Application To Serve On Academic Research Council

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APPLICATION TO SERVE ON ACADEMIC RESEARCH COUNCIL

Thank you for your interest in a position as a representative on the Academic Research
Council (ARC) of the Consumer Financial Protection Bureau (CFPB). Please complete
and submit this questionnaire as part of the application and selection process for the
ARC. CFPB may 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 ARC. CFPB will use the
information you provide only for those purposes authorized by law, or as outlined under
the attached Privacy Act Statement. Please ensure that all information you provide is
complete and accurate.
Part I: Basic Information
Last Name

First Name

Middle Initial

Email Address

Current Principal Employer

Employer Address

Position/Title

Length of Employment at Current Employer

Work Phone

Cell Phone

Other

Place of Birth

Date of Birth

Gender

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

List any Federal advisory committee or board on which you are currently a member and the number of
years you have served on that committee or board if these details are not listed fully on your CV.

List any financial institutions you have worked at or been professionally affiliated with not listed on your
CV.

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1. Have you ever been convicted of a felony?
□ 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

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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;
(7) To the public in the form of names, affiliations, and other pertinent biographical information of board or
committee members; and
(8) Appropriate agencies, entities, and persons to the extent necessary to obtain information relevant to
making a 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.
The Bureau has a special interest in ensuring that women, minority groups, and individuals with disabilities are
adequately represented on the Board and Councils, and therefore, encourages applications from qualified
candidates from these groups. In furtherance of this interest, the Bureau invites applicants to the Board and
Councils to voluntarily self-identify their race or ethnicity. Submission of this information is voluntary and refusal
to provide it will not disqualify you from consideration for service on the Board or Councils. The information
obtained will be kept confidential and will only be used for internal management purposes. There have been
occasions when members of the public and/or Congress have requested information regarding the
demographic composition of the Board and Councils. If the Bureau receives and responds to such a request,
data provided will not identify any specific individual."

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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.
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)

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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)
__________________________________________________________