Form 10-2201A Form 10-2201A Information Release Form

NPS Form 10-2201A (Rev. 04/2018) OMB Control No. 1024-0245

National Park Service Expiration Date 09/30/2018

INFORMATION RELEASE FORM

United States Park Police

Headquarters

1100 Ohio Drive, S.W.

Washington, D.C. 20002

DATE: ___________________________________

TO WHOM IT MAY CONCERN:

I, ____________________________________________________, authorize the United States Park Police to conduct a qualifications review to determine my qualifications for employment as an officer with the United States Park Police. I understand that this permission includes access to and review of any and all records concerning myself regardless of the confidentiality or whether they are of public or private nature. It is my specific intent to provide access to all my non-medical personal records and information, no matter how personal or confidential.

I understand that any information ascertained or developed through the use of this release will be used to determine my qualifications to be an officer with the United States Park Police. I further understand that refusal to grant this authorization will constitute a basis for rejection of my application.

INFORMATION REGARDING DISCLOSURE OF YOUR

SOCIAL SECURITY NUMBER UNDER PUBLIC LAW 93-579 SECTION 7(b)

Disclosure by you of your social security number (SSN) is mandatory to obtain the services, benefits, or processes that you are seeking. The SSN is used as an identifier throughout your Federal career from the time of application through retirement. The information gathered through the use of the number will be used only as necessary in personnel administration processes carried out in accordance with the established regulations and published notices of systems of records. The SSN also will be used for the selections 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 identifies can only be distinguished by the SSN.

SUBSCRIBED BEFORE ME THIS _________ DAY

OF ______________________________ 20_____

_________________________________________

(NOTARY PUBLIC)

(SEAL)

SIGNED: _________________________________________________

SOCIAL SECURITY NUMBER: ________________________________

NOTICES

PRIVACY ACT NOTICE

Authority: U.S.C. Title 54, 5 U.S.C. 3301, 3302, 3307, 3309, 3313, and Executive Order 9397.

Purpose: The information collected on this form will be used to review your qualifications for employment in connection with the pre-employment qualification determination phase of the United States Park Police application process.

Routine uses:  In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, all or a portion of the records or information contained in this system may be disclosed outside DOI as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other government agencies, authorized organizations and individuals. The disclosure is only permitted as described under the routine uses for the system of records notice “OPM/GOVT–5 Recruiting, Examining, and Placement Records” when is compatible with the purpose for which the records were compiled.

Disclosure: Voluntary, however, failure to provide the requested information may impede our ability to review your qualifications for 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 determination of your pre-employment qualifications. The authority for soliciting and verifying your SSN is Executive Order 9397. It will be used primarily to identify your records with the United States Park Police and other Federal agencies in connection with lawful requests for information about you from former employers, educational institutions, and financial or other organizations in accordance with established regulations and published notices of system of records.

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 qualifications determination phase of the application process to help us determine your qualifications 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 determination of your pre-employment qualifications, 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 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. 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.

This form is valid for 1 year from date of notary

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