Attachment_E_-_FD-979a.pdf

FD-979a (9-9-04) FBI File Number:

Non-Personnel Consent to Release Information

To Whom It May Concern:

I hereby give consent to any authorized representative of the Federal Bureau of Investigation to obtain any information in your files pertaining to my academic, achievement, athletic, attendance, credit (including credit card and payment device numbers), disciplinary, employment, law enforcement (including, but not limited to, any record of charge, prosecution, or conviction for civil or criminal offenses), military, or professional license records (including any grievance records). I hereby direct each entity to which this form is presented to release such information upon request of the authorized recipient as described above, regardless of any other agreement or direction I may have made.

This consent is executed with full knowledge and understanding that the information is for the official use of the Federal Bureau of Investigation in connection with the determination of suitability for employment and/or eligibility for new or continued access to classified information of a current or prospective government employee with whom I am associated. Consent is granted for the Federal Bureau of Investigation to furnish such information as is described above to third parties in the course of fulfilling its official responsibilities.

Copies of this consent that show my signature are as valid as the original signed by me. This consent is valid for one (1) year from the date signed.

Signature (sign in ink)

Full Name (type or print clearly) Date Signed

Other Names Used Social Security Account No.

Signature of Parent or Guardian (if required)

Place of Birth Date of Birth

Signature of Witness

Name & Title of Witness

PRIVACY ACT STATEMENT

Authority: The collection of information requested by this form is authorized under Executive Order 10450, Security Requirements for Government Employees; Executive Order 12968, Access to Classified Information; and the Fair Credit Reporting Act, 15 U.S.C. §§1681 et seq. Providing requested information is voluntary; however, failure to furnish the requested information and consent may affect our ability to complete the determination of suitability for employment and/or eligibility for new or continued access to classified information of a current or prospective government employee with whom you are associated.

Principal Purpose: The information will be used principally to obtain such academic, achievement, athletic, attendance, credit, disciplinary, educational, employment, law enforcement, military, and professional license records as may be necessary to determine the suitability for employment and/or eligibility for new or continued access to classified information of a current or prospective government employee with whom you are associated. Your Social Security Account Number (SSAN) identifies you in most of the above-listed transactions. We will use your SSAN to accurately identify your records and to process investigations, inquiries, and/or determinations related to this consent.

Routine Uses: In addition to disclosures within the Department of Justice on a need-to-know basis, information reported on this form may be disclosed in accordance with all applicable routine uses as may be published at any time in the Federal Register, including all routine uses for the FBI Central Records System. These routine uses include the following disclosures: to potential sources in order to locate, seek, and obtain information or records pertaining to you; to any appropriate governmental authorities responsible for civil or criminal law enforcement, counterintelligence, or security matters to which the information may be relevant; to non-FBI employees performing Federal assignments; to courts or adjudicative bodies when the FBI considers it has an interest in the proceedings;

or as otherwise mandated by law, treaty, or Executive Order.

FBI/DOJ

Non-Personnel Consent to Release Information