IQM:BUSINESS INVESTIGATIONS PERSONAL SECURITY QUESTIONNAIRE TO SCREEN AN APPLICANT OR VENDER Candidate's Criminal and Driving History Detailed

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

Candidate's Last Name Social Security Number

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.

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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.

ADVANCED PERSONNEL SECURITY QUESTIONNAIRE(S)

1. To process Employment Verifications, Military Service, Education, or Special References,  it is necessary to utilize additional advanced PSQ (s); ( Personnel Security Questionnaire ).
   
2. If your entries are complete, you may submit the data by clicking on the Submit Button above.
   
3. Select  advanced PSQ that you require from the Links below.

   Additional Advanced Forms

   1. Authorization and Release Statement
   2. Criminal and Driving History
   3. Educational, Training and Military Attainment
   4. Employment Activity Detailed
   5. Basic Personnel Security Questionnaire
   6. Character References