DPC - FOREIGN CONTACT FORM
You must use this form to report any foreign contact you have in which you plan to continue contact with after returning to the US.
Email address *
First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Work Location *
Today's Date *
MM
/
DD
/
YYYY
Name of Foreign National *
Your answer
Relationship to Foreign National
Your answer
Their Citizenship *
Your answer
Their Place of Birth (if unknown, state so) *
Your answer
Their Date of Birth (if unknown, estimate age) *
Your answer
Their Current Residence *
Your answer
Their occupation, position and/or title (include employer's name and address) *
Your answer
Date of First Encounter or Contact (you can estimate) *
MM
/
DD
/
YYYY
Is the above date estimated? *
Location of First Encounter *
Your answer
Circumstances of First Encounter *
Your answer
Who initiated the contact? *
Your answer
Frequency of the Contact or Visit on average *
Nature of the contact or visit on average *
Required
Last Personal Contact or visit (you can estimate) *
MM
/
DD
/
YYYY
Is the above date estimated? *
Location of that visit *
Your answer
Circumstance of that visit *
Your answer
Last Telephonic, Written or Email Contact (you can estimate) *
MM
/
DD
/
YYYY
Is the above date estimated? *
Circumstances of that contact: *
Your answer
Does the foreign contact have affiliations with any foreign intelligence or government organization(s), or other foreign political groups? *
Required
If "Yes", list the government with which the organization(s) are associated:
Your answer
Does the foreign contact have any affiliations with any criminal or subversive organization(s)? *
Required
If "Yes" identify the organization(s) *
Your answer
Did the contact result in any unusual or suspicious circumstances? *
If "Yes" please explain
Your answer
Please provide additional biographic information on the foreign contact if possible
Your answer
Is this a close or continuing relationship? *
If "Yes" please explain
Your answer
By entering the last four digits of your SSN below (this information is confidential and secured) you are indicating that all the information you have provided here is true to the best of your knowledge. *
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Centralized Security Services, Inc.. Report Abuse - Terms of Service