Form 10-2201A Form 10-2201A Information Release Form

NPS Form 10-2201A (Rev. 07/2017) OMB Control No. 1024-0245

National Park Service Expiration Date XX/XX/XXXX

INFORMATION RELEASE FORM

United States Park Police

Headquarters

1100 Ohio Drive, S.W.

Washington, D.C. 20002

DATE: ___________________________________

TO WHOM IT MAY CONCERN:

I, ____________________________________________________, authorize the United States Park Police to conduct a qualifications review to determine my qualifications for employment as an officer with the United States Park Police. I understand that this permission includes access to and review of any and all records concerning myself regardless of the confidentiality or whether they are of public or private nature. It is my specific intent to provide access to all my non-medical personal records and information, no matter how personal or confidential.

I understand that any information ascertained or developed through the use of this release will be used to determine my qualifications to be an officer with the United States Park Police. I further understand that refusal to grant this authorization will constitute a basis for rejection of my application.

INFORMATION REGARDING DISCLOSURE OF YOUR

SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)

Disclosure by you of your social security number (SSN) is mandatory to obtain the services, benefits, or processes that you are seeking. The SSN is used as an identifier throughout your Federal career from the time of application through retirement. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with the established regulations and published notices of systems of records. The SSN also will be used for the selections of persons to be included in statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants who have identical names and birth dates, and whose identifies can only be distinguished by the SSN.

SUBSCRIBED BEFORE ME THIS _________ DAY

OF ______________________________ 20_____

_________________________________________

(NOTARY PUBLIC)

(SEAL)

SIGNED: _________________________________________________

SOCIAL SECURITY NUMBER: ________________________________

NOTICES

PRIVACY ACT NOTICE

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing Federal Investigative forms.

Authority: The authority to collect information on the attached form is derived from one or more of the following:

Title 5, Code of Federal Regulations, section 5.2; Title 5, United States Code, sections 1303, 1304, and 3301; sections 8(b), 8(c), and 9(c) of Executive Order 10450; Title 42, United States Code, section 2455; and Title 22, United States Code, sections 1434 and 2585.

Purposes and Uses: The information you supply will be used principally as a basis for a review to determine your qualification for employment purposes. As part of such a review, the Standard Form 87 (Fingerprint Chart) will be sent to the Federal Bureau of Investigation and may be retained there. This information and information developed through this review may be furnished to designated officers and employees of agencies and departments of the Federal Government for employment purposes.

Effects of Nondisclosure: The Personal Qualification Statement requests specific information. It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Under 5 U.S.C. 8315, a false answer to questions relating to membership in the Communist Party, U.S.A., or other communist or fascist organizations could deprive you of your right to an annuity when you reach retirement age. Deliberately and materially making false or fraudulent statements on this form will be grounds for not hiring you or for firing you after you begin work. In addition, these violations will become part of your permanent record for future employment.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number (SSN) is needed to identify records unique to you. Although disclosure of your SSN is not mandatory, failure to disclose your SSN may prevent or delay the determination of your pre-employment qualifications. The authority for soliciting and verifying your SSN is Executive Order 9397. The SSN is used as an identifier throughout your Federal career from the time of application through retirement. It will be used primarily to identify your records with the United States Park Police and other Federal agencies in connection with lawful requests for information about you from former employers, educational institutions, and financial or other organizations. The information gathered through the use of the SSN will be used only as necessary in personnel administration processes carried out in accordance with established regulations and published notices of system of records. The SSN also will be used for the selection of persons to be included in statistical studies of personnel management matters. The use of the SSN is made necessary because of the large number of present and former Federal employees and applicants who have identical names and birth dates, and whose identities can only be distinguished by the SSN.

PAPERWORK REDUCTION ACT STATEMENT

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) as part of the pre-employment qualifications determination phase of the application process to help us determine your qualifications for the position of a United States Park Police Officer. Your response is required to obtain or retain a benefit; however, failure to provide the requested information may prevent or delay the determination of your pre-employment qualifications, adversely affecting your consideration for appointment as a United States Park Police Officer. The OMB Control Number, 1024-0245, is currently valid. We may not collect this information and you are not required to respond unless this number is displayed.

ESTIMATED BURDEN STATEMENT

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 the burden estimate or any other aspect of this collection of information to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Dr. (MS-242), Reston, VA 20192. Do not send your completed form to this address.

This form is valid for 1 year from date of notary

RECORDS RETENTION - TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule Management and Accountability) (Item 10D) (N1-79-08-9))