PFPA Form 1407 Internal Affairs Request

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

PENTAGON FORCE PROTECTION AGENCY
INTERNAL AFFAIRS REQUEST

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 Notice
Pentagon Force Protection Agency will not disclose information collected on this form to any source other than
what has been authorized under the Privacy Act of 1974 or 5 U.S. Code 552a for routine uses (i.e., information
verifying an applicant’s employment may be disclosed to a prospective Agency that require information obtained
in the completion of this form to help in the determination as to the individual’s fitness for federal employment in
the field of law enforcement) as identified in the system of records notice OPM/GOVT-5 at
http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article- View/Article/570737/opmgovt-5/. Your obligation to
respond is voluntary, but failure to provide requested information could impede processing.
1. To (Name of Employer)

2. From Recruitment Branch
a. Officer Signature:

b. Date:

The following person is an applicant with the Pentagon Force Protection Agency. The applicant listed your organization as a current or
former employer. As part of the applicant background investigation a more in depth investigation must be performed for those applicants
coming from a law enforcement background. Please provide a brief synopsis of any negative or disparaging information as it relates to
job performance and/or disciplinary actions. This will assist us in determining his/her suitability for employment with the Pentagon
Force Protection Agency. Please attach additional sheets as required. A signed “Authorization for Release of Information” is attached.
Our process is time sensitive and we would appreciate any assistance. Please fax your findings to (703) 695-0235. Thank you for your
time and consideration in this matter.

3. Applicant
a. Name:

b. Address:

4. Verification of Employment
a. Dates of Employment:

d. Date of Birth:

b. Eligible for Re-Hire:

Yes

No

5. Remarks
a. Disciplinary Actions (suspensions/reprimands/counseling, etc.):
b. General comments - Job Performance and Rating(s):
6. Employer Certification
a. Print Name:

b. Phone:

c. Position/Title

Signature:
Date Signed:
PFPA FORM 1407, April 2018

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FOR OFFICIAL USE ONLY – PRIVACY SENSITIVE
Any misuse or unauthorized disclosure can result in both civil and criminal penalties.