IQM Inc.
BUSINESS INVESTIGATIONS
PURCHASE ORDER AND INVOICE

Full Five Years
Background Investigation Process for
Nuclear Security Access Authorization

 669 Airport Freeway
Hurst, Texas 76053
Phone: (817) 282-3377
Fax: (817) 282-8833
Email:
iqm@crime-free.com

IQM Business Investigations Work Order Elements
Complete one for each candidate.

Client's Authorization Signature and Title or PIN Number

First__________________ Initial____ Last__________________ Title_________________

Bypass If Registration is on File at IQM

Division/Unit Organization Name

Mail Address City State Zip

Phone: AC Number Ext Fax: AC Number

Email

Investigative Description and Case Requirements

Candidate for Clearance

Last Name First Name Full Middle Name

Date of Birth Social Security Number

Notes (e.g.) Name of power plant, purchase order reference, split the investigation into "Temporary"/"Full Five Years", etc.
Item Case or Element Description Order Special instructions Quantity
7-1100 Activity Verification - 5 yr. Required
7-2700 National Credit Report Required
7-1410 Education Check w/Transcript Any college must be checked
7-1500 Military Service Verification? If active in last 5 years
7-1620 Special References If self employed or unemployed
7-2000 Court Contact Optional
7-2800 Civil Court Contact Optional
7-2500 Driver's License Record Optional
7-3000 Personnel Test or/ (MMPI-2) Plant may offer
7-3320 Special Purpose Interview Special case option
7-3400 Urine Collection Clinic Fee Plant may offer
7-3500 Drug Abuse Lab Screen-NIDA Plant may offer
7-3600 NIDA Lab Screen-Commercial Precautionary option

BASIC PERSONNEL SECURITY QUESTIONNAIRE (PSQ)

Instructions About The Use Of This Secure Electronic Personnel Screening Form

  1. Start by printing out this form. Have the candidate read and sign the authorization and releases. Draft the data on the printout. the hand written version is your file copy for audit purposes.
  2. Next key in the candidate's personal data either on-line or off-line and SAFELY AND SECURELY send the Personnel Security Questionnaire (PSQ).
  3. Activity/Employment Verifications, Educationand Credit Risk will be checked. Other options like driver's licence or court records will also be done.
  4. With the use of your PIN number, you are attesting that you have a signed release. We may need a cop of the original from time to time.

CANDIDATE'S AUTHORIZATION AND RELEASE

I hereby authorize and request any person or other entity, including but not limited to present and former employers, schools, law enforcement agencies, insurance companies, financial institutes, government agencies, including all entities which have information relating to my employment history, special training, worker's compensation, education, and credit history, to furnish the representative of the business investigations agency with any and all information and copies of records in their possession regarding me in connection with my employment application. I further authorize the investigative agency to release the results of the background check to my prospective employer. By signing below, I hereby release and hold harmless the owners of the business investigations agency, and their client, and their directors, officers, employees, and agents from claims arising out of or in any connection with their legitimate gathering or disclosures of information as authorized by this release. I am willing that a copy of this Authorization and Release be accepted with the same authority as original. Supporting documents are reviewed by the witness.

Applicant's Signature___________________________________________________

Social Security Number ________/________/__________ Date ______ /_____ /_____

FAIR CREDIT REPORTING ACT

DISCLOSURE AND AUTHORIZATION STATEMENT

 

NOTE: PLEASE READ CAREFULLY BEFORE SIGNING BELOW

For the purpose of evaluating my application for access authorization, I understand my prospective employer my obtain or have prepared a consumer report or investigative report concerning my prior employment, military record, education, credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, criminal background record, or mode of living.

I understand that upon written request to that employer, I will be informed whether an investigative consumer report was requested, and given full information as to the nature and scope of this investigation. (I understand that an investigative consumer report is a report in which information concerning my character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with neighbors, friends, or associates with whom I am acquainted).

By signing below, I am authorizing my prospective employer to obtain a consumer or investigative consumer report on me as part of the Company’s screening process for Employment. During the period in which I remain employed, I further authorize the Company to obtain additional consumer or investigative consumer reports on me to evaluate my trustworthiness and reliability for purposes of determining continuing employment.

By my signature below, I also acknowledge that I am entitled to a summary of my rights under the federal Fair Credit Reporting Act. The full document may be viewed on the Internet at: www.ftc.gov/os/statutes/fcra.htm.

 

Name of applicant: _________________________________________________

(please print)

Signature of applicant: _______________________________________________

Date signed: ________________________________

CANDIDATE'S BASIC HISTORICAL DATA

Last Name First Name Middle Name

Alias (e.g. Maiden Name, Frequently Used Nick Name)

Provide A Physical Description For True Identity Verification Purposes Only

Physical Description

Height in inches Weight in pounds

Color of Eyes Color of Hair

Date And Place Of Birth

Date of birth -- mm/dd/yy   Social Security Number

Non-U.S.A. Identification Number Issuing Nation

Birth City County State/Providence Nation

Current Data

Present Street Address Apt. Number

City County State Zip

Nation; Home Phone-AC Number

Explanatory Note

Driver License Number State Enter the date of expiration : -- mm/dd/yyyy

Support Documentation (e.g.: INS Permit or a birth certificate):

Document Type Number

Criminal Convictions and Driving Violations History

You are a candidate for a security clearance with a company that is meeting regulations or has a Crime-Free workplace policy. Past experiences tend to predict future occurences, therefore you are given the opportunity to explain any criminal or traffic history that may appear on your record. It has been demonstrated that it is much better to provide your side of the story prior to an evaluator being surprised by the discovery of a criminal history. The same can be said about motor vehicle violations. The investigators will verify your claims of good character and reputation in the community. In addition to checking dates and addresses, the investigators may query the criminal courts and state driver's license agencies for any records in your name. The official record will be checked, so this questionnaire is a test of your honesty.

  1. Have you ever been convicted, or found guilty of violating any law (Including serious traffic offenses)?                     Yes No
  2. If you answered yes, please provide detailed information below for each offense.
  3. If you answered no, go to the bottom of the form and submit your input. skip to the next section about employment activities.

    4. EVENT A.

    Convicted of what?

    Location/County/Jurisdiction
    Enter the date of Adjudication  : -- mm/dd/yyyy
    Your Address/Street of your residence during this event
    City County State Zip

    EVENT B.

    Convicted of what?

    Location/County/Jurisdiction
    Enter the date of Adjudication; : -- mm/dd/yyyy
    Your Address/Street of your residence during this event
    City County State Zip

    Please provide an explanation about the crime for which you were convicted, or pleaded "guilty" or "no contest", or received a deferred sentence from the courts you listed above.

    Please provide the particulars of the jurisdiction and/or current restrictions as a result of the courts decision relevant to the events discussed above.

Data About Your Last 5 Year's Activity

Instructions About Reporting Candidate's Employment Activity

The investigators may verify your claimed periods of: Employment, Self-Employment, Unemployment, Educations, Training and Military Services. In addition to checking dates of the activity, questions will be asked concerning your performance and behavior.

Begin with your last period of activity: employment, self-employment, unemployment, education, training, institutional or military service. You may still be employed on another job. If so, that is where you start.

You must CAREFULLY, CONSISTENTLY and CHRONOLOGICALLY account for MAJOR periods of time (usually 30 days or more) during the scope of this investigation. The period of time to be covered will be defined by your proctor. In some cases, the activity periods may overlap, for example school attendance and work or a job and the National Guard. That is OK.

Only three activity blocks are provided. You may need more. When you have additional activity blocks to report, SUBMIT the three blocks that are completed, RESET the form. Go back to the top and add your personal identification data and enter the next three activity blocks.

ACTIVITY A.

Describe Your Most Recent Major Activity Period:

Dates of Activity:

Enter the Start date : -- mm/dd/yyyy

Enter the Stop date : -- mm/dd/yyyy
  • If you were UNEMPLOYED during this period, leave the organizational questions blank. Instead go to the block on about the Alternate Verification".

Organization Or Employer Name

Organization Name Division/Unit

Organization  A. Phone-AC Number Ext Fax-AC Number

Activity Location

Address/Street Name

City County State Zip

Your Position/Title While On This Job

Why Did You Leave This Activity?:

Activity Supervisor And Employment Conditions

First Name Last Title

Did this employer screen for drugs? Do pre-employment check?

Address/Street of your residence during this activity

City County State Zip

Alternate Verifier

Provide details about an alternate person, a non-relative, who can verify this reported activity.

First Initial Last

Relationship

Verifier A: Phone-AC Number Ext Fax-AC Number

Additional comments about this activity?

ACTIVITY B.

Describe Your Most Recent Major Activity Period:

Dates of Activity:

Enter the Start date : -- mm/dd/yyyy

Enter the Stop date : -- mm/dd/yyyy
  • If you were UNEMPLOYED during this period, leave the organizational questions blank. Instead go to the block on about the Alternate Verification".

Organization Or Employer Name

Organization Name Division/Unit

Organization  B. Phone-AC Number Ext Fax-AC Number

Activity Location

Address/Street Name

City County State Zip

Your Position/Title While On This Job

Why Did You Leave This Activity?:

Activity Supervisor And Employment Conditions

First Name Last Title

Did this employer screen for drugs? Do pre-employment check?

Address/Street of your residence during this activity

City County State Zip

Alternate Verifier

Provide details about an alternate person, a non-relative, who can verify this reported activity.

First Initial Last

Relationship

Verifier B: Phone-AC Number Ext Fax-AC Number

Additional comments about this activity?

ACTIVITY C.

Describe Your Most Recent Major Activity Period:

Dates of Activity:

Enter the Start date : -- mm/dd/yyyy

Enter the Stop date : -- mm/dd/yyyy
  • If you were UNEMPLOYED during this period, leave the organizational questions blank. Instead go to the block on about the Alternate Verification".

Organization Or Employer Name

Organization Name Division/Unit

Organization  C. Phone-AC Number Ext Fax-AC Number

Activity Location

Address/Street Name

City County State Zip

Your Position/Title While On This Job

Why Did You Leave This Activity?:

Activity Supervisor And Employment Conditions

First Name Last Title

Did this employer screen for drugs? Do pre-employment check?

Address/Street of your residence during this activity

City County State Zip

Alternate Verifier

Provide details about an alternate person, a non-relative, who can verify this reported activity.

First Initial Last

Relationship

Verifier A: Phone-AC Number Ext Fax-AC Number

Additional comments about this activity?

ACTIVITY D.

Describe Your Most Recent Major Activity Period:

Dates of Activity:

Enter the Start date : -- mm/dd/yyyy

Enter the Stop date : -- mm/dd/yyyy
  • If you were UNEMPLOYED during this period, leave the organizational questions blank. Instead go to the block on about the Alternate Verification".

Organization Or Employer Name

Organization Name Division/Unit

Organization  D. Phone-AC Number Ext Fax-AC Number

Activity Location

Address/Street Name

City County State Zip

Your Position/Title While On This Job

Why Did You Leave This Activity?:

Activity Supervisor And Employment Conditions

First Name Last Title

Did this employer screen for drugs? Do pre-employment check?

Address/Street of your residence during this activity

City County State Zip

Alternate Verifier

Provide details about an alternate person, a non-relative, who can verify this reported activity.

First Initial Last

Relationship

Verifier D: Phone-AC Number Ext Fax-AC Number

Additional comments about this activity?

Candidate's Educational, Training and Military Achievements

Instructions The investigators may verify your claims of educational, training and military attainment.
In addition to checking dates of attendance, questions will be asked concerning your behavior.

You may have listed this information above if the activity was during the scope of the investigation. List it again. Begin with your last period of educational, training or military activity. Include ALL educational and training institutes attended as required by your proctor. Provide concise names and locations of those institutions.

In addition, regardless of when you attended or served, list all college educational and military sevice. Provide details about that institution and/or military organization.

ACHIEVEMENT A.   Background information about

Name of Institution/Service Your ID Number
Institution Street Address
City County State Zip
Area Code   Phone Number Fax Area Code   Fax Number
Did you complete? If no, highest grade or level completed

Reason for leaving

Dates of Enrollment/Service:

Enter the Start date : -- mm/dd/yyyy

Enter the Stop date : -- mm/dd/yyyy

Special Accomplishments

What type documentation do you have?

ACHIEVEMENT B. ; Background information about

Name of Institution/Service Your ID Number
Institution Street Address
City County State Zip
Area Code Phone Number Fax Area Code Fax Number
Did you complete? If no, highest grade or level completed

Reason for leaving

Dates of Enrollment/Service:

Enter the Start date : -- mm/dd/yyyy

Enter the Stop date : -- mm/dd/yyyy

Special Accomplishments


What type documentation do you have?

Verification of the Candidate's Character and Reputation in the Community

The investigators will verify your claims of good character, reputation and financial responsibility in the community. In addition to checking dates and addresses, questions will be asked concerning your behavior. Only certain kinds of references may be used. Please provide a total of four (4) references.

Notes

INSERT THE DATA ABOUT YOUR REFERENCES INTO THE FOLLOWING FIELDS

1. A reference of my good character and reputation

First Initial Last Title

Street Address

City

County State Zip

Reference's Phone - Area Code Number

Alternate Phone (work) - Area Code Number Ext.

Nature of Relationship

Dates of Association

Enter the date when you had your first association with the reference: -- mm/dd/yyyy

Enter the date when you ended your association with the reference: -- mm/dd/yyyy

Enter the date of last contact with the reference: -- mm/dd/yyyy

2. A reference of my good character and reputation

First Initial Last Title

Street Address

City

County State Zip

Reference's Phone - Area Code Number

Alternate Phone (work) - Area Code Number Ext.

Nature of Relationship

Dates of Association

Enter the date when you had your first association with the reference: -- mm/dd/yyyy

Enter the date when you ended your association with the reference: -- mm/dd/yyyy

Enter the date of last contact with the reference: -- mm/dd/yyyy

3. A reference of my good character and reputation

First Initial Last Title

Street Address

City

County State Zip

Reference's Phone - Area Code Number

Alternate Phone (work) - Area Code Number Ext.

Nature of Relationship

Dates of Association

Enter the date when you had your first association with the reference: -- mm/dd/yyyy

Enter the date when you ended your association with the reference: -- mm/dd/yyyy

Enter the date of last contact with the reference: -- mm/dd/yyyy

4. A reference of my good character and reputation

First Initial Last Title

Street Address

City

County State Zip

Reference's Phone - Area Code Number

Alternate Phone (work) - Area Code Number Ext.

Nature of Relationship

Dates of Association

Enter the date when you had your first association with the reference: -- mm/dd/yyyy

Enter the date when you ended your association with the reference: -- mm/dd/yyyy

Enter the date of last contact with the reference: -- mm/dd/yyyy