Application and Related Forms

OMB Control #3170-0037 Expires:XX/XX/XXXX

OFFICE OF PERSONNEL SECURITY

FBI NAME CHECK REQUEST – ADVISORY COMMITTEES

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Applicant Information

1. NAME OF ADVISORY COMMITTEE TO WHICH YOU ARE APPLYING TO BE A REPRESENTATIVE 1B. EMAIL ADDRESS

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2. LAST NAME 3. FIRST NAME 4. MIDDLE NAME

Full Legal Name From (Date)		To (Date)
6. PLACE OF BIRTH (CITY, STATE/COUNTRY) 7. DATE OF BIRTH (MMDDYYYY) 8. SOCIAL SECURITY NUMBER
9. COUNTRY OF CITIZENSHIP (If you are a U.S. citizen born outside the U.S., please attach a copy of your U.S. Passport or Naturalization Form.)
10. PRESENT EMPLOYER NAME 11. DATE EMPLOYMENT STARTED (MM/YYYY) 12. EMPLOYER PHONE EMPLOYER ADDRESS (NUMBER, STREET, CITY, STATE, ZIP/COUNTRY, AS APPLICABLE) RESIDENTIAL ADDRESSES FOR THE PAST 5 YEARS, STARTING WITH MOST RECENT. ENTER DATES IN MM/YYYY FORMAT:
Number and Street Name, City, State, ZIP/Country From (Date) To (Date)
15. OTHER RELEVANT IDENTIFYING INFORMATION (FEDERAL EMPLOYMENT, ARRESTS, ETC.) – INCLUDE DATES:
Fingerprinting - You will receive an email from HSPD12Admin with a subject line: “USAccess - Sponsorship complete.” Follow the
instructions in the email to select a place close to you Security Office at [email protected]	to be fingerprinted. If you have any questions, please cont or 202-435-7657.	act the Personnel
Applicant Certification I certify that the statements I have made on this form and all attached supporting documents are true, complete and correct, to the best of my knowledge.

5. HAVE YOU PREVIOUSLY USED A DIFFERENT NAME OR SPELLING OF YOUR NAME? YES NO LIST OTHER NAMES USED. ENTER DATES IN MMYYY FORMAT:

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;

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 XX/XX/XXXX. 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].