Credit Check Form_Fillable.pdf

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SV0115-21
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United States Department of Justice

Disclosure and Authorization Pertaining to Consumer Reports

Pursuant to the Fair Credit Reporting Act (Title 15, U.S. Code, Section 1681)

This is a release for the Department of Justice to obtain one or more consumer/credit reports about you in connection with your application for Federal employment, during the course of your

Federal employment (including employment under contract), and/or connection with your security clearance or your access to classified information. One or more reports about you may be obtained for purposes of evaluating your fitness for employment, promotion, reassignment, retention, access to classified information, or other employment proposes.

I,_____________________________________________________, hereby authorize the Department of (Print Clearly) Justice to obtain, and I further instruct any consumer/credit reporting agency to release to DOJ, any such report(s) for the above purposes.

Signature

Date

D&B #

Company

DOJ-555

Revised Dec. 2004 Security and Emergency Planning Staff

Print Clearly:
Date:
Social Security Number:
Current Organization Assigned:

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