Attachment 9-DHS Form 11000-9 Fair Credit Reporting Act.pdf
DHS Form PDF 55 KB Posted
- Attached to
- Student Support RFP Artesia, NM FLETC
- Solicitation number
- 70LART25RPFB00005
About this file
This is DHS Form 11000-9 (07/2023), a disclosure and authorization form pertaining to consumer reports pursuant to the Fair Credit Reporting Act. The form authorizes the Department of Homeland Security to obtain consumer/credit reports for employment purposes, including evaluating fitness for employment, promotion, reassignment, retention, or access to classified and sensitive but unclassified information.
The form requires the applicant's signature, date, and current organization assigned. It includes a Privacy Act Statement citing the Homeland Security Act of 2002 and Executive Order 9397 as authority, and notes that while providing information is voluntary, failure to do so may prevent fitness or suitability determination for employment or access to information. The form is exempt from Paperwork Reduction Act requirements per 5 C.F.R. 1320.3(h)(1).
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Other versions and copies of DHS Form 11000-9
| File | Revision | Posted | Attached to |
|---|---|---|---|
| Section_J_Attachment 15 - DHS Form 11000-9.pdf | Revision not stated | AMENDMENT 0003 _Sol_70FBR427R00000001 Level II Armed Guard Security Services | |
| 2.2.1 Attachment 15 - DHS Form 11000-9.pdf | Revision not stated | Level II Armed Security Guard Services- DR-4847-CTM | |
| Attachment 9-DHS Form 11000-9 Fair Credit Reporting Act.pdf | Revision not stated | Training Support Services | |
| Attachment 9-DHS Form 11000-9 Fair Credit Reporting Act.pdf | Revision not stated | Transportation Service FLETC Artesia, NM | |
| Exhibit_4_DHS_Form_11000-9.pdf | Revision not stated | Protective Security Officer Services | |
| Exhibit_4_DHS_Form_11000-9.pdf | Revision not stated | Protective Service Officers (PSO) at various locations in Maryland |
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Text version
DEPARTMENT OF HOMELAND SECURITY
DISCLOSURE AND AUTHORIZATION
PERTAINING TO CONSUMER REPORTS
PURSUANT TO THE FAIR CREDIT REPORTING ACT
DHS Form 11000-9 (07/2023)
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.
I, authorized the 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.
, hereby
Signature
Date
Current Organization Assigned
PRIVACY ACT STATEMENT
Authority: Homeland Security Act of 2002; 5 U.S.C. § 11001, “Enhanced Personnel Security Programs”; and Executive Order 9397, “Numbering System for Federal Accounts Relating to Individual Persons”.
Principle Purpose: To obtain consumer/credit reports in connection with an individual’s application for employment or ongoing employment with the DHS.
Routine Use(s): The information collected on this form may be disclosed as generally permitted under 5 U.S.C. §552a(b) of the Privacy Act of 1974, as amended. This includes using the information as necessary and authorized by the routine uses published in “DHS/ALL-023 Personnel Security Management System of Records”.
Disclosure: Providing this information is voluntary; however, failure to provide this information may prevent an individual's fitness or suitability determination for employment, promotion, reassignment, retention, and/or access to information.
PUBLIC BURDEN STATEMENT
In accordance with 5 C.F.R. 1320.3(h)(1), this information collection is exempt from the requirements of Public Law 104-13, "Paperwork Reduction Act of 1995".
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