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Page 28
Last name
First name
and means of support.
Est.
Present
To Date 
(Month/Year)
Est.
From Date 
(Month/Year)
Provide dates of unemployment.
Provide address of this verifier. 
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Street
City
State
Country
Zip Code
Verifier telephone number
Extension
International or DSN phone number
Day
Night
Provide the telephone number for this person.
Enter your Social Security Number before going to the next page
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Section 13A - Employment Activities - (Continued)
Provide the reason for leaving the employment activity.
YES
NO 
(If NO, proceed to 13A.6)
For this employment have any of the following happened to you in the last seven (7) years?
notice of unsatisfactory performance. 
Left by mutual agreement following 
notice of unsatisfactory performance 
Left by mutual agreement following 
charges or allegations of misconduct
Quit after being told you would be 
fired
Fired
Select your type of incident:
Provide the reason(s) for unsatisfactory performance.
Provide the charges or allegations of misconduct.
Provide the reason for quitting.
Provide the reason for being fired.
Reason:
Est.
Employment departure date
Provide the date you were fired. 
(Month/Year)
Est.
Est.
Est.
Provide the date you left following charges or allegations 
of misconduct. 
(Month/Year)
Provide the date you quit after being told you would be 
fired.
(Month/Year)
Provide the date you left by mutual agreement following 
a notice of unsatisfactory performance. 
(Month/Year)
Est.
Date:
(Month/Year)
Date: 
(Month/Year)
Est.
#1
#2
Est.
Date: 
(Month/Year)
Date: 
(Month/Year)
Est.
#3
#4
YES
NO
For this employment, in the last seven (7) years
in the workplace, such as a violation of security policy?
Entry #4
Entry #4
Entry #4
13A.4  Complete the following if employment type is unemployment.
13A.6 
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a)
(b)
Address
APO or FPO
APO/FPO State Code
Zip Code
Zip Code
(Provide City and Country 
Does your unemployment verifier have an APO/FPO address?
(a) 
(b) 
YES 
NO
13A.5 
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Page 29
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Section 13B - Employment Activities - Former Federal Service
YES
NO 
(If NO, proceed to Section 13C)
Provide your position title.
Provide the name of the federal agency for 
which you are/were employed.
Street
City
State
Country
Provide the location of the agency.  
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide dates of federal civilian employment.
From Date
Est.
To Date
Present
Est.
Entry #2
Section 13C - Employment Record
Have any of the following happened to you in the last seven (7) years at employment activities that you have not previously listed? 
- Fired from a job?  
- Quit a job after being told you would be fired? 
the workplace, such as violation of a security policy?
NO 
(If NO, proceed to Section 14)
YES
Enter your Social Security Number before going to the next page
(Month/Year)
(Month/Year)
Provide your position title.
Provide the name of the federal agency for 
which you are/were employed.
Street
City
State
Country
Provide the location of the agency. 
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide dates of federal civilian employment.
From Date
Est.
To Date
Present
Est.
Entry #1
(Month/Year)
(Month/Year)
Provide your position title.
Provide the name of the federal agency for 
which you are/were employed.
Street
City
State
Country
Provide the location of the agency. 
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide dates of federal civilian employment.
From Date
Est.
To Date
Present
Est.
Entry #4
(Month/Year)
(Month/Year)
Provide your position title.
Provide the name of the federal agency for 
which you are/were employed.
Street 
City
State
Country
Provide the location of the agency. 
(Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code.)
Zip Code
Provide dates of federal civilian employment.
From Date
Est.
To Date
Present
Est.
Entry #3
(Month/Year)
(Month/Year)
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Page 30
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
No 
Yes
I don't know
Were you born a male after December 31, 1959? 
Section 14 - Selective Service Record
Provide registration number:
Provide explanation:
Provide explanation:
The Selective Service website, www.sss.gov
, can help provide the 
registration number for persons who have registered. Note: Selective 
Service Number is not your Social Security Number.
Section 15 - Military History
YES
NO
(If NO, proceed to Section 15.2) 
Have you EVER served in the U.S. Military?
Army
Army National 
Guard
Navy
Air Force
Air National 
Guard
Marine Corps
Coast Guard
Provide the branch of service you served in.
15.1  Complete the following if you responded 'Yes' to having served in the U.S. Military.
State of service, if 
National Guard
Enlisted
Not Applicable
Officer
Officer or enlisted
Provide your dates of service.
From Date 
(Month/Year)
Est.
To Date 
(Month/Year)
Present
Est.
Provide your service number.
YES
NO
Provide the type of discharge you received:
Honorable
Dishonorable
Bad Conduct
Other (provide type)
Under Other than 
Honorable Conditions
General
Provide the date of 
discharge listed 
(Month/Year) 
Est.
Have you registered with the Selective Service System (SSS)?
YES
NO
(If NO, proceed to Section 15)
Inactive Reserve
Active Duty
Active Reserve
Provide your status
Entry #1
Army
Army National 
Guard
Navy
Air Force
Air National 
Guard
Marine Corps
Coast Guard
Provide the branch of service you served in. . State of service, if 
National Guard
Enlisted
Not Applicable
Officer
Officer or enlisted
Provide your dates of service.
From Date 
(Month/Year)
Est.
To Date 
(Month/Year)
Present
Est.
Provide your service number.
YES
NO
Provide the type of discharge you received:
Honorable
Dishonorable
Bad Conduct
Other (provide type)
Under Other than 
Honorable Conditions
General
Provide the date of 
discharge listed 
(Month/Year) 
Est.
Inactive Reserve
Active Duty
Active Reserve
Provide your status
Entry #2
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Page 31
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 15 - Military History - (Continued)
YES
NO
(If NO, proceed to Section 15.3) 
Court of Inquiry, etc?
Est.
Provide the date of the court martial or other disciplinary procedure. 
(Month/Year)
Entry #1
Provide a description of the Uniform Code of Military Justice (UCMJ) 
offense(s) for which you were charged.
Provide the name of the disciplinary procedure, such as Court Martial, 
Article 15, Captain's mast, Article 135 Court of Inquiry, etc.
and state or country if overseas).
such as found guilty, found not guilty, fine, reduction in rank,  
imprisonment, etc.
Est.
Provide the date of the court martial or other disciplinary procedure. 
(Month/Year)
Entry #2
Provide a description of the Uniform Code of Military Justice (UCMJ) 
offense(s) for which you were charged.
Provide the name of the disciplinary procedure, such as Court Martial, 
Article 15, Captain's mast, Article 135 Court of Inquiry, etc.
and state or country if overseas).
such as found guilty, found not guilty, fine, reduction in rank,  
imprisonment, etc.
15.2
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Page 32
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 15 - Military History - (Continued)
YES
NO 
(If NO, proceed to Section 16)
Have you EVER 
Military (Specify Army, Navy,  
Air Force, Marines, etc.)
Intelligence Service
Diplomatic Service
Security Forces
Militia
Other Defense Forces
Other Government Agency
During your foreign service, which organization were you serving under?
Complete the following if you responded 'Yes' to having EVER
security forces, militia, other defense force, or government agency.
Provide your period of service.
From Date
Est.
To Date
Est.
Present
(Month/Year)
(Month/Year)
Provide the name of the foreign organization.
Provide the name of the country.
Provide the highest position/rank held.
Provide division/department/office in which you served.
Provide a description of the reason for leaving this service.
Provide the contact's address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Middle name
Last name
First name
Suffix
Provide the contact's full name.
Provide the length of your association with the contact.
Contact #1
From Date
Est.
To Date
Est.
Present
(Month/Year)
(Month/Year)
YES
NO 
(If NO, proceed to Section 16)
Provide the frequency of contact.
Provide the contact's official title.
15.3
Provide the contact's address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street 
City
State
Country
Zip Code
Middle name
Last name
First name
Suffix
Provide the contact's full name.
Provide the length of your association with the contact.
From Date
Est.
To Date
Est.
Present
Provide the contact's official title.
Provide the frequency of contact.
Contact #2
(Month/Year)
(Month/Year)
Page 32
Entry #1
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Page 33
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Section 15 - Military History - (Continued)
Military (Specify Army, Navy,  
Air Force, Marines, etc.)
Intelligence Service
Diplomatic Service
Security Forces
Militia
Other Defense Forces
Other Government Agency
During your foreign service, which organization were you serving under?
Complete the following if you responded 'Yes' to having EVER
security forces, militia, other defense force, or government agency.
Provide your period of service.
From Date
Est.
To Date
Est.
Present
(Month/Year)
(Month/Year)
Provide the name of the foreign organization.
Provide the name of the country.
Provide the highest position/rank held.
Provide division/department/office in which you served.
Provide a description of the reason for leaving this service.
Provide the contact's address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street
City
State
Country
Zip Code
Middle name
Last name
First name
Suffix
Provide the contact's full name.
Provide the length of your association with the contact.
Contact #1
From Date
Est.
To Date
Est.
Present
(Month/Year)
(Month/Year)
YES
NO 
(If NO, Proceed to Section 16)
Provide the frequency of contact.
Provide the contact's official title.
Provide the contact's address. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street 
City
State
Country
Zip Code
Middle name
Last name
First name
Suffix
Provide the contact's full name.
Provide the length of your association with the contact.
From Date
Est.
To Date
Est.
Present
Provide the contact's official title.
Provide the frequency of contact.
Contact #2
(Month/Year)
(Month/Year)
Page 33
Entry #2
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Night
Middle name
First name
Last name
Provide e-mail address for this person. 
Suffix
Provide telephone number for 
this person.
International or DSN 
phone number
Extension
From Date
Est.
Provide dates known.
To Date
Present
Est.
(Month/Year)
(Month/Year)
Provide relationship to you. (Check all that apply)
City
Provide home or work address for this person. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street 
State
Country
Zip Code
Provide mobile/cell telephone 
number for this person.
I don't know
Schoolmate
Other (Provide explanation)
Provide rank/title
Friend
Neighbor
Not applicable
Provide full name.
I don't know
Work associate
Day
Night
Day
International or DSN 
phone number
Extension
I don't know
Section 16 - People Who Know You Well
at least 
the last seven (7) years. Do not list your spouse, former spouse (s), other relatives, or anyone listed elsewhere on this form.
Entry #1
Night
Middle name
First name
Last name
Provide e-mail address for this person. 
Suffix
Provide telephone number for 
this person.
International or DSN 
phone number
Extension
From Date
Est.
Provide dates known.
To Date
Present
Est.
(Month/Year)
(Month/Year)
Provide relationship to you. (Check all that apply)
City
Provide home or work address for this person. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street 
State
Zip Code
Provide mobile/cell telephone 
number for this person.
I don't know
Schoolmate
Provide rank/title
Friend
Neighbor
Not applicable
Provide full name.
I don't know
Work associate
Day
Night
Day
International or DSN 
phone number
Extension
I don't know
Entry #2
Night
Middle name
First name
Last name
Provide e-mail address for this person. 
Suffix
Provide telephone number for 
this person.
International or DSN 
phone number
Extension
From Date
Est.
Provide dates known.
To Date
Present
Est.
(Month/Year)
(Month/Year)
Provide relationship to you. (Check all that apply)
City
Provide home or work address for this person. (
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Street 
State
Country
Zip Code
Provide mobile/cell telephone 
number for this person.
I don't know
Schoolmate
Provide rank/title
Friend
Neighbor
Not applicable
Provide full name.
I don't know
Work associate
Day
Night
Day
International or DSN 
phone number
Extension
I don't know
Entry #3
Country
Other (Provide explanation)
Other (Provide explanation)
Page 34
Page 35
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
Country #1
Provide date married. 
(Month/Day/Year)
Middle name
First name
Last name
#1
From 
(Month/Year)
To 
(Month/Year)
Suffix
Est.
Est.
Present
Maiden name?
NO
YES
Middle name
First name
Last name
#2
From 
(Month/Year)
To 
(Month/Year)
Suffix
Est.
Est.
Present
Maiden name?
NO
YES
Country #2
Provide your spouse's country(ies) of citizenship.
Section 17 - Marital Status
Divorced 
(Complete 17.2 and 17.3)
Separated
(Complete 17.1 and 17.3)
Annulled
(Complete 17.2 and 17.3)
Married (including Common Law)
(Complete 17.1 and 17.3)
Never Married 
(Complete 17.3)
Provide your current marital status.
Widowed
(Complete 17.2 and 17.3)
Middle name
Provide spouse's date of birth.
Suffix
Last name
First name
Est.
Complete the following about your current spouse only. 
Provide spouse's full name.
(Month/Day/Year) 
DS 1350
Alien registration
U.S. Naturalization certificate
U.S. Passport (current or most recent)
U.S. Citizenship certificate
FS 240 or 545
None (Provide explanation)
Other (Provide explanation)
Provide your spouse's U.S. Social Security Number.
Provide document number.
Not applicable
Explanation
Provide spouse's place of birth.
City
County
State
Country 
(required)
17.1  Complete the following if you selected 'Married' or 'Separated.'
Not applicable
used for each name).
Middle name
First name
Last name
#3
From 
(Month/Year)
To 
(Month/Year)
Suffix
Est.
Est.
Present
Maiden name?
NO
YES
Middle name
First name
Last name
#4
From 
(Month/Year)
To 
(Month/Year)
Suffix
Est.
Est.
Present
Maiden name?
NO
YES
Page 36
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
NO
YES 
Street Address/Unit/Duty Location
City or Post Name
State
Country
If you have indicated an APO/FPO address, complete (a)
(b)
Address
APO or FPO
APO/FPO State Code
Zip Code
Zip Code
Provide your spouse's  APO/FPO address.  
States.) 
Does your spouse have an APO/FPO address?
(a) 
(b) 
YES 
NO
Provide date of separation.  
(Month/Day/Year)
Est.
Provide place married. (
Provide City and Country if outside the United States; otherwise, provide City or County and State.)
City
County
State
Country
Provide telephone number.
Extension
Provide email address.
Use my current telephone number
International or DSN phone number
(Provide City and Country if outside the United States; otherwise, provide City, State and 
Zip Code)
Street
City
State
Country
Zip Code
Are you separated from your spouse?
City
State
Country
If legally separated, provide the location of the record. 
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip Code)
Zip Code
Not Applicable
Day
Night
17.1  Complete the following if you selected 'Married' or 'Separated.'
(Continued)
Section 17 - Marital Status - (Continued)
Page 37
Form approved: 
OMB No. 3206 0005 
QUESTIONNAIRE FOR 
NATIONAL SECURITY POSITIONS
Standard Form 86 
Revised December 2010 
U.S. Office of Personnel Management 
5 CFR Parts 731, 732, and 736
Enter your Social Security Number before going to the next page
YES
NO 
(If NO, complete (a))
I don't know
Est.
Provide the country(ies) of citizenship for your former spouse.
Country #1
Country #2
Provide the date you married your 
former spouse.
(Month/Day/Year)
Est.
Middle name
Provide the date of birth of your 
former spouse. 
(Month/Day/Year)
Suffix
Last name
First name
Est.
Provide the full name of your former spouse.
Entry #1
Provide the place of birth for your former spouse. 
City
State
Country 
(Required)
Zip Code
17.2  Complete the following if you selected 'Divorced', 'Annulled', 'Widowed', or 'Other Former Spouses'.
Provide the place married. (
Provide City and Country if outside the United States; otherwise, provide City, State and Country.)
City
State
Country
Section 17 - Marital Status - (Continued)
Annulled
Widowed
Divorced
Provide the status of this marriage.
(
Provide City and Country if outside the United States; otherwise, provide City, State and Zip 
Code)
City
State
Country
Zip Code
Is this former spouse deceased?
Provide City and Country if outside the United 
States; otherwise, provide City, State and Zip Code)
Street 
City
State
Country
Zip Code
I don't know
(a)
Provide the date divorced, annulled or widowed. 
(Month/Day/Year)
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