TVA-13045A Personnel Security Questionnaire (Short Form)

TVA SENSITIVE INFORMATION

OMB No. 3316-0063

Exp. Date: 12/31/2016

Tennessee Valley Authority

Personnel Security Questionnaire (Short Form)

This form is to be completed in conjunction with Form TVA 1 - Application For Employment.

Please TAB to gray areas

Instructions - Please read carefully and complete every item. If the answer is “no” or “none,” state so. If more space is needed, use a separate sheet of paper. The information will be used to determine eligibility for security clearance or access authorization. This form will not be accepted unless it is properly completed and signed. Please type or print all information.

Personal Data

1. Full Name (Last, First, Middle)					Date (mm/dd/yyyy)
     					     
2. Other Names Used (Include maiden name, former married names, aliases, nicknames, etc., and the dates used)
Name			From (mm/yyyy)		To (mm/yyyy)
     			     		     
     			     		     
     			     		     
3. Social Security Number		4. Date of Birth (mm/dd/yyyy)	5. Birthplace (City, State & County)
     		     	     
6. Driver’s License Number		State of Issue	7. Sex
     		     	Male Female
8. Race
White Black/African American Hispanic/Latino Asian (Non Hispanic) Native Hawiian or Pacific Islander American Indian/Alaska Native Not Applicable (Non-US) Two or more races Please list: _________________________________________________
9. Marital Status:
Single Married Divorced Widowed Separated
10. Are you authorized to work in the United States? Yes No
U.S. citizen
Lawfully admitted for permanent residence (permanent residence card [green card]) -				A#     
Granted asylum and granted an employment authorization document
Refugee and granted an employment authorization document
Temporary work visa or employment authorization document
None of the above. Explain:	     

Certification of Accuracy

I have read all of the questions on this form. I certify that the information furnished in answer to the questions on this form is correct and complete to the best of my knowledge and belief. I understand that the accuracy of this information is of great importance in the consideration of my eligibility for security clearance or access authorization. A false statement or omission of material fact may be sufficient cause for rejection of my security clearance and/or employment and may be punishable by law.

Signature		Date
Burden Estimate Statement (Pursuant to 5 CFR 1320.21) 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this burden, to Agency Clearance Officer, Tennessee Valley Authority, 1101 Market Street, Chattanooga, TN 37402; and to the Office of Management and Budget, Paperwork Reduction Project (3316-0063), Washington, DC 20503.
Privacy Act Statement Subsection (e) (3) of 5 U.S.C § 552a (Section 3 of the Privacy Act) requires that TVA inform you of its authority to request information and the uses which TVA may make of the information requested. That subsection further requires TVA to inform you of the effects of not providing any or all the requested information. TVA’s authority to request the information you will provide is derived from the TVA Act (16 U.S.C. §§ 831-831ee), Executive Order No. 10450, the Atomic Energy Act of 1954, as amended, and a number of other statutes and Presidential Executive orders. Information provided on this form may be furnished to people, agencies, organizations, or institutions in order to obtain information regarding you in connection with an investigation to determine: (1) fitness for TVA employment; (2) clearance to perform services for TVA under personal services, consultant, or other contracts; or (3) security clearance or clearance for access to TVA installations. Furnishing the requested information is voluntary; however, failure to provide all or part of the information may result in a lack of further consideration for employment, clearance or access, or in the termination of your employment. Information provided on this form is normally used only to determine fitness for employment or security clearance or clearance for access to TVA installations. Information obtained on this form may be furnished to third parties as authorized by law. For example, should a dispute arise or a congressional inquiry be made regarding TVA employment practices, the information may be made available outside of TVA in the course of that dispute or inquiry. Further, information provided may be provided to another federal agency if relevant to a decision to be made by that agency. In addition, information on this form may be made available to law enforcement agencies in the exercise of their duties, or to a prospective employer or TVA contractor upon proper request.

TVA 13045A [07-22-2014] TVA SENSITIVE INFORMATION