Form 10-2201B Form 10-2201B Release to Obtain a Credit Report

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

National Park Service Expiration Date 09/30/2018

RELEASE TO OBTAIN A CREDIT REPORT

Fair Credit Reporting Act of 1970, as amended

United States Park Police

Headquarters

1100 Ohio Drive, S.W.

Washington, D.C. 20002

Information provided by you on this form will be furnished to a consumer reporting agency in order to obtain information in connection with the pre-employment qualification determination phase of the application process to determine your fitness for Federal employment. The information obtained may be re-disclosed to other Federal agencies for the above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law.

Please take notice that at one or more consumer credit reports may be obtained for pre-employment qualification determination purposes pursuant to the Fair Credit Reporting Act, as amended, 15 U.S.C. Section 1681, et. Seq. Should a decision be made not to offer you employment, based either in whole or in part on the consumer credit report, the consumer reporting agency that provided the report played no role In the agency's decision to take such adverse action.

1. Applicant’s Full Name		Last			First		Middle				Suffix (i.e. Jr. Sr. I, II, III)
		     			     		     				     
2. Other Names Used
Check One	Alias Maiden Name Nickname
	     
Check One	Alias Maiden Name Nickname
	     
Check One	Alias Maiden Name Nickname
	     
3. Date of Birth (mm/dd/yyyy)				4. Social Security Number				5. Home Telephone Number
     				     				     
6. Current Occupation						7. Employer Name
     						     
8. Present Address			House Number, Street, Apt #
			     
			City						State	Zip Code
			     						     	     
9. Previous Address			House Number, Street, Apt #
			     
			City						State	Zip Code
			     						     	     

I hereby authorize the United States Park Police to obtain such report(s) from any consumer/credit-reporting agency for employment purposes.

Print Full Name:	     
Signature:		Date:	     

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 Suitability Phase of the application process to help us determine your suitability 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 processing of your pre-employment suitability determination, 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 10 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.

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