Form DEA-320 DEA Ambassador Program Volunteer Application

Applicant Name

Name:

Last Name

First Name

Middle Name

Date of Birth:

Are you a U.S. Citizen:

Yes

No

Acquired by:

Birth

Marriage

Naturalization

Contact Information

Home Address:

Street

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

E-mail Address:

Employment Information

Current Employer Work Address:
Job Title:		Street City State Zip Code

Memberships and Community Groups

Pl Please list any organizations, associations, or community groups to which you belong:

DEA-320 (4/2017) 1

Authorization to Conduct Law Enforcement Check
DRUG ENFORCEMENT ADMINISTRATION
PRIVACY ACT STATEMENT AND CONSENT
Providing the information requested is voluntary. The authorities for the collection of this information are E.O. 9397; E.O. 10450; E.O. 12356; 5 U.S.C. §§ 301, 3301, and 9101; and 5 C.F.R. parts 5, 732, and 736. The principal purposes for which the information will be used are to screen qualifications of applicants to the Ambassador Program, to ensure the accuracy of Department of Justice records, and to perform background checks as necessary. The information provided may be disclosed to employees of the Department of Justice who have a need to know the information for the performance of their duties and designated officers and employees of agencies conducting an investigation of you. For additional guidance regarding how your information may be used or disclosed, along with a complete list of the Privacy Act routine uses related to this collection, please consult the Department of Justice System of Records Notice titled “Personnel Investigations and Security Clearance Records for the Department of Justice," DOJ-006, 67 F.R. 59864 (9/24/2002), accessible at http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=2002_register&docid=02- 24206-filed.pdf, If background checks are performed, or the Office of Personnel Management System of Records Notice titled “General Personnel Records,” OPM/GOVT-1, 71 F.R. 35342 (5/24/2006). Giving us the information we ask for is voluntary. However, we may not be able to consider your application or complete your investigation, if you don’t give us each item of information we request. This may affect your prospects of being selected as a DEA Ambassador. CONSENT
Full Name (typed or printed)		Full Name (Signature)
Date of Authorization
All applications must be signed.

DEA-320 (4/2017) 2