Fair Credit Reporting Act of 1970

FAIR CREDIT REPORTING ACT OF 1970, AS AMENDED

PLEASE TAKE NOTICE THAT ONE OR MORE CONSUMER CREDIT REPORTS
MAY BE OBTAINED FOR EMPLOYMENT PURPOSES PURSUANT TO THE FAIR
CREDIT REPORTING ACT, AS AMENDED, 15 U.S.C. & 1681, ET SEQ. SHOULD A
DECISION TO TAKE ANY ADVERSE ACTION AGAINST YOU BE MADE, BASED
EITHER IN WHOLE OR IN PART ON THE CONSUMER CREDIT REPORT, THE
CONSUMER REPORTING AGENCY THAT PROVIDED THE REPORT PLAYED NO
ROLE IN THE AGENCYS DECISION TO TAKE SUCH ADVERSE ACTION.
Information provided by you on this form will be furnished to the consumer reporting
agency in order to obtain information in connection with an investigation to determine
your (1) fitness for Federal employment, (2) clearance to perform contractual service
for the Federal government, and/or (3) security clearance or access. The information
obtained may be redisclosed to other Federal agencies for the above purposes in
fulfillment of official responsibilities to the extent that such disclosure is permitted by
law.
I hereby authorize the _______________________ to obtain such reports from any
(Name Of Requesting Agency)

consumer/credit reporting agency for employment purposes.
_________________________________
(Print Name)

_________________
(SSN)

_________________________________
(Signature)

__________________
(Date)

Your Social Security Number is needed to keep records accurate, because other
people may have the same name. Executive Order 9397 also asks Federal agencies
to use this number to help identify individuals in agency records.