Application and Related Forms

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Application to serve on the
Academic Research Council (ARC)

OMB No: 3170-0037
Expiration: 07/31/2016

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.
General information

1

Please provide
your personal
information

FIRST NAME

LAST NAME

EMAIL

CURRENT PRINCIPAL EMPLOYER

EMPLOYER‘S ADDRESS

M.I.

CITY

STATE

POSITION/TITLE

ZIP CODE

HOW LONG AT EMPLOYER

YR
WORK PHONE

MO

CELL PHONE

PLACE OF BIRTH

DATE OF BIRTH

GENDER
MALE

Consumer Financial
Protection Bureau

FEMALE

PREFER NOT TO ANSWER

OTHER

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ACADEMIC RESEARCH COUNCIL APPLICATION

OMB No: 3170-0037
Expiration: 07/31/2016

Experience

2

3

4

5

List your business
or professional
experience not
listed on your
résumé/CV

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 if these
details are not
fully listed on your
résumé/CV.
List any financial
institutions you
have worked
at or been
professionally
affiliated with
not listed on your
résumé/CV.

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

Consumer Financial
Protection Bureau

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ACADEMIC RESEARCH COUNCIL APPLICATION

OMB No: 3170-0037
Expiration: 07/31/2016

Personal history

6

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

NO

Are you a US citizen?

YES

NO

If no - are you a permanent resident (i.e. possess a green card)?

YES

NO

Have you been a party to a civil or criminal action involving a financial institution
or service provider?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

If yes - please explain on the attached continuation sheet.

7
8

If yes - please explain on the attached continuation sheet.

9

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)?
If yes - please explain on the attached continuation sheet.

10
11

Are you currently engaged in any business before the CFPB?
If yes - please explain on the attached continuation sheet.
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?
If yes - please explain on the attached continuation sheet.

12

Have you now or ever been under investigation by the IRS for possible
criminal offenses?
If yes - please explain on the attached continuation sheet.

Consumer Financial
Protection Bureau

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ACADEMIC RESEARCH COUNCIL APPLICATION

OMB No: 3170-0037
Expiration: 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.
FIRST NAME

LAST NAME

M.I.

CONTINUATION FIELD (IF NEEDED)

Consumer Financial
Protection Bureau

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ACADEMIC RESEARCH COUNCIL APPLICATION

OMB No: 3170-0037
Expiration: 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;
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.

Consumer Financial
Protection Bureau

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ACADEMIC RESEARCH COUNCIL APPLICATION

OMB No: 3170-0037
Expiration: 07/31/2016

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.”

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.

Consumer Financial
Protection Bureau

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ACADEMIC RESEARCH COUNCIL APPLICATION

OMB No: 3170-0037
Expiration: 07/31/2016

Signature

13

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.
* Typing your name works as your signature.
SIGNATURE

DATE

Please note the following before submission:
§§ We strongly encourage electronic submission.
§§ Once you have completed the application save
the document as “LASTNAME_FIRSTNAME_
DATE”. Once saved please click the blue “Submit
application” button below. If you experience
issues with the submit function, please email
the application and your resume to
[email protected].
§§ To complete the application package, you
must also attach a copy of your résumé/CV. If
you prefer not to submit electronically, please
mail your complete application package, which
includes this form as well as a copy of your
résumé/CV.
Attn: Advisory Board and Council Office
Consumer Financial Protection Bureau
1275 1st Street NE, Washington, DC 20002.
§§ Applications submitted electronically must
be received on or before 5:00 p.m. EST
February 28, 2017.

Attach necessary and/or required
documents to this application
To attach your resume, click on the attach
file button below. You can upload multiple
files, but only one file can be attached
per click.
To confirm that your files have attached
properly follow the navigation path below:
View > Show/Hide > Navigation Panes >
Attachments
Attach file

Save the pdf application before submitting
* Submission will be sent via email

Submit application

§§ Mailed applications must be postmarked on or
before 5:00 p.m. EST February 28, 2017.

Consumer Financial
Protection Bureau

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