Form 10-2201B Form 10-2201B Release to Obtain a Credit Report

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

National Park Service Expiration Date XX/XX/XXXX

RELEASE TO OBTAIN A CREDIT REPORT

Fair Credit Reporting Act of 1970, as amended

United States Park Police

Headquarters

1100 Ohio Drive, S.W.

Washington, D.C. 20002

Information provided by you on this form will be furnished to a consumer reporting agency in order to obtain information in connection with the pre-employment qualification determination phase of the application process to determine your fitness for Federal employment. The information obtained may be re-disclosed to other Federal agencies for the above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law.

Please take notice that at one or more consumer credit reports may be obtained for pre-employment qualification determination purposes pursuant to the Fair Credit Reporting Act, as amended, 15 U.S.C. Section 1681, et. Seq. Should a decision be made not to offer you employment, based either in whole or in part on the consumer credit report, the consumer reporting agency that provided the report played no role In the agency's decision to take such adverse action.

1. Applicant’s Full Name		Last			First		Middle				Suffix (i.e. Jr. Sr. I, II, III)
		     			     		     				     
2. Other Names Used
Check One	Alias Maiden Name Nickname
	     
Check One	Alias Maiden Name Nickname
	     
Check One	Alias Maiden Name Nickname
	     
3. Date of Birth (mm/dd/yyyy)				4. Social Security Number				5. Home Telephone Number
     				     				     
6. Current Occupation						7. Employer Name
     						     
8. Present Address			House Number, Street, Apt #
			     
			City						State	Zip Code
			     						     	     
9. Previous Address			House Number, Street, Apt #
			     
			City						State	Zip Code
			     						     	     

I hereby authorize the United States Park Police to obtain such report(s) from any consumer/credit-reporting agency for employment purposes.

Print Full Name:	     
Signature:		Date:	     

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 an investigation to determine your qualification for employment purposes, including a security clearance and an evaluation of qualifications, suitability, and loyalty to the United States. As part of such an investigation, 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 investigation may be furnished to designated officers and employees of agencies and departments of the Federal Government for employment purposes, including security clearance determination, an access determination, an evaluation of qualifications, suitability, and loyalty to the U.S. Government, and a determination regarding qualifications or suitability for performing a contractual service to the Federal Government. The information may also be disclosed to any agency of the Federal Government having a working relationship with regard to Office of Personnel Management activities, to the intelligence agencies of the Federal Government, or to others having reasons as published in the Federal Register.

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 processing of your pre-employment suitability determination. 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 Office of Personnel Management 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 Suitability Phase of the application process to help us determine your suitability 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 processing of your pre-employment suitability determination, 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 10 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.

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