ATCH-6_50310222R0007-Fingerprint Form.pdf

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U.S. Securities and Exchange Commission

Personnel Security Operations Branch

Fingerprint Privacy Act Advisement

Purpose As an SEC appointee with a conditional offer, employee, contractor, student, or other person requesting access to SEC facilities or information, who is the subject of a national fingerprint-based criminal history records check, you have certain rights with respect to the collection and use of your fingerprints and to the accuracy of the information obtained from the check.

Acknowledgment I am hereby advised that my fingerprints will be used to check the Criminal History Record Information (CHRI) of the Federal Bureau of Investigation (FBI). I acknowledge by my signature below that I have been provided with the Privacy Act Statement, located on the second page of this form, prior to the submission of my fingerprints and associated personal information.

If the CHRI sent to the SEC by the FBI based on a check of my fingerprints shows a criminal history, the officials making a determination of my fitness or suitability for employment and/or national security decision must provide me with an opportunity to complete or challenge the accuracy of the information in the Record. I understand that I may submit a challenge request directly to the FBI at https://www.edo.cjis.gov or by sending the challenge request in writing to the FBI at FBI CJIS Division, Attention: Criminal History Analysis Team 1, 1000 Custer Hollow Road, Clarksburg, WV 26306.

I understand that the SEC will not take adverse action against me, based in whole or in part upon the CHRI, without first providing access to a copy of the CHRI. I will further be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny fitness or suitability, or reach an unfavorable national security decision based on information in the criminal history record.

Copies of this acknowledgment that show my signature are as valid as the original. This acknowledgment is valid until the termination of my affiliation with the SEC.

1. Name (Last/Family) 2. First (Given) 3. Middle (or NMN) 4. Other Names Used 5. Suffix

6. Home Street Address

7. City 8. State 9. Zip Code 10. Phone Number

Signature (full name in ink) Date Signed (mm/dd/yyyy)

Note: The officials receiving the CHRI will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation, or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.

v.1 09/2018

Privacy Act Statement

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L.

92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by

NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.