Application and Related Forms

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Application to serve on the
Community Bank Advisory Council
or Credit Union Advisory Council

OMB No: 3170-0037
Expiration: XX/XX/
XXXX

Thank you for your interest in a position on the Community Bank Advisory Council
(CBAC) or the Credit Union Advisory Council (CUAC) of the Consumer Financial
Protection Bureau (CFPB). CFPB will use the information you provide only for those
purposes authorized by law, or as outlined under the attached Privacy Act Statement.
Please ensure that all information you provide is complete and accurate.

Please complete and submit this questionnaire as
part of the application and selection process for
the advisory committees.
To evaluate potential sources of conflicts of interest,
the Bureau will ask potential candidates to provide
information related to financial holdings and/or
professional affiliations, and to allow the Bureau
to perform a background check. CFPB will use the
information you provide only for these purposes or
other purposes authorized by law, or as outlined
under the attached Privacy Act Statement.
The Bureau does not accept applications from
federally registered lobbyists or current elected
officials for a position on the advisory committees.

A complete application packet must include:
1. A recommendation letter from a third
party describing the applicant’s interests
and qualifications to serve on the advisory
committees
2. A cover letter explaining your interest and
qualifications;
3. A resume or curriculum vitae for the applicant;
4. A complete questionnaire; and
5. A typed signature which will serve as an
electronic signature.

Only complete applications will be given
consideration for review of membership on the
advisory committees.

Consumer Financial
Protection Bureau

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

General information

1
2

Credit Union
Advisory Council

Community Bank
Advisory Council

Select advisory group to which you
are applying to be a representative
* Choose one
Please provide
your personal
information

FIRST NAME

LAST NAME

M.I.

HAVE YOU PREVIOUSLY USED A DIFFERENT NAME OR SPELLING OF YOUR NAME?
LIST OTHER NAMES USED

YES

FROM

MM
LIST OTHER NAMES USED

TO

YY

MM

FROM

MM
EMPLOYER

NO

YY

TO

YY

MM

YY

EMAIL

POSITION/TITLE

HOW LONG AT EMPLOYER

YR

EMPLOYER‘S ADDRESS

CITY

STATE

WORK PHONE

MO

ZIP CODE

CELL PHONE

PLACE OF BIRTH

DATE OF BIRTH

GENDER
MALE

FEMALE

PREFER NOT TO ANSWER

OTHER

RACE/ETHNICITY
AMERICAN INDIAN OR ALASKA NATIVE
HISPANIC OR LATINO

Consumer Financial
Protection Bureau

ASIAN

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

WHITE

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Third-party recommender

3

Please list
the name(s),
title(s) and
organization(s)
of your
recommender(s).

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

Consumer Financial
Protection Bureau

M.I.

M.I.

M.I.

M.I.

M.I.

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Third-party recommender (continued)

3

Please list
the name(s),
title(s) and
organization(s)
of your
recommender(s).

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

LAST NAME

FIRST NAME

TITLE

ORGANIZATION

Consumer Financial
Protection Bureau

M.I.

M.I.

M.I.

M.I.

M.I.

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Experience

4

5

List your business
or professional
experience not
listed on your
resume/CV

Identify the
statutory
membership
category that is
most applicable
to you
* Choose one

6

What are the
products that your
institution offers
* Choose all that
apply

Consumer protection

Financial services

Community development

Fair lending and civil rights

Consumer financial products
or services

Depository institution primarily
serving underserved communities

Representing communities that
have been significantly impacted
by higher-priced mortgage loan

Other

Card Services (Credit cards,
Debit cards, and Prepaid cards)

Consumer Loans (Collateral Loans,
Debt consolidation, Home Equity
Lines, Personal Loans/Small Dollar,
Overdraft Protection, Personal Lines
of Credit)

Checking & Savings
Commercial Banking
Loans (Auto Loans, Boat Loans,
RV Loans, Student Loans)

Credit reporting, cards, payments
Mobile banking

Mortgages

Mobile payments

Wealth Management (Bonds,
CD’s, Money market, Stock)

Other

Consumer Financial
Protection Bureau

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Experience (continued)

7

What is your institution’s asset size

8

Select your
region.

$
Ex: 3.5 million

* Choose one

Please see the map at consumerfinance.gov/about-us/the-bureau/bureau-structure/
supervision-enforcement-fair-lending/supervision-regional-directors to make the
appropriate selection.
MIDWEST
NORTHEAST
SOUTHEAST
WEST

9

10

List other
affiliations and/
or service as a
community leader
that would benefit
you in your role as
a member of the
advisory group.

List any Federal
advisory
committee or any
board on which
you are currently
a member and the
number of years
you have served
on that committee
or board.

Consumer Financial
Protection Bureau

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Personal history

11
12

Are you a U.S. citizen?

YES

NO

If no - are you a permanent resident (i.e. possess a green card)?

YES

NO

Have you been a party to a civil or criminal action involving a financial institution
or service provider?

YES

NO

YES

NO

YES

NO

YES

NO

YES

NO

If yes - please explain on the attached continuation sheet.

13

Are you now or have you in the last year been subject to the registration and
reporting requirements of the Lobbying Disclosure Act (2 U.S.C. 1605)?
If yes - please explain on the attached continuation sheet.

14
15

Are you currently engaged in any business before the CFPB?
If yes - please explain on the attached continuation sheet.
Have you failed to pay any tax, penalty, or interest liability during the current or
last three calendar years within forty-five (45) days of the date of which the IRS
gave notice of the amount due and request for payment?
If yes - please explain on the attached continuation sheet.

16

Have you now or ever been under investigation by the IRS for possible
criminal offenses?
If yes - please explain on the attached continuation sheet.

Consumer Financial
Protection Bureau

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Continuation sheet to form
If you need more space for an answer, use this sheet. Please number each answer to correspond to the
number on this form. When you have completed your answers, attach to this form.
FIRST NAME

LAST NAME

M.I.

CONTINUATION FIELD (IF NEEDED)

Consumer Financial
Protection Bureau

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Affiliations, representations, and/or positions with boards, advisory councils, or
similar groups
List all positions and relationships you currently
hold or held at any time during the past two
years, whether or not you were compensated and
whether or not you currently hold that position.
Positions include an officer, director, employee,
trustee, general partner, proprietor, representative,
executor, member, or consultant of any of the
following:
§ Corporation, partnership, trust, or other business
entity
§ Non-profit or volunteer organization
§ Educational institution
§ Any government or industry advisory board
or council

Do not list any position with a:
§ Religious entity
§ Social entity
§ Fraternal entity
§ Political entity
§ Any position held by your spouse or
dependent child
List all relationships outside your current employer,
in which you represent the interests of a party, or
you or your affiliates receive from a party a fee,
income, or any other benefit from a party, if the
information is not listed on your resume/CV.

Positions you hold or have held

A

ORGANIZATION

CITY

STATE

ZIP CODE

TYPE OF ORGANIZATION

POSITION/TITLE

BRIEF DESCRIPTION

Consumer Financial
Protection Bureau

YEARS HELD

YR

MO

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Positions you hold or have held (continued)

B

ORGANIZATION

CITY

STATE

ZIP CODE

TYPE OF ORGANIZATION

POSITION/TITLE

YEARS HELD

YR

BRIEF DESCRIPTION

C

MO

ORGANIZATION

CITY

STATE

ZIP CODE

TYPE OF ORGANIZATION

POSITION/TITLE

BRIEF DESCRIPTION

Consumer Financial
Protection Bureau

YEARS HELD

YR

MO

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Positions you hold or have held (continued)

D

ORGANIZATION

CITY

STATE

ZIP CODE

TYPE OF ORGANIZATION

POSITION/TITLE

YEARS HELD

YR

BRIEF DESCRIPTION

E

MO

ORGANIZATION

CITY

STATE

ZIP CODE

TYPE OF ORGANIZATION

POSITION/TITLE

BRIEF DESCRIPTION

Consumer Financial
Protection Bureau

YEARS HELD

YR

MO

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Positions you hold or have held (continued)

F

ORGANIZATION

CITY

STATE

ZIP CODE

TYPE OF ORGANIZATION

POSITION/TITLE

YEARS HELD

YR

BRIEF DESCRIPTION

G

MO

ORGANIZATION

CITY

STATE

ZIP CODE

TYPE OF ORGANIZATION

POSITION/TITLE

BRIEF DESCRIPTION

Consumer Financial
Protection Bureau

YEARS HELD

YR

MO

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Signature
I certify that the statements I have made on this form and all attached statements are true,
complete, and correct to the best of my knowledge.
* Typing your name works as your signature.
SIGNATURE

DATE (MM-DD-Y Y Y Y)

Please note the following before submission:
§ Once you have completed the questionnaire, we recommend saving a copy for your files.
§ Prior to attaching/uploading your documents, please save them in the following format: ”LASTNAME_
FIRSTNAME_DOCUMENTTITLE.” Failure to do so may result in application processing delays.
§ To complete the application package, you must also attach a copy of your cover letter, resume/CV, and a
third-party letter of recommendation.
§ If you require a reasonable accommodation to complete the application, please contact
[email protected].
§ Completed applications packages must be received on or before 11:59 p.m. EST February 27, 2020.
Attach necessary and/or required documents to this application
§ Cover letter
§ Resume/CV
§ Third-party letter of recommendation

Consumer Financial
Protection Bureau

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

Privacy Act Statement
5 U.S.C. 552a(e)(3)

The information that you provide will be used by the Consumer Financial Protection Bureau (CFPB)
to determine qualifications, suitability, and availability for service on advisory boards, bodies, panels,
committees or other similar groups. The information will be used to conduct background clearances and/or
for annual reports on advisory boards, bodies, panels, committees or other similar groups.
Information collected by the CFPB will be treated in accordance with the System of Records Notice (SORN),
CFPB.016 CFPB Advisory Boards and Committees, 83 FR 23435. The information will be used by and
disclosed to employees, contractors, agents, and others authorized by the CFPB to receive this information to
assist in related activities. Information may be disclosed in accordance with the Routine Uses described in the
SORN, including to:
Appropriate agencies, entities, and persons when (a) the CFPB suspects or has confirmed that there has
been a breach of the system of records; (b) the CFPB has determined that as a result of the suspected or
confirmed breach there is a risk of harm to individuals, the CFPB (including its information systems, programs,
and operations), the Federal Government, or national security; and (c) the disclosure made to such agencies,
entities, and persons is reasonably necessary to assist in connection with the CFPB’s efforts to respond to the
suspected or confirmed breach or to prevent, minimize, or remedy such harm;
Another Federal agency or Federal entity, when the CFPB determines that information from this system of
records is reasonably necessary to assist the recipient agency or entity in (a) responding to a suspected or
confirmed breach or (b) preventing, minimizing, or remedying the risk of harm to individuals, the recipient
agency or entity (including its information systems, programs, and operations), the Federal Government, or
national security, resulting from a suspected or confirmed breach.
Another federal or state agency to (a) permit a decision as to access, amendment or correction of records to
be made in consultation with or by that agency, or (b) verify the identity of an individual or the accuracy of
information submitted by an individual who has requested access to or amendment or correction of records;
To the Office of the President in response to an inquiry from that office made at the request of the subject of a
record or a third party on that person’s behalf;
Congressional offices in response to an inquiry made at the request of the individual to whom the record
pertains;
Contractors, agents, or other authorized individuals performing work on a contract, service, cooperative
agreement, job, or other activity on behalf of the CFPB or Federal Government and who have a need to
access the information in the performance of their duties or activities;
The U.S. Department of Justice (“DOJ”) for its use in providing legal advice to the CFPB or in representing
the CFPB in a proceeding before a court, adjudicative body, or other administrative body before which the
CFPB is authorized to appear, where the use of such information by the DOJ is deemed by the CFPB to be
relevant and necessary to the litigation, and such proceeding names as a party or interests: (a) The CFPB; (b)
Any employee of the CFPB in his or her official capacity; (c) Any employee of the CFPB in his or her individual
capacity where DOJ has agreed to represent the employee; or (d) The United States, where the CFPB
determines that litigation is likely to affect the CFPB or any of its components;

Consumer Financial
Protection Bureau

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CBAC/CUAC APPLICATION

OMB No: 3170-0037
Expiration: 01/31/2023

To the public in the form of names, affiliations, and other pertinent biographical information of board or
committee members; and
Appropriate agencies, entities, and persons to the extent necessary to obtain information relevant to making
a determination of whether an individual is eligible to serve on a CFPB board or committee.
The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011, 1012, 1014,
codified at 12 U.S.C. §§ 5491, 5492, 5494.
Providing your identifying information is voluntary, but not doing so may result in non-selection of a
prospective advisory board, body, panel, committee, or other similar group membership. However, failure to
provide your Social Security number may not be the reason for non-selection.
The Bureau has a special interest in ensuring that women, minority groups, and individuals with disabilities
are adequately represented on the Board and Councils, and therefore, encourages applications from
qualified candidates from these groups. In furtherance of this interest, the Bureau invites applicants to
the Board and Councils to voluntarily self-identify their race or ethnicity. Submission of this information is
voluntary and refusal to provide it will not disqualify you from consideration for service on the Board or
Councils. The information obtained will be kept confidential and will only be used for internal management
purposes. There have been occasions when members of the public and/or Congress have requested
information regarding the demographic composition of the Board and Councils. If the Bureau receives and
responds to such a request, data provided will not identify any specific individual.

Paperwork Reduction Act

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person
is not required to respond to a collection of information unless it displays a valid OMB control number. The
OMB control number for this collection is 3170-0037. It expires on 01/23/2023. The time required to complete
this information collection is estimated to average approximately 1 hour per response, including the time for
reviewing any instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Comments regarding this collection of information,
including the estimated response time, suggestions for improving the usefulness of the information, or
suggestions for reducing the burden to respond to this collection should be submitted to Bureau at the
Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G Street NW, Washington, DC 20552,
or by email to [email protected].

Consumer Financial
Protection Bureau

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