TVA 17353 Contractor Security Questionnaire

TVA SENSITIVE INFORMATION

OMB #3316-0063 Exp. Date: MM/DD/YYYY

Tennessee Valley Authority

Contractor Security Questionnaire

You have 5 working days to return this completed form to the requesting contracting company.
Failure to do so will result in denial to work as a TVA contractor.

Please type or print all information Please TAB to gray areas

Name (Last, First, Middle)				Date (mm/dd/yyyy)
     				     
Social Security Number	Date of Birth	Drivers License Number/State of Issue		Sex/Race
     	     	     		     
Permanent Address (where you currently live)
     
Birthplace (City & State)		Are you a citizen of the United States? Yes No
     		If no, list country of citizenship:	     

Begin with present date and go back five years.

Today is	     	, therefore you must go back to	     
	Month/Year		Month/Year (five years ago)

Photocopy this page if you need more room to list your information.

List the city and state locations where you have LIVED during the past five years. Include any temporary addresses where you lived when away from home on the job.			List the city and state where you WORKED during the past five years. You must provide all job sites (city/state only) where you worked over 30 days, or job sites where you frequently worked on and off.
City	State		City	State
     	     		     	     
City	State		City	State
     	     		     	     
City	State		City	State
     	     		     	     
City	State		City	State
     	     		     	     
City	State		City	State
     	     		     	     
City	State		City	State
     	     		     	     
City	State		City	State
     	     		     	     
City	State		City	State
     	     		     	     

Police Arrest Information

Have you ever been convicted of an offense against the law, or are you now under charges for any offense against the law (includes Felony, Misdemeanor, and Traffic Convictions)? Yes No If yes, please list all of your convictions and/or charge(s) below. Also report any Court Martial and Non-Judicial punishment while in the military. You are not required to report (1) speeding tickets of less than $200, (2) juvenile court convictions, or (3) convictions for which a court expungement order has been issued. If additional space is needed, please use a separate sheet of paper.

Date	Location (City/State)	Offense/Charge	Sentence/Fine Imposed
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

United States of America

Tennessee Valley Authority

Authority for Release of Information

For the purpose of establishing my eligibility for employment to perform services as an employee of a TVA contractor at Tennessee Valley Authority (TVA) and/or for access to TVA installations, I voluntarily consent to a thorough investigation and any required updates. This specifically includes release to TVA of information by my present and former employers, law enforcement agencies, educational institutions, medical personnel or institutions, and others, whether or not specifically mentioned herein. This investigation may be carried out by TVA, its agents, or contractors.

Accordingly, I authorize and request any employers, courts, or law enforcement agencies, educational institutions, medical personnel or institutions, or individuals - neighbors, friends, associates with whom I am acquainted or others, who possess information, recorded or not, pertinent to the above matters, to provide such information, facts, or opinions to the personnel who contact them.

I hereby release TVA and 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 any attempts to comply, with this authorization.

Certification of Accuracy by Applicant

I certify that the information furnished in answer to the questions on this form are 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 to work at Tennessee Valley Authority (TVA) facilities and TVA owned or controlled property. A false statement of omission of material fact may be sufficient cause for rejection for employment at TVA as a contractor and may be punishable by law.

Name	     	SSN	     
	Please Print
	Signature		Date

Burden Estimate Statement (Pursuant to 5 CFR 1320.21)

Public reporting burden for this collection of information is estimated to average 30 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 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 or 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 of 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 17353 [10-??-2013] Page 6 of 6 TVA SENSITIVE INFORMATION