,n the last 9 years* have you had an active passport that was issued (y a foreign governmentK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

,f you answered ;es to one or more of the +uestions a(ove* provide a detailed entry for each period of foreign activity.

4. Month@;ear?: !6@!!9. To >Month@;ear?:


39/48

$irm and@or 'overnment: %.. 'overnment.

2planation of ;our ,nvolvement

, have had lunch twice and dinner once with Alan =ovell* a %.. colleague with whom ,

wor)ed closely during the last three years of my government career. Alan is currently posted at the %.. 2m(assy in Cashington..

. 0ates of Activity

$rom >Month@;ear?: !4@!!6. To >Month@;ear?: 4!@!!6.

$irm and@or 'overnment: %nited Ara( 2mirates.

2planation of ;our ,nvolvement

As part of my responsi(ilities as TA?*, met twice with %A2 officials to descri(e the commercial offerings of our firm. The firsttime was in A(u 0ha(i in Fanuary !!6 and the second time in Mc=ean* A. 0r. &aeedA(dullah of the &tate &ecurity 0epartment was present at the first meeting in the %A2and he was the only %A2 official at the second meeting in Mc=ean* A. , have had noother contact with %A2 officials outside of my government service..

>2nd of =ist?

ection 8$< Foreign Countries You ?ave Visite:

=ist foreign countries you have visited* ecept on travel under official 'overnment orders*wor)ing (ac) 9 years. >Travel as a dependent or contractor must (e listed.? ,nclude short trips toanada or Meico. ,f you lived near a (order and have made short >one day or less? trips to theneigh(oring country* you do not need to list each trip. 0o not repeat travel covered in sections 8*4!* or 44.

$oreign Travels > Not Applica(le: I Bo NOT hec)edH J . ?

4. ,ndicate the purpose of your visit. ,f you lived near a (order and have made short >oneday or less? trips to the neigh(oring country* provide the time period* purpose* countryand chec) the Many &hort Trips (o.

0ates of Activity

$rom >Month@;ear?: !4@!!6. To >Month@;ear?: !4@!!6.


40/48

Business: I Bo ,& hec)edHJ . 2nd of ountries isited =ist?

Many &hort Trips: I Bo NOT hec)edH J .

. 0ates of Activity


Month@;ear?: !"@4895. To >Month@;ear?: !6@4895.


41/48

>2nd of ountries isited =ist?

Many &hort Trips: I Bo NOT hec)edH J .

>2nd of =ist?

ection 89< Your Militar. Recor:

Answer the following +uestion.

ave you ever received other than an honora(le discharge from the militaryK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

,f ;es* provide the date of discharge and type of discharge (elow.

0ate of 0ischargeMonth@;ear: L @ L .Type of 0ischarge: $ield is (lan)H

ection &%< Your elective ervice Recor:


a. Are you a male (orn after 0ecem(er 34* 48#8K;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

,f you answered ;es to +uestion a* answer the following +uestion.

(. ave you registered with the &elective &ervice &ystemK;es: I Bo NOT hec)edH J . No: I Bo NOT hec)edH J .

,f you answered ;es to +uestion (* provide your registration num(er. ,f No* show the reasonfor your legal eemption.

egistration Num(er: $ield is (lan)H=egal 2emption 2planation > , 0o Not now: I Bo NOT hec)edH J . ?

$ield is (lan)H

ection &8< Your Me:ical Recor:



42/48

,n the last 9 years* have you consulted with a mental health professional >psychiatrist* psychologist* counselor* etc.? or have you consulted with another health care provider a(out amental health related conditionK;es: I Bo ,& hec)edHJ . No: I Bo NOT hec)edH J .

,f you answered ;es* provide an entry for each treatment to report* unless the consultation>s?involved only marital* family* or grief counseling* not related to violence (y you.

>No 2ntry No 2ntry


43/48

(. ave you ever (een charged with or convicted of a firearms or eplosives offenseK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

c. Are there currently any charges pending against you for any criminal offenseK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

d. ave you ever (een charged with or convicted of any offense>s? related to alcohol or drugsK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

e. ,n the last 9 years* have you (een su(ect to court martial or other disciplinary proceedingsunder the %niform ode of Military FusticeK >,nclude non-udicial* aptain/s mast* etc.?;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

f. ,n the last 9 years* have you (een arrested for* charged with* or convicted of any offense>s? notlisted in response to a* (* c* d* or e a(oveK >=eave out traffic fines of less than E4#! unless theviolation was alcohol or drug related.?


,f you answered ;es to a* (* c* d* e* or f a(ove* provide an entry for each occurrence to report.

>No 2ntry


44/48

c. ,n the last 9 years* have you (een involved in the illegal purchase* manufacture* traffic)ing* production* transfer* shipping* receiving* or sale of any narcotic* depressant* stimulant*hallucinogen* or canna(is for your own intended profit or that of anotherK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

,f you answered ;es to a or ( a(ove* provide an entry for each controlled su(stance or prescription drug used.

>No 2ntry such as li+uor* (eer* wine? resulted in any

alcohol-related treatment or counseling >such as for alcohol a(use or alcoholism?K;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

,f you answered ;es* provide an entry for each treatment to report. 0o not repeat informationreported in response to section 4.

>No 2ntry


45/48

0efense 0epartment: I Bo NOT hec)edH J .

&tate 0epartment: I Bo NOT hec)edH J .

Office of 0o Not now: I Bo NOT hec)edH J . ?

Not e+uired: I Bo NOT hec)edH J .

onfidential: I Bo NOT hec)edH J .

&ecret: I Bo NOT hec)edH J .

Top &ecret: I Bo NOT hec)edH J .

&ensitive ompartmented ,nformation: I Bo ,& hec)edHJ .

G: I Bo NOT hec)edH J .

=: I Bo NOT hec)edH J .

Other: I Bo NOT hec)edH J .

>2nd of =ist?Answer the following +uestion.

(. To your )nowledge* have you ever had a clearance or access authori1ation denied* suspended*or revo)ed* or have you ever (een de(arred from government employmentK >An administrativedowngrade or termination of a security clearance is not a revocation.?


,f you answered BYes>B provide the re+uested information (elow.

>No 2ntry


46/48

Answer the following +uestions.

a. ,n the last 9 years* have you filed a petition under any chapter of the (an)ruptcy code >toinclude hapter 43?K;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

(. ,n the last 9 years* have you had your wages garnished or had any property repossessed forany reasonK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

c. ,n the last 9 years* have you had a lien placed against your property for failing to pay taes orother de(tsK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

d. ,n the last 9 years* have you had any udgments against you that have not (een paidK;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

,f you answered ;es to a* (* c* or d* provide an entry for each occurrence to report.

>No 2ntry s?K


(. Are you currently over 8! days delin+uent on any de(t>s?K;es: I Bo NOT hec)edH J . No: I Bo ,& hec)edHJ .

,f you answered ;es to a or (* provide an entry for each occurrence to report.

>No 2ntry


47/48

,f you answered ;es* provide the information a(out each pu(lic record civil court action.

>No 2ntry


48/48

,f you need to su(mit additional documents with your re+uest* give a (rief title or description ofeach attachment you plan to provide >e.g.* map with directions to residence?. One sheet with content on front and (ac) is two pages.?

Crite your social security num(er and the ,nvestigation e+uest num(er on the margin of eachattachment you su(mit.

2pected Attachments>No 2ntry

Documents

La Borrachera Seca