Application and Related Forms

OMB Control NO. 3170-0037
Expiration Date: XX/XX/20XX

CFPB OFFICE OF PERSONNEL SECURITY

FBI NAME CHECK REQUEST – ADVISORY BOARD
KEYBOARD SHORTCUTS: Use the TAB key to advance to the next field, arrow keys to select buttons.
Use numbers only to enter dates, phone numbers and other numeric fields (slashes and dashes added automatically).

APPLICANT INFORMATION
1. NAME OF ADVISORY BOARD TO WHICH YOU ARE APPLYING TO BE A REPRESENTATIVE

2. LAST NAME

3. FIRST NAME

4. MIDDLE NAME

5. OTHER NAMES USED – LIST DATES (MM/YYYY, FROM–TO)

a.

Dates:

to

b.

Dates:

to

6. PLACE OF BIRTH (CITY, STATE/COUNTRY)

7. DATE OF BIRTH (MM/DD/YYYY)

8. COUNTRY OF CITIZENSHIP

9. SOCIAL SECURITY NUMBER

10. PRESENT EMPLOYER

11. DATE STARTED PRESENT POSITION (MM/YYYY)

12. EMPLOYER ADDRESS

13. EMPLOYER TELEPHONE

Ext.
14. RESIDENTIAL ADDRESSES FOR THE PAST 5 YEARS, INLCUDING DATES (MM/YYYY, FROM – TO). START WITH MOST RECENT.
DATES
ADDRESS (Number and Street Name, City, State/Country)

a.

–

b.

–

c.

–

d.

–

e.

–

15. OTHER RELEVANT IDENTIFYING INFORMATION (FEDERAL EMPLOYMENT, ARRESTS, ETC.), INCLUDING DATES

16. OFFICIAL USE ONLY:

Badge Required:

YES

NO

APPLICANT CERTIFICATION
I certify that the statements I have made on this form and all attached supporting documents are true,
complete and correct to the best of my knowledge.

Applicant Signature:

Rev. 08/22/14

Date:

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OMB Control NO. 3170-0037
Expiration Date: XX/XX/20XX

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.
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 MM/DD/YYYY. The time required to complete this information collection is estimated to average approximately 10 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.

Rev. 08/22/14

FBI Name Check Request – Advisory Board

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