[별지 제22호서식] <개정 2020.3.17.>											(1st page)
PERSONAL QUESTIONNAIRE * FOR OFFICIAL USE ONLY											[PHOTO] or photo file (3㎝×4㎝)ㆍ (3.5㎝×4.5㎝)
NAME	Last/First/Middle					GENDER
DATE OF BIRTH	Month/Day/Year
NATIONALITY (Include any dual nationality)			PLACE OF BIRTH				City/Country
ALIEN REGISTRATION NUMBER			DATE & PLACE OF ENTRY TO KOREA				Month/Day/Year City/Country
RESIDENTIAL ADDRESS IN KOREA
WORKPLACE				JOB/TITLE
TELEPHONE NUMBERS (Include Area Code)	OFFICE : MOBILE :
EDUCATION	SCHOOL NAME	PERIOD (MM/YY-MM/YY)			TYPE OF DEGREE			MAJOR				LOCATION (City/Country)
210mm×297mm [백상지(80/㎡) 또는 중질지(80/㎡)]

											(2nd page)
EMPLOYMENT HISTORY & PARTICIPATION IN CIVIC/POLITICAL ASSOCIATION	EMPLOYER/ VERIFIER NAME			PERIOD (MM/YY-MM/YY)			JOB TITLE/ POSITION		LOCATION (City/Country)		REWARD & PUNISHMENT (MM/YY)
FAMILY INFORMATION	RELATION	NAME Last/First/Middle			DATE OF BIRTH		FINAL ACADEMIC DEGREE		CAREER		ADDRESS
RELATIVES & ASSOCIATES IN KOREA	RELATION		NAME Last/First/Middle			CAREER		JOB TITLE/ POSITION		TELEPHONE NUMBER
I declare that statements made in this form are true and correct, and agree if false information is knowingly or willingly provided on this form, I can be penalized in accordance with the relevant statute. DATE : SIGNATURE :
210mm×297mm [백상지(80/㎡) 또는 중질지(80/㎡)]

(3rd page)

Consent to the Collection and Use of Personal Information

The National Intelligence Service, Ministry of National Defense, and National Police Agency intend to collect and use personal information, sensitive information, and personally identifiable information of the applicant for the conduction of background check pursuant to Article 46 (Processing of Personally Identifiable Information) of the "Regulations on Security Work," and Article 15 (Collection and Use of Personal Information), Article 23 (Limitation to Processing of Sensitive Information), and Article 24 (Limitation to Processing of Personally Identifiable Information) of the "Personal Information Protection Act."

■ Collection and use of personal information

Items	Name, gender, photo, nationality, place of birth, alien registration number, date & place of entry to korea, residential address in korea, workplace, job/title, telephone numbers(including office, mobile), education(including school name, period, type of degree, major, location), employment history & participation in civic/political association(including employer/verifier name, period, job title/position, location, reward&punishment), family information(including relation, name, date of birth, final academic degree, career, address), relatives & associates in korea(including relation, name, career, job title/position, telephone number)
Purpose of collection/use	Background check and verification
Retention/ use period	2 years

※ The above is the minimum information required to carry out background check and the applicant has the right to refuse the collection and use of personal information. However, in case of refusal, there may be restrictions in appointment (employment) and security clearance, as background check cannot be carried out pursuant to "Regulations on Security Work."

☞ I agree to the collection and use of personal information as described above.   I agree [  ]    I do not agree [  ]

■ Processing of sensitive information

Items	Participation in civic/political association
Purpose of collection/use	Background check and verification
Retention/ use period	2 years

※ The above is the minimum information required to carry out background check and the applicant has the right to refuse the processing of sensitive information. However, in case of refusal, there may be restrictions in appointment (employment) and security clearance, as background check cannot be carried out pursuant to "Regulations on Security Work."

☞ I agree to the processing of sensitive information as described above.          I agree [  ]    I do not agree [  ]

■ Processing of personally identifiable information

Items	Alien registration number
Purpose of collection/use	Background check and verification
Retention/ use period	2 years

※ A separate consent is not required under subparagraph 1 of Article 24-2 (1) of the "Personal Information Protection Act"     and Article 46 of the "Regulations on Security Work."

☞ I have read and understood that personally identifiable information will be processed as described above. [  ]

We comply with personal information protection regulations that personal information processors are required to follow under the "Personal Information Protection Act." We will protect the rights of the information provider in accordance with relevant laws, and the collected information will not be used for purposes other than reasons agreed to by the information provider.

mm dd, yyyy

Applicant (representative):                  (seal or signature)

Legal representative (if needed):             (seal or signature)        Contact information:

210mm×297mm [백상지(80/㎡) 또는 중질지(80/㎡)]