USSS Citizens Academy Application_ICR_2024-03-07

OMB Control Number 1620-NEW
Expiration Date: xx/xx/xxxx

U.S. SECRET SERVICE

CITIZENS ACADEMY APPLICATION FORM
PERSONAL DATA:
Name
First

Middle

Date of Birth

Place of Birth

Last

Maiden
SSN

Race

HOME ADDRESS AND POINT OF CONTACT:
Address
Street
Home Phone

City
Work Phone

State

Zip

Cell Phone

E-mail Address
In the event of an emergency, please list the name and phone number of a relative or close associate
that can be contacted:

Name

Relationship

Phone

ADDITIONAL INFORMATION:
Employer/Job Title
Address
Street

City

State

Zip

Do you know anyone who currently works for the U.S. Secret Service? Who?

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OMB Control Number 1620-NEW

AUTHORIZATION TO CONDUCT LAW ENFORCEMENT CHECK
Have you ever been arrested?

Yes

No

Have you ever been charged with a felony offense?

Yes

No

If Yes, list details pertaining to the charge, including date, place, law enforcement agency, charge,
court, and disposition:

I hereby authorize the U.S. Secret Service to conduct a standard check of law enforcement records. I understand this check will
include, but not be limited to, any record of charges, prosecutions, or convictions for criminal or civil offenses. This check will be
used for the purpose of the U.S. Secret Service Citizens Academy application process. My consent is valid for three months from
the date authorized below. Any information obtained will be used for the purpose of providing clearance to participate in the U.S.
Secret Service Citizens Academy.

Full Name (typed or printed)

Full Name (Signature)

Date of Authorization
PRIVACY ACT STATEMENT

All information requested for access to our facility for the Citizens Academy event is collected under authority derived from 18 U.S.C. 3056 and
Executive Order 9397. The routine uses of information requested include referral to other Federal, State and Local agencies for determining
suitability for access to secure areas, and/or sensitive, unclassified material of the U.S. Secret Service. Submission of the information is
voluntary; however, failure to provide information requested may prohibit processing and cause denial of access to secure areas or sensitive
material protected by the U.S. Secret Service. Disclosure of your social security number is voluntary; however, the information is necessary to
identify and separate individuals with similar or identical names or initials. Refusal to disclose your social security number will inhibit access to
secured areas of the U.S. Secret Service. The System Of Records Notice (SORN) that covers this collection of information is DHS/ALL-023 Department of Homeland Security Personnel Security Management, which describes the Department's collection and maintenance of records
related to suitability determinations and to verify eligibility for access to classified information or assignment to a sensitive position. This SORN
was published in the Federal Register on February 23, 2010 (75 FR 8088).

CONSENT
Full Name (typed or printed)

Full Name (Signature)

Date of Authorization

PAPERWORK REDUCTION ACT STATEMENT
In accordance with 5 CFR 1320.5(b), an agency may not conduct or sponsor an information collection, and a person is not required to
respond to a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The
public reporting burden for this collection of information is estimated at 15 minutes per response, including the time for reviewing
instructions, completing the form, and submitting the form . Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to: U.S. Secret Service, Office of Strategic Planning and Policy,
Enterprise Policy Division, 245 Murray Lane SW, Building T-5, Mail Stop #8404, Washington, DC 20223; OMB Number 1620-New. Do not
mail your completed form to this address.

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