9871 Data On Convictions

Sensitive Information

Data on Convictions

OMB No. 3316-0063
Exp. Date: 09/30/2007

Please check below your response to questions about your criminal history:
Your response must include Felony, Misdemeanor, and Traffic Convictions.
You must also report any Court Martial and Non-Judicial punishment while in the military.
You are not required to report:

(a) Speeding tickets of less than $200,
(b) Juvenile court convictions, or
(c) Convictions for which a court expungement order has been issued.

1. Have you ever been convicted of an offence against the law?

Yes

No

2. Are you now under charges for any offense against the law?

Yes

No

Please list your conviction(s) and/or charge(s) below (if more space is needed, use plain paper):
Date

Location

Charge/Offense

Penalty Imposed

I certify that the information furnished in answer to the questions on this form is correct and complete to the best of my knowledge
and belief. I understand that the accuracy of this information is of great importance in the consideration of my eligibility for employment,
security clearance, or access authorization. I understand that a false statement or omission of material fact may be sufficient cause
of rejection or revocation of my security clearance and/or employment and may be punishable by law.
I understand that while working as a TVA employee or a contractor at TVA my continued employment is subject to my meeting the TVA
Personnel Security Policy requirements. I also understand that I am required to report within 2 days to my supervisor if I am arrested or
charged with any criminal act, and that failure to comply could result in disciplinary action up to and including termination.
Print Name

SSN
Date
Signature

Burden Estimate Statement (Pursuant to 5 CFR 1320.21)
Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this burden, to Agency Clearance Officer, Tennessee Valley Authority, 1101 Market Street, Chattanooga, TN 37402; and to the Office of Management and Budget,
Paperwork Reduction Project (3316-0063), Washington, DC 20503.
Privacy Act Statement
Subsection (e) (3) of 5 U.S.C. § 552a (Section 3 of the Privacy Act) requires that TVA inform you of its authority to request information and the uses which TVA may make of
the information requested. That subsection further requires TVA to inform you of the effects of not providing any or all of the requested information.
TVA’s authority to request the information you will provide is derived from the TVA Act (16 U.S.C. §§ 831-831ee), Executive Order No. 10450, the Atomic Energy Act of
1954, as amended, and a number of other statutes and Presidential Executive orders. Information provided on this form may be furnished to people, agencies,
organizations, or institutions in order to obtain information regarding you in connection with an investigation to determine: (1) fitness for TVA employment; (2) clearance to
perform services for TVA under personal services, consultant, or other contracts; or (3) security clearance or clearance for access to TVA installations.
Furnishing the requested information is voluntary; however, failure to provide all or part of the information may result in a lack of further consideration for employment,
clearance or access, or in the termination of your employment.
Information provided on this form is normally used only to determine fitness for employment or security clearance for access to TVA installations. Information obtained on
this form may be furnished to third parties as authorized by law. For example, should a dispute arise or a congressional inquiry be made regarding TVA employment
practices, the information may be made available outside of TVA in the course of that dispute or inquiry. Further, information provided may be provided to another federal
agency if relevant to a decision to be made by that agency. In addition, information on this form may be made available to law enforcement agencies in the exercise of their
duties, or to a prospective employer or TVA contractor upon proper request.

TVA 9871 (8-2007)

Sensitive Information