Application to Serve on Advisory Board

OMB Control #3170-0037
Expiration Date: 07/31/2016

BACKGROUND INFORMATION

APPLICATION TO SERVE ON
ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
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, or as outlined under the attached Privacy Act
Statement. Please ensure that the information you provide is complete and accurate.

Part I: Basic Information
Name of Advisory Group to which you are applying to be a representative
Consumer Advisory Board

Last Name

Community Bank Advisory Council

First Name

Academic Research Council

Middle Initial

Credit Union Advisory Council

E-mail Address

Current Employer

Employer Address

Position/Title

How long at employer?

Work Phone

Cell Phone

Other

Place of Birth

Date of Birth

Social Security Number
*Voluntary - See Privacy Act

List your business or professional experience not listed on your resume.

Identify your area of expertise (select only one).
Consumer protection
Financial services
Community development

Depository institution primarily serving
underserved communities

Fair lending and civil rights

Representing communities that have been significantly
impacted by higher-priced mortgage loans

Consumer financial products or services

Other

List education and any specialized experience not listed on your resume.

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

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

1

OMB Control #3170-0037
Expiration Date: 07/31/2016
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.

1.

Have you ever been convicted of a felony? (A felony is defined as any violation of law punishable by
imprisonment longer than one year).
Yes – Please explain on the attached continuation sheet.
No

2.

Are you a US citizen?
Yes
No
If no, do you have permanent residency status?
Yes
No

3.

Have you been a party to a civil or criminal action involving a financial institution or service provider?
Yes – Please explain on the attached continuation sheet.
No

4.

Are you now or have you in the last year been subject to the registration and reporting requirements of the
Lobbying Disclosure Act (2 U.S.C. 1605)?
Yes – Please explain on the attached continuation sheet.
No

5.

Are you currently engaged in any business before the CFPB?
Yes – Please explain on the attached continuation sheet.
No

6.

Have you failed to pay any tax, penalty, or interest liability during the current or last three calendar years
within forty-five (45) days of the date of which the IRS gave notice of the amount due and request for
payment?
Yes – Please explain on the attached continuation sheet.
No

7.

Have you now or ever been under investigation by the IRS for possible criminal offenses?
Yes – Please explain on the attached continuation sheet.
No

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

2

OMB Control #3170-0037
Expiration Date: 07/31/2016

Part II: Affiliations, Representations, and/or Positions with Boards, Advisory
Councils, or Similar Groups
Please list all relationships outside of your current employer in which you represent the interests
of a party or in which you or your affiliates receive a fee, income, or any other benefit from a party
Additionally, please list all positions and relationships you currently hold or held at any time
during the past two years, whether or not you were compensated, and whether or not you
currently hold that position. Positions include an officer, director, employee, trustee, general
partner, proprietor, representative, executor, member, or consultant of any of the following:
• Corporation, partnership, trust, or other business entity
• Non-profit or volunteer organization
• Educational institution
• Any government or industry advisory board or council
Do not list any position with a:

o

o Religious entity
o Social entity
o Fraternal entity
o Political entity
Any position held by your spouse or dependent child

Positions You Hold or Have Held (List up to 10 relevant position starting with the most recent)
Organization
Type of organization
(include city and state where organization is located)

Position

Years Held Brief Description

1

2

3

4

5

6

7

8

9

10

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

3

OMB Control #3170-0037
Expiration Date: 07/31/2016

Part III: Institution Background
Please provide basic information about the financial institutions you have worked at, if the
information is not listed on your resume

1

Institution Name

Location

Designation / Type

Approx.
Assets ($)

2

3

4

5

6

7

8

9

10

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

4

OMB Control #3170-0037
Expiration Date: 07/31/2016

Privacy Act Statement
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;
To the public in the form of names, affiliations, and other pertinent biographical information of board or committee
(7)
members; and
Appropriate agencies, entities, and persons to the extent necessary to obtain information relevant to making a
(8)
determination of whether an individual is eligible to serve on a CFPB board or committee.
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. Providing your identifying information is voluntary, but not doing so may result in non-selection of a
prospective advisory board, body, panel, committee, or other similar group membership. However, failure to provide your Social
Security number may not be the reason for non-selection.

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

5

OMB Control #3170-0037
Expiration Date: 07/31/2016

Paperwork Reduction Act

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 OMB control number for this collection is 3170-0037. It expires on
07/31/2016. The time required to complete this information collection is estimated to average approximately 45 minutes per response,
including the time for reviewing any instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. The obligation to respond to this collection of information is voluntary. Comments regarding this
collection of information, including the estimated response time, suggestions for improving the usefulness of the information, or suggestions for
reducing the burden to respond to this collection should be submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA
Office), 1700 G Street NW, Washington, DC 20552, or by email to [email protected].

The Bureau will not disclose any personally identifiable information collected except to the extent that it is required to do so by law and as
provided in the Privacy Act Statement listed below. Additionally, the Bureau will treat the information collected consistent with its
confidentiality regulations at 12 C.F.R. Part 1070, et seq.

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

6

OMB Control #3170-0037
Expiration Date: 07/31/2016

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
Please save the document as "LASTNAME_FIRSTNAME_DATE" before submitting.

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)

Attach Resume

Submit

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

7