Attachment 15 DHS Form 11000 9.pdf
PDF 14 KB Posted
- Attached to
- Level II Armed Security Guards / DR-4827-NC Federal contract opportunity
- Solicitation number
- 70FBR426R00000001
- Issued by
- Federal Emergency Management Agency
About this file
This document is a Department of Homeland Security (DHS) Disclosure and Authorization form for consumer reports under the Fair Credit Reporting Act. The form authorizes DHS to obtain consumer/credit reports about an individual in connection with employment processes, including evaluating fitness for employment, promotion, reassignment, retention, or access to classified or sensitive information.
The form requires the individual to provide personal details such as signature, date, Social Security Number, assigned organization, street address, city, state, zip code, and email address. The Privacy Act section explains that while providing a Social Security Number is not mandatory, failure to do so may impede obtaining a credit report and potentially result in denial of access to classified or sensitive information. The form is identified as DHS Form 11000-9, with a date notation of 10/08 and 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 .