Sample Agency Disclosure Notice, Privacy Act Statement, and Instructions

Sample

Army & Air Force Exchange Service IDENTIFICATION & PRIVILEGE CARD APPLICATION (Read Agency Disclosure Notice, Privacy Act Statement, and Instructions before completing form.)	OMB NO. 0702- OMB approval expires MMM DD, YYYY
AGENCY DISCLSOURE NOTICE The public reporting burden for this collection of information is estimated to average 15 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0702-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS. Responses should be sent to your local Human Resources Office that provided you the form.
PRIVACY ACT STATEMENT AUTHORITY: Title 10 U.S.C. §3013, “Secretary of the Army”; Title 10 U.S.C. §8013, “Secretary of the Air Force”; Army Regulation 215-3, “Nonappropriated Funds Personnel Policy”; Army Regulation 215-8/AFI 34-211(I), “Army and Air Force Exchange Service Operations”; and E.O. 9397 (SSN), as amended. PRINCIPAL PURPOSES(S): To collect information necessary to process a request to obtain privileges as an authorized patron of the Exchange. ROUTINE USE(S): Your records may be disclosed outside of DoD pursuant to Title 5 U.S.C. §552a(b)(3) regarding DoD “Blanket Routine Uses” published at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx. This includes disclosure to Federal agencies, and state, local and territorial government including to the U.S. Department of Justice/U.S. Attorneys, to the Department of Labor, Department of Veterans Affairs, Social Security Administration, Federal agencies that have special civilian employee retirement programs; or a national, state, county, municipal, or other publicly recognized charitable or income security administration agency. DISCLOSURE: Voluntary, however, failure to provide all the requested information may result in the denial of your application for inadequate data. A copy of the Privacy Impact Assessment (PIA) for this collection may be located at http://ciog6.army.mil/Portals/1/PIA/2013/EXHRM-TMG.pdf
INSTRUCTIONS Print all information in ink. Make sure the information is complete and accurate. Have your sponsor complete Section I, Section II, the Affidavit for Lost and Stolen Card, and sign and date the form. Section III will be completed by an Exchange Human Resource Associate. Do not place any information in this section. Complete Section IV, the Dependent Relationship to Sponsor, and Sign and Date under the Dependent Relationship. Present the form to the Human Resource associate. Do not complete section V until directed by the Human Resource associate after you receive your privilege card.