Attachment 6E_ VA0710.pdf
PDF 85 KB Posted
- Attached to
- Z1DA--NCO5 - MATOC II Federal contract opportunity
- Solicitation number
- 36C24524R0024
About this file
This document is an Authorization for Release of Information Protected Under the Fair Credit Reporting Act. It authorizes the Department of Veterans Affairs (VA) and its agents to obtain the signatory's credit reports from consumer or credit reporting agencies for employment purposes. The authorization is valid for 5 years or until the signatory's affiliation with the VA terminates, whichever is sooner. The information obtained may be disclosed to other federal agencies as permitted by law to determine the signatory's suitability and/or fitness for employment with the federal government.
The related federal contract opportunity is solicitation 36C24524R0024 for the NCO 5 MATOC II Multiple Site requirements, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 5. This is a civilian agency contract opportunity, but no additional details about the required products or services, response dates, pricing terms, or set asides are provided in the given documentation.
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Text version
AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE
I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
SIGNATURE OF EMPLOYEE (Sign in ink) TYPE OR PRINT LEGIBLY FULL NAME DATE SIGNED
OTHER NAMES USED HOME TELEPHONE NUMBER (Include Area Code)
CURRENT ADDRESS (Include Street, City, State, and ZIP Code)
VA FORM
OCT 2017 0710
..\logos\VA Form Bar-04(NEW LOGO).jpg Department of Veterans Affairs logo
AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 16 81)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE
I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
SIGNATURE OF EMPLOYEE (Sign in ink)
TYPE OR PRINT LEGIBLY FULL NAME
DATE SIGNED
OTHER NAMES USED
HOME TELEPHONE NUMBER (Include Area Code) CURRENT ADDRESS (Include Street, City, State, and ZIP Code)
VA FORM
OCT 2017
V A Form 0 7 1 0, OCTOBER 2017 VA Form 0710, AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
0710, Authorization, Release, Information, Protected, Fair, Credit, Reporting, Act Missie Vaccaro-Palomaki
MAY 1998
OCTOBER 2017
Trish Moore (07)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE.
I Authorize the Department of Veterans Affairs (V A), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows V A to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
V A is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
Signature of Employee (Sign in ink):
| TYPE OR PRINT LEGIBLY FULL NAME: |
| DATE SIGNED: |
| OTHER NAMES USED: |
| HOME TELEPHONE NUMBER (Include Area Code): |
| CURRENT ADDRESS (Include Street, City, State, and ZIP Code): |
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