Form PFPA Form 1400 PFPA Form 1400 Authorization for Release of Information

OMB No. xxxx-xxxx
OMB approval expires
XXXXX XX XXXX

PENTAGON FORCE PROTECTION AGENCY
AUTHORIZATION FOR RELEASE OF INFORMATION

The public reporting burden for this collection of information, xxxx-xxxx, is estimated to average 5 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 burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected].
Respondents should be aware that not withstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if
it does not display a current valid OMB control number.

Privacy Act Statement
Authority:

5 U.S.C. 1302, Regulations; 3109, Employment of experts and consultants; temporary or intermittent; 3301, Civil service; general;
3302, Competitive service; rules; 3304, Competitive service; examinations; 3305, Competitive service; examinations; when held; 3307,
Competitive service; maximum-age entrance requirements; exceptions; 3309, Preference eligible; examinations; additional points for; 3313,
Competitive service; registers of eligible; 3317, Competitive service; certification from registers; 3318, Competitive service; selection from
certificates; 3319, Alternative ranking and selection procedures; 3326, Appointments of retired members of the armed forces to positions in the
Department of Defense; 4103, Establishment of training programs; 5533, Dual pay from more than one position; limitations; exceptions; DoDD
5105.68, Pentagon Force Protection Agency; and E. O. 9397 (SSN), as amended.

Principle
Purposes (s):

The information obtained in the completion of this form is used to help in the determination as to the individual’s fitness for federal employment
in the field of law enforcement.

Routine Uses (s):

In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended, the records
contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows:
To disclose information to any source from which additional information is requested (to the extent necessary to identify the individual, inform
the source of the purposes of the request, and to identify the type of information requested), when necessary to obtain information relevant to an
agency decision concerning hiring or retaining an employee, issuing a security clearance, conducting a security or suitability investigation of an
individual, classifying positions, letting a contract, or issuing a license, grant or other benefit. To disclose information to a Federal agency, in
response to its request, in connection with hiring or retaining an employee, issuing a security clearance, conducting a security or suitability
investigation of an individual, classifying positions, letting a contract, or issuing a license, grant, or other benefit by the requesting agency, to the
extent that the information is relevant and necessary to the requesting agency's decision in the matter.
The complete list of routine uses can be found online in the applicable system of records notice at
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570737/opmgovt-5/

Disclosure:

Voluntary; however, failure to provide all or part of the information may result in a lack of further consideration for employment, clearance
access, or the termination of your employment.

Carefully read this authorization to release information about you, then sign and date it in ink.
I Authorize any investigator, special agent, or other duly accredited representative of the Pentagon Force
Protection Agency conducting my background investigation, to obtain any information relating to my activities
from individuals, employers, or criminal justice agencies. This information may include, but is not limited to,
performance, attendance, disciplinary history, employment history, and criminal history record information.
I Understand that the purpose for furnishing such information to PFPA is for use in making a determination as
to my fitness for federal employment in the field of law enforcement.
I Authorize custodians of records and other sources of information pertaining to me to release such information
upon request of the investigator, special agent, or other duly accredited representative of PFPA authorized above
regardless of any previous agreement to the contrary.
I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and
other sources of information, a separate specific release may be needed and I may be contacted for such a release at a
later date.
I Understand that the information released by records custodians and sources of information is for official use by
PFPA only for the purposes provided in this Authorization for Release of Information Form, and that it may be
disclosed by the Government only as authorized by law. Photocopies of this authorization that show my signature are valid. This

authorization is valid for one (1) year from the date signed.
Photocopies of this authorization that show my signature are valid. This authorization is valid for one (1) year from
the date signed.
1. Signature: (Sign in Ink)
2. Full Name: (Type or Print Legibly) 3. Date Signed: (mm/dd/yyyy)
4. Other Names Used
7. Current Street Address:

PFPA FORM 1400, April 2018

5. Date Of Birth:

6. Social Security Number:

8. City: (Country)

PREVIOUS EDITIONS ARE OBSOLETE

9. State:

10. Zip Code:
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