3170-XXXX Application to Serve on Advisory Board, Body, Panel, Com

OMB#3170-XXXX

APPLICATION TO SERVE ON
ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau
You are being considered for a position as a representative on an Advisory Board, Body, Panel, Committee
or other similar group (generally, “Advisory Group”) of the Consumer Financial Protection Bureau (CFPB).
Please complete and submit this questionnaire as part of the application and selection process for the
Advisory Group. CFPB will use this information to perform a background check, conduct a conflict of
interest review, and perform other similar due diligence activities associated with your application and
possible selection as a representative on the Advisory Group. CFPB will use the information you provide
only for these purposes or other purposes authorized by law, and will not disclose it unless required by law.
(See the Privacy Act Notice.) Please ensure that the information you provide is complete and accurate.

BACKGROUND INFORMATION
Name of Advisory Group to which you are applying to be a representative

Name (Print last, first, middle initial)

E-mail Address

Position/Title

How long at employer?

Employer

Address

Work Phone

Cell Phone

Other

Place of Birth

Date of Birth

Social Security Number

List your business experience.

List education and any specialized experience.

List other affiliations and/or service as a community leader that would benefit you in your role as a member of the advisory
group.

List any Federal advisory committee or any board on which you are currently a member and the number of years you have
served on that committee or board.

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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FINANCIAL DISCLOSURE: Liabilities
Please list the following types of Liabilities in the boxes provided below for yourself, your spouse and
any dependent children


A liability over $10,000 owed at any time during the reporting period, other than a loan from a
financial institution or business entity granted on terms made available to the general public
A loan over $10,000 from an individual, such as a friend or a business associate



Do not include:
 Any liability, such as a mortgage, a student loan, or a credit card account, from a financial
institution or business entity granted on terms made available to the general public
 Loans secured by automobiles, household furniture, or appliances, unless the loan exceeds the
purchase price of the item it secures
 Liabilities that you owe to your spouse or to the parent, sibling, or child of you, your spouse, or
your dependent child
Liabilities
Name of creditor (include city and state
where creditor is located)

Type of liability (personal loan, margin account, etc.)

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APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB#3170-XXXX
Privacy Act Notice
The information that you provide will be used by the Consumer Financial Protection Bureau (CFPB) to determine qualifications,
suitability and availability for service on advisory boards, bodies, panels, committees or other similar groups. The information will
be used to conduct background clearances and/or for annual reports on advisory boards, bodies, panels, committees or other
similar groups. The information will be used by and disclosed to employees, contractors, agents, and others authorized by the
CFPB to receive this information to assist in related activities. The information may also be disclosed to:
(1) Appropriate agencies, entities, and persons when: (a) the CFPB suspects or has confirmed that the security or confidentiality
of information in the system of records has been compromised; (b) the CFPB has determined that, as a result of the
suspected or confirmed compromise, there is a risk of harm to economic or property interests, identity theft or fraud, or
harm to the security or integrity of this system or other systems or programs (whether maintained by the CFPB or another
agency or entity) that rely upon the compromised information; and (c) the disclosure made to such agencies, entities, and
persons is reasonably necessary to assist in connection with the CFPB’s efforts to respond to the suspected or confirmed
compromise and prevent, minimize, or remedy such harm;
(2) Another federal or state agency to (a) permit a decision as to access, amendment or correction of records to be made in
consultation with or by that agency, or (b) verify the identity of an individual or the accuracy of information submitted by an
individual who has requested access to or amendment or correction of records;
(3) To the Office of the President in response to an inquiry from that office made at the request of the subject of a record or a
third party on that person’s behalf;
(4) Congressional offices in response to an inquiry made at the request of the individual to whom the record pertains;
(5) Contractors, agents, or other authorized individuals performing work on a contract, service, cooperative agreement, job, or
other activity on behalf of the CFPB or Federal Government and who have a need to access the information in the
performance of their duties or activities;
(6) The U.S. Department of Justice (“DOJ”) for its use in providing legal advice to the CFPB or in representing the CFPB in a
proceeding before a court, adjudicative body, or other administrative body before which the CFPB is authorized to appear,
where the use of such information by the DOJ is deemed by the CFPB to be relevant and necessary to the litigation, and such
proceeding names as a party or interests:
(a) The CFPB;
(b) Any employee of the CFPB in his or her official capacity;
(c) Any employee of the CFPB in his or her individual capacity where DOJ has agreed to represent the employee; or
(d) The United States, where the CFPB determines that litigation is likely to affect the CFPB or any of its components;
(7) A court, magistrate, or administrative tribunal in the course of an administrative proceeding or judicial proceeding, including
disclosures to opposing counsel or witnesses (including expert witnesses) in the course of discovery or other pre-hearing
exchanges of information, litigation, or settlement negotiations, where relevant or potentially relevant to a proceeding, or in
connection with criminal law proceedings; and
(8) To the public in the form of names, affiliations, and other pertinent biographical information of board or committee
members.
The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011, 1012, 1014, codified at 12 U.S.C. §§
5491, 5492, 5494. You are not required to provide any identifying information, but not doing so may result in non-selection of a
prospective advisory board, body, panel, committee or other similar group membership.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this
collection is 3170-XXXX. It expires on MM/DD/YYYY. The time required to complete this information collection is estimated to
average approximately 60 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.
The Consumer Financial Protection Bureau (CFPB) prohibits discrimination in all its programs and activities on the basis of race,
color, national origin, gender, religion, age, political beliefs, sexual orientation, marital or family status, parental status or
protected genetic information. (Not all prohibited bases apply to all programs.) Persons with disabilities who require
alternative means of communication of program information (Braille, large print, audiotape, etc.) should contact Liza Strong,
Labor and Employee Relations, Office of Human Capital. To file a complaint of discrimination, contact the Treasury Department
at 202-622-9252. CFPB is an equal opportunity provider and employer.

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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I certify that the statements I have made on this form and all attached statements are true, complete, and correct to the
best of my knowledge.
Signature
Date (mm/dd/yy)

Continuation Sheet to Form
If you need more space for an answer, use this sheet. Please number each answer to correspond to the
number on this form. When you have completed your answers, attach to this form.
Name (Last, First, Middle)

__________________________________________________________

Social Security Number

__________________________________________________________

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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