Section_J_Attachment 15 - DHS Form 11000-9.pdf

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)