Contract Personnel Questionnaire Prepare in duplicate. Type or print all responses. If answer is No, state so. Attach sheets if more space is needed. Privacy Act: The collection of this information is authorized by 39 U.S.C. 401. This information will be used as a basis for an investigation to determine your fitness and suitability for contractual service to the U.S. Postal Service. As part of the investigation, FD-258, Fingerprint Chart—Applicant, will be sent to the FBI for a criminal record check. As a routine use, the information may be disclosed to an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal proceeding to which the USPS is a party or has an interest; to a government agency in order to obtain information relevant to a USPS decision concerning security clearances, contracts, licenses, grants, permits or other benefits; to a government agency upon its request when relevant to its decision concerning employment, security clearances, security or suitability investigations, contracts, licenses, grants or other benefits; to a congressional office at your request; to an expert, consultant, or other person under contract with the USPS to fulfill an agency function; to the Federal Records Center for storage; to the Office of Management and Budget for review of private relief legislation; to an independent certified public accountant during an official audit of USPS finances; to an investigator, administrative judge or complaints examiner appointed by the Equal Employment Opportunity Commission for an investigation of a formal EEO complaint under 29 CFR 1614; and to the Merit Systems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel practices and other matters within their jurisdiction. Completion of this form is voluntary; however, if the information is not provided you may be denied access to postal premises, denied access to the mail, or you may be denied participation under a USPS contract. A false answer to any question on this form is punishable by law (18 U.S.C. 1001). 1. Print Your Full Name (Last, first, middle name) 2. Print Your Mailing Address (Include Apt./Suite No.) 3. City, State and ZIP+4 Code 4a. Home Telephone No. (Include Area Code) 4b. Work Telephone No. (Include Area Code) 5. List Other Names Used. (i.e., maiden name, names by former marriages, names changed legally or otherwise, aliases, nicknames. Specify which and dates used.) 6. Social Security No. (SSN) 7. Date of Birth 8. Place of Birth (City and State/Country) . Female . Male 9. Sex . Contractor's Employee . Contractor . Sub-Contractor Type of Screening (Check one)10. . Other . ADP 11. Highway Contract No. and Termini (if applicable) 12. Contractor's Name and Mailing Address 13. Have You Had a Security Screening by USPS or Other Federal Agencies 14. Are You Presently a Highway Contract Driver? (If Yes, include Contract No. Within the Last Year? and Termini.) . Yes . No . Yes . No . Agency: Dates and Places of Residence. (If actual places of residence differ from the mailing addresses, furnish and identify both. Begin with present residence and go back for the past five years.) 15. Number and Street From To City State ZIP+4 Code (Date) (Date) Employment. (List ALL periods of employment for the past five years starting with your present employment. Include dates when unemployed. Give name under which employed if different from name now used.) 16. Education. (List ALL education. Include highest level of education obtained.) 17. From (Date) To (Date) Employer's and Supervisor's Names Employer's Address Occupation From (Date) To (Date) School Name School Location Degrees Highest Level Obtained Reason for Leaving Your Name During Period of Employment No5Yes 5 Do You Have a Valid License? (Driver/Chauffeur) If Yes, include License No., State, and Expiration Date. 18a. No5Yes 5 18b. Commercial Driver's License PS Form 2025, April 1995 (Continued on Reverse) 19a. Are You a United States Citizen? 19b. Are You a Citizen of American Samoa or Any Other 5 Yes 5 No Territory Owing Allegiance to the United States? 5 Yes 5 No 19c. Are You an Alien With Permanent Residence Status? (If "yes," be prepared to show Form l–151 or l–551.) 5 Yes 5 No 20a. Military Service (Past or Present). (If Yes, complete items 20b, 20c, 20d, 20e, and 20f.) 5 Yes 5 No Where You Discharged from the Military Service Under Honorable Conditions? (If your discharge was changed to "honorable" 20e. or "general" by a Discharge Review Board, answer "Yes". If you received a clemency discharge, answer "No".) If No, enter the date and type of discharge you received in the blocks below. 5 Yes 5 No Discharge Date (Month, Day, Year) Type of Discharge 20f. While in Military Service, Were You Ever Convicted by Court Martial? 5 Yes 5 No 21a. Have You Ever Been Convicted of, or Forfeited Collateral for Any Felony/Misdemeanor Violation (Except Traffic Violations)? (Generally, a felony is defined as any violation of law punishable by imprisonment of one year or longer.) 5 Yes 5 No 21b. During the Last 10 Years Have You Forfeited Collateral, Been Convicted, Been Imprisoned, Been on Probation, or Been on Parole for any Violation of Law? (Do not include violations reported in question 21a.) 5 Yes 5 No 21c. Have You Ever Been Convicted of, or Forfeited Collateral for Any Assaults, Firearms or Explosives Violations? 5 Yes 5 No 21d. Are You Now Under Charges for Any Violation of Law? 5 Yes 5 No If any answers to 21a-21d are "Yes", provide date, place, court location, charge, and disposition on an attached sheet. 21e. Are You Delinquent on any Federal Debt? (Include delinquencies arising from Federal taxes, overpayment of benefits, or other debts to the U.S. Government plus defaults on Federally guaranteed or insured loans such as student and home mortgage loans.) 5 Yes 5 No 20b. Dates of Service 20c. Branch of Service (Army, Navy, Air Force, Marines, etc.) 20d. Serial No. (In none, provide Grade or Rating at time of separation) To From Court Martial Date (Month, Day, Year) Place (City and State/Country) Charge Disposition Date Place (City and State) Court Charge Action Taken If necessary, attach additional sheets. 22. In the Past 5 Years, Have You Been Convicted of any Traffic Violations (Other Than Parking) or Currently Have Charges Pending? (If Yes, complete information below.) 5 Yes 5 No Date Place (City and State) Court Charge Action Taken If necessary, attach additional sheets. . Check Here if Your Driver's Abstract from Department of Motor Vehicles is Attached. Warning Review this form carefully to ensure you have answered all questions fully and correctly. Failure to answer all questions may result in your being denied access to mail and/or Postal premises. A fine not to exceed $250,000 or imprisonment of not more than five years or both is provided by law (18 U.S.C. 1001) for making a false statement or concealing any material fact on this Questionnaire. Certification I certify that the statements made by me on this questionnaire are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. Applicant's Signature Date Signed I attest I have advised the Applicant to truthfully complete this Questionnaire, and the Applicant has passed the Drug Screening Test (If applicable, provide documentation). Contractor's Signature (Sign and print name) Telephone No. (Include area code) Date Signed For Use of Postal Official Responsible for Reviewing for Completeness and Legibility. (See Administrative Support Manual 272.23, Contractor Clearance, for complete instructions.) USPS Official Signature (Sign and print name) Telephone No. (Include Area Code) Date Signed Organization, City, State, and ZIP+4Code PS Form 2025, April 1995 (Reverse)