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

NPS Form 10-2201B (Rev. 04/2018)
National Park Service

OMB Control No. 1024-0245
Expiration Date XX/XX/20XX

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

Check One

Check One

Alias

Maiden Name

Alias

Maiden Name

Nickname

Alias

Maiden Name

Nickname

3. Date of Birth (mm/dd/yyyy)

Nickname

4. Social Security Number

6. Current Occupation
8. Present Address

7. Employer Name
House Number, Street, Apt #
City

9. Previous Address

5. Home Telephone Number

State

Zip Code

State

Zip Code

House Number, Street, Apt #
City

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:

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NPS Form 10-2201B (Rev. 04/2018)
National Park Service

OMB Control No. 1024-0245
Expiration Date XX/XX/2019

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 preemployment 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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