Form 1600-XX Specific Release Form

OMB Control Number 2120-XX

Expiration Date:

SPECIFIC RELEASE

I hereby authorize any Special Agent of the Federal Aviation Administration bearing this release, or a copy thereof, to obtain the information identified below pertaining to me which is maintained by the person or organization specified below:

I have also been known by the following name(s):

(If none, state “None”).

P ERSON OR ORGANIZATION:

A DDRESS:

The information to be released is as follows:

MEDICAL (May include, but not limited to: dates of confinement; participation or treatment; diagnosis; doctor’s orders; medication sheets, urine result reports; attendance sheets; prognosis and medical opinions regarding my health, recovery and/or rehabilitation; as well as any other information indicated below):

I am aware that the information released by the above named person or organization may, but not necessarily, contain data pertaining to my use and/or abuse of alcohol and/or drugs, and my participation in a rehabilitation program with the above named organization.

OTHER (Specify):

The execution of this release is voluntary on my part, and is made without duress or promise on the part of the Federal Aviation Administration. I am aware that this release is valid only when presented to the addressee within 3 months from the date of its execution by me to obtain financial records (as defined by the Right to Financial Privacy Act) and has no expiration for other purposes.

I have read and fully understand the Privacy Statement on the back of this form. I understand the purpose for which the information to be released as described in the Privacy Statement. I hereby release any Individual, Including record custodians, from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or attempts to comply, with this authorization. I consent to the release of any and all financial information obtained with this release to any Federal agency that requests it, consistent with the conditions of its collection under the Right to Financial Privacy Act, for employment suitability or security clearance purposes.

S ignature (Full Name) Social Security Number Area Code and Telephone Number Date (Month, Day, Year)

Current Address (Street, City, State, Zip) Signature of Parent/Guardian (As Required)

PRIVACY ACT STATEMENT

Information requested on this form is solicited under the authority of Title 49, Code of Federal Regulations (C.F.R.) Subtitle A. Part 1, Subpart C, Section 1.47. Title 5 United States Code, Section 3301, Title 5, C.F.R., Parts 731 and 732, Executive Orders (E.O.) 10577, and 10450, all pertain to government employees and is the authority for employee/applicant investigations. The authority, organization and functions of Security and Hazardous Materials and, the Region/Center Security and Hazardous Materials Divisions and Security and Investigations Divisions are required to execute the investigations program are prescribed in Orders 1100.2, Organization—FAA Headquarters and 1100.5, FAA Organization—Field.

Information provided by you on this form will be furnished to the addressee in order to obtain information concerning your activities in connection with an investigation to determine your (1) fitness for Federal employment, (2) clearance to perform contractual service for the Federal government, (3) security clearance or access. The information obtained may be furnished to Federal agencies for the above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law.

Your consent is voluntary and, in the case of financial records, may be revoked at any time before the information is released. In the case of financial records maintained at a financial institution (as defined by the Right to Financial Privacy Act), your consent is not required as a condition of doing business with any financial Institution. If you do not provide your consent the Federal Aviation Administration will not be able to obtain the requested data. Consequently, failure to furnish all or part of the Information requested of you on the form may result in discontinuance of the investigation, and a lack of further consideration for employment, clearance or access, or in the termination of your employment.

ROUTINE USE OF RECORDS

The information collected may be disclosed to other agencies and departments of the Federal Government and District of Columbia Government for employment purposes including fitness determinations, security clearances, access determinations, or evaluations of qualifications, suitability and/or loyalty to the United States Government. The information also may be disclosed to representatives of Federal agencies and departments who require access to the file pursuant to an investigation or inquiry conducted under appropriate authority, including investigations completed by the FAA and referred to other agencies for further investigation, prosecution, or administrative action. Moreover, the information may be disclosed to authorized representatives of U.S. air carriers where air safety might be affected. Finally, in the event of an indication of any violation or potential violation of the law, relevant information may be referred to the agency charged with responsibility for investigating or prosecuting the violation or enforcing the regulation.

PAPERWORK REDUCTION ACT STATEMENT

The information garnered from a signed Specific Release form is used by FAA Special Agents to obtain information related to a specific investigation. We estimate that this form will take 5 minutes to complete. 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 associated with this collection of information is 2120-XXXX. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave. SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, AES-20.

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