Attachment 017-Personal Identify Information (PII) Sheet.pdf

Fingerprint Check Only OR (select only one) Background Investigation/LincPass

(No LincPass required) (HSPD-12/LincPass Required)

The USDA Credential Matrix indicates that a performing non-employee requires a LincPass, or in some cases, a fingerprint check. The information collected on this Personal Identity Information (PII) sheet is required for both processes. This information is to be collected and transmitted in accordance with The Privacy Act of 1974.

Instructions: Enter the information below for the non-employee applicant. If form is incomplete or if required attachments are not included, package will not be processed and will be returned to Requestor.

*Required Attachments – if not included, form will not be processed and will be returned to Requestor

Finger Print Charts (2)

*Company/Organization Name/ :

number & ate

*Area/Location/Duty Station (of employee; city and state)

*USDA POC Name, Title, Address, and Telephone Number

*Sponsor Name, Address, and Telephone Number

*Name(s) of Individual to Receive Finger Print Results (AO and/or HR Liaison)

*Length of Appointment (NTE Date)

*Type of Investigation Required for ARS Position

*Position to Which Appointed *Existing Background Investigation? Yes/No/Don’t Know. If yes, enter the agency that conducted the investigation (e.g.

USDA, Treasury, Energy, etc.).

*Name (Last, First, Middle): Enter applicant's complete name as it appears on their government-issued ID (e.g. driver’s license or passport). If the information doesn’t match, the non-employee will encounter problems during enrollment and may have to reapply.

*Date of Birth (mm/dd/yyyy) *Place of Birth: City/State. If outside U.S., enter City/Country.

*Gender

*Social Security Number

*Country of Citizenship

*Home Address: Enter the full address as it appears on the applicant’s government-issued ID.

*Phone/Type (e.g. Business)

*E-mail Address (business e-mail preferred) Required for enrollment notification. If the applicant does not have a business email address, enter the address of the person who will manage enrollment activities, e.g. Security Officer or Supervisor.

Please PSS Staff Use Only Date Cleared:

Recipient:

BOTH

NACI