2.2.1 Attachment 15 - DHS Form 11000-9.pdf
PDF 14 KB Posted
- Attached to
- Level II Armed Security Guard Services- DR-4847-CTM Federal contract opportunity
- Solicitation number
- 70FBR826Q00000004
About this file
This is a DHS Form 11000-9, a Disclosure and Authorization document pertaining to consumer reports under the Fair Credit Reporting Act. The form authorizes the Department of Homeland Security to obtain one or more consumer/credit reports about an individual in connection with employment application or ongoing employment with the Department. Reports may be obtained for employment purposes including evaluating fitness for employment, promotion, reassignment, retention, or access to classified information and sensitive unclassified information.
The form requires the individual's signature, date, Social Security Number, assigned organization, street address, city, state, zip code, and email address. The Privacy Act statement advises that authority for soliciting the Social Security Number is Executive Order 9397, and the SSN will be used to identify the individual when conducting or obtaining a credit report. While disclosure of the SSN is voluntary, failure to provide it may impede acquisition of a credit report and could result in denial of access to classified and/or sensitive unclassified information. The form is dated 10/08 with a FEMA edit from 2017.
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Text version
DEPARTMENT OF HOMELAND SECURITY
DISCLOSURE AND AUTHORIZATION
PERTAINING TO CONSUMER REPORTS
PURSUANT TO THE FAIR CREDIT REPORTING ACT
This is a release for the Department of Homeland Security to obtain one or more consumer/credit reports about you in connection with your application for employment or in the course of your employment with the Department. One or more reports about you may be obtained for employment purposes, including evaluating your fitness for employment, promotion, reassignment, retention, or access to classified information and/or sensitive, but unclassified information.
,hereby authorized the I, Department of Homeland Security to obtain such report(s) from any consumer/credit reporting agency for employment purposes. Copies of this authorization that show my signature are as valid as the original signed by me.
Signature
Date
Social Security Number
Organization Assigned
Street Address:_______________________________________________________________________
City:___________________________________________ State:_______ Zip Code :______________
Email Address: ______________________________________________________
The Privacy Act, 5 U.S.C. 552a, requires that federal agencies inform individuals, at the time information is solicited from them, whether the disclosure is mandatory or voluntary, by what authority such information is solicited, and what uses will be made of the information. You are hereby advised that authority for soliciting your Social Security Number (SSN) is Executive Order 9397. Your SSN will be used to identify you precisely when it is necessary to conduct and/or obtain a credit report on you. Although the disclosure of your SSN is not mandatory, your failure to do so may impede the acquisition of a credit report concerning you and possibly result in the denial of your being approved for access to classified and/or sensitive, but unclassified information.
DHS Form 11000-9 (10/08) (FEMA edit 2017)
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File details come from the government source that posted it. Updated .