When listing all references, DO NOT use any family or relatives and DO NOT list anyone twice!
At any section in this form, if more entries need to be made, continue on the back of that particular page.
Also information given in this packet is protected by the Privacy Act Statement of 1974

ENLISTMENT SECURITY QUESTIONNAIRE

PERSON

SSN_________________________LAST NAME___________________________FIRST NAME_______________________________

MIDDLE NAME__________________________DOB (YYMMDD)__________________ CITY OF BIRTH__________________________

COUNTY OF BIRTH______________________STATE OF BIRTH____________ COUNTRY OF BIRTH__________________________

GENDER____________________ HEIGHT________WEIGHT___________EYE COLOR______________ HAIR COLOR____________

REIGISTERD TO VOTE? YES NO PRIOR SERVICE YES NO

RACE_____________________AGGREGATE RATE__________________________ETHNIC CATEGORY_________________________

RELIGION ___________________________________________________________________

DRIVERS LICENSE STATE_________ EXPIRATION DATE (YYMMDD)______________ LICENSE #___________________________

MARITAL STATUS______________________TOTAL DEPENDENTS______________ MINOR DEPENDENTS___________________

CURRENT ADDRESS: STREET_____________________________________________________ CITY__________________________

COUNTY________________________ STATE____________________ZIP_____________________ COUNTRY_____________________

DATES AT CURRENT ADDRESS: FROM (YYMMDD)_______________________ TO (YYMMDD)______________________

CURRENT TELEPHONE #: CELL: __________________________________ HOME:__________________________________________

PHYSICAL SCREENING CRITERIA

PERSONAL SCREENING CRITERIA

ALIASES

ALIAS NAME TYPE________________________ LAST NAME_________________________FIRST NAME________________________

MIDDLE NAME_______________________ FROM (YYMMDD)_____________________TO (YYMMDD)_________________________

CITIZENSHIP

PASSPORT #___________________________ DATE ISSUED_____________________EXPIRATION DATE________________________

RESIDENCES

Working back 10 years. All periods must be accounted for in your list. Be sure to indicate the actual physical location of your residence; DO NOT use a post office box as an address. For addresses in the last five years, if address is “General Delivery” a Rural or Star Route, or is difficult to locate, provide directions for locating the residence on an additional sheet

FROM (YYMMDD)_________________________ TO (YYMMDD)_________________________________

STREET ADDRESS_____________________________________________________________ CITY________________________________

STATE____________ COUNTY_______________________ ZIP ______________________ COUNTRY____________________________

IS THIS ADDRESS YOUR HOME OF RECORD ADDRESS? YES NO

REFERENCE LAST NAME _______________________________ FIRST NAME______________________________________________

MIDDLE NAME____________________ RELATIONSSHIP (NON-FAM ILY)_________________________________________________

REFERENCE STREET ADDRESS_______________________________________________ CITY_________________________________

COUNTY______________________________ STATE___________ ZIP______________________

REFERENCE 9 DIGIT PHONE________________________________________________________________

REFERENCE ALTERNATE 9 DIGIT PHONE___________________________________________________

FROM (YYMMDD)_________________________ TO (YYMMDD)_________________________________

STREET ADDRESS_____________________________________________________________ CITY________________________________

STATE____________ COUNTY_______________________ ZIP ______________________ COUNTRY____________________________

IS THIS ADDRESS YOUR HOME OF