2L_DOJ555_USDOJ_Disclosure.pdf

United States Department of Justice

Disclosure and Authorization Pertaining to Consumer Reports

Pursuant to the Fair Credit Reporting Act

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 employment; in the course of your employment with the Department; or in connection with your employment in a position for which a background investigation by the Department is required. 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.

I, ____________________________________________, hereby authorize the Department of Justice to obtain such report(s) from any consumer/credit reporting agency for employment purposes.

Signature

Date

Current Organization Assigned

DOJ-555

Revised Oct. 2008 Security and Emergency Planning Staff

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Privacy Act Notice

The Department of Justice is collecting this information for the purpose of determining your trustworthiness, suitability, eligibility and/or qualifications for initial or continued employment, access to sensitive or national security information, or to perform certain services requiring a background investigation. Authority for collecting this information includes 5 U.S.C. §§ 3301 and 3302; the Classified Information Procedures Act of 1980; and Executive Orders 10450 and 12968, as applicable. Providing this information is voluntary. However, failure to provide complete information may affect our ability to complete your investigation or complete it in a timely manner, which may affect your placement or employment prospects. This information is maintained in the system of records DOJ-006, Personnel Investigation and Security Clearance Records for the Department of Justice, 67 Fed. Reg. 59,864-02 (Sept. 24, 2002), as amended by 69 Fed. Reg. 65,224 (Nov. 10, 2004), and 72 Fed. Reg. 3410, (Jan. 25, 2007). This information may be disclosed, in accordance with published routine uses. Routine uses applicable to this system include disclosures to certain individuals in the following circumstances:

• Designated officers and employees of agencies, offices, and other establishments in the executive, legislative, and judicial branches of the Federal Government, in connection with the hiring or continued employment of an employee or contractor, the conduct of a suitability or security investigation of an employee or contractor, or the grant, renewal, suspension, or revocation of a security clearance, to the extent that the information is relevant and necessary to the hiring agency's decision;

• In the event that a record in this system, either alone or in conjunction with other information, indicates a violation or potential violation of law-- criminal, civil, or regulatory in nature--the relevant records may be referred to the appropriate federal, state, local, foreign, or tribal law enforcement authority or other appropriate agency charged with the responsibility for investigating or prosecuting such violation or charged with enforcing or implementing such law;

• Contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative agreement, or other assignment for the Federal government, when necessary to accomplish an agency function related to this system of records.

For a complete list of applicable routine uses, see the system of records notice listed above.

DOJ-555

Revised Oct. 2008 Security and Emergency Planning Staff