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 Statement: Your information will be used as a basis for an investigation to determine your fitness and suitability for contractual services to the U.S. Postal Service® (USPS®). Collection is authorized by 39 U.S.C. 3061. Providing the information is voluntary, but if not provided you may be denied access to Postal Service premises, denied access to the mail, or denied participation under a USPS contract. We may disclose your information as follows: in relevant legal proceedings; to law enforcement when the USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local or foreign govern- ment agencies regarding personnel matters; to the Equal Employment Opportunity Commission; to the Merit Systems Protection Board or Office of Special Counsel. 1. Print Your Full Name (Last, First, Middle Name) 2. Print Your Mailing Address (Include Apartment/Suite Number) 3. City, State and ZIP+4 Code™ 4a. Home Telephone Number (Include Area Code) 4b. Work Telephone Number (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.) 10. Type of Screening (Check one) 13. Contractor's Name and Mailing Address 14. Have You Had a Security Screening by USPS or Other Federal Agencies Within the Last Year? 11. Are You Presently a Highway Contract Driver? (If Yes, include Contract Number and Termini.) 12. Highway Contract Number and Termini (If applicable) 7. Date of Birth (MM/DD/YYYY) 8. Place of Birth (City and State/Country) 9. Sex6. Social Security Number (SSN) 15. 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.) 16. 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.) From (MM/YYYY) To (MM/YYYY) From (MM/YYYY) To (MM/YYYY) Number and Street City State ZIP+4 Code Employer's and Supervisor's Names Employer's Address (City, State, Zip+4Code) Occupation Reason for Leaving Male Female Sub-ContractorContractor's Employee ADPContractor Yes No Yes No Other Agency: Your Name During Period of Employment 17a. Are You a United States Citizen? Yes No 17b. Are You a Citizen of American Samoa or Any Other Territory Owing Allegiance to the United States? Yes No 17c. Provide Alien Registration Number if not a United States Citizen 18b. Commercial Driver's License 18a. Do You Have a Valid License? (Driver/Chauffeur) If “Yes”, include License Number, State, and Expiration Date. Yes No Yes No PS Form 2025, July 2009, (Page 1 of 2) PSN 7530-01-000-9519 (Continued on Page 2) 19b. Have you registered with the Selective Service System? If “Yes”, provide your registration number. If “No”, show the reason for your legal exemption. 19a. Are you a male born after December 21, 1959? If “No”, go to 20a. If Yes, go to 19b. 20a. Military Service (Past or Present). (If Yes, complete Items 20b, 20c, 20d, 20e, and 20f.) 20c. Branch of Service (Army, Navy, Air Force, Marines, etc.)20b. Dates of Service (MM/YYYY) To From 20d. Serial Number (If none, provide Grade or Rating at time of separation) Yes Yes No No Yes No Yes No Yes No Yes No 19. Your Selective Service Record 19c. Registration Number 19d. Legal Exemption Explanation 20e. Were You Discharged from the Military Service Under Honorable Conditions? (If your discharge was changed to "honorable" 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. Yes No Discharge Date (MM/YYYY) Type of Discharge 20f. While in Military Service, Were You Ever Convicted by Court Martial? Yes No Court Martial Date (MM/DD/YYYY) Place (City and State/Country) Charge Disposition 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.) 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.) 21c. Have You Ever Been Convicted of, or Forfeited Collateral for Any Assaults, Firearms or Explosives Violations? 21d. Are You Now Under Charges for Any Violation of Law? Yes 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.) Yes Date (MM/YYYY) Place (City and State) Court Charge Action Taken If necessary, attach additional sheets. No 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.) Yes No Date (MM/YYYY) 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 Service 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 (MM/DD/YYYY) 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 Number (Include area code) Date Signed (MM/DD/YYYY) For Use of Postal Service 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 Number (Include Area Code) Date Signed (MM/DD/YYYY) Organization, City, State, and ZIP+4 Code PS Form 2025, July 2009 (Page 2 of 2)