OVQ_Release_Authorization.pdf

OVERSEAS VETTING QUESTIONNAIRE

AUTHORIZATION FOR RELEASE OF INFORMATION

Carefully read this authorization to release information about you, then sign and date it.

I Authorize any investigator, special agent, or other duly accredited representative of the United States Department of State (State) or other authorized Federal agency conducting my background investigation, reinvestigation, or ongoing evaluation of my eligibility for a security certification to obtain any information relating to my activities, conduct, and character from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or any other sources of information. This information may include, but is not limited to current and historic academic, residential, achievement, performance, attendance, disciplinary, employment, criminal, financial and credit information, and publicly available social media information. I authorize State or the authorized Federal agency conducting my investigation, reinvestigation, or ongoing evaluation of eligibility to disclose the record of my investigation or ongoing evaluation to the requesting agency for the purpose of making a determination of eligibility for a security certification.

I Understand that, for these purposes, publicly available social media information includes any electronic social media information that has been published or broadcast for public consumption, is available on request to the public, is accessible on-line to the public, is available to the public by subscription or purchase, or is otherwise lawfully accessible to the public. I further understand that this authorization does not require me to provide passwords; log into a private account; or take any action that would disclose non-publicly available social media information.

I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and date of birth with information in SSA records and provide the results of the match) to State or other Federal agency requesting or conducting my investigation for the purposes outlined above. I authorize SSA to provide explanatory information to State, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy.

I Understand that, for financial or lending institutions, medical institutions, hospitals, health care professionals, and other sources of information, separate specific releases may be needed, and I may be contacted for such releases at a later date.

I Authorize any investigator, special agent, or other duly accredited representative of State, the Federal Bureau of Investigation, the Department of Defense, the Department of Homeland Security, the Office of the Director or National Intelligence, the Office of Personnel Management, and any other authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of determining my eligibility for a security certification in accordance with 5 U.S.C. 9101 and Executive Order 13467, as amended. I understand that I may request a copy of such records as may be available to me under the law.

I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of State or any Federal agency authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by State only for the purposes provided in this Overseas Vetting Questionnaire, and that it may be disclosed only as authorized by law.

I Authorize the information to be used to conduct officially sanctioned and approved personnel security-related studies and analyses, which will be maintained in accordance with the Privacy Act, where applicable.

Photocopies of this authorization with my signature are valid. This authorization shall remain in effect so long as I am applying for or retain a security certification.

ID Type ID Number Date of Birth

Current Street Address Apt. # City/Town/Village State/Province/Territory Postal Code Country

Full Name Signature