VA Form 0710 AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED UNDER THE FAIR CREDIT REPORTING ACT TITLE 15 SECTION 1681.pdf
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- Attached to
- MSO-2020-CMP-0025 Bowling Green CBOC Federal contract opportunity
- Solicitation number
- 36C24920R0048
About this file
This document contains a VA form titled "AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED UNDER THE FAIR CREDIT REPORTING ACT" and details of a related federal contract opportunity for a Community Based Outpatient Clinic in Bowling Green, Kentucky. The VA form is used to authorize the agency to obtain an applicant's credit report for employment screening purposes and remains valid for five years or upon termination of affiliation with the VA. The related solicitation is for the construction of a new Bowling Green CBOC to be awarded through the Veterans Health Administration VISN 9. Offerors should respond by the listed solicitation number with the project to be delivered as an outpatient medical facility to serve veterans in the local area.
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Text version
AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE
I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
SIGNATURE OF EMPLOYEE (Sign in ink) TYPE OR PRINT LEGIBLY FULL NAME DATE SIGNED
OTHER NAMES USED HOME TELEPHONE NUMBER (Include Area Code)
CURRENT ADDRESS (Include Street, City, State, and ZIP Code)
VA FORM
OCT 2017 0710
..\logos\VA Form Bar-04(NEW LOGO).jpg Department of Veterans Affairs logo
AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 16 81)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE
I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
SIGNATURE OF EMPLOYEE (Sign in ink)
TYPE OR PRINT LEGIBLY FULL NAME
DATE SIGNED
OTHER NAMES USED
HOME TELEPHONE NUMBER (Include Area Code) CURRENT ADDRESS (Include Street, City, State, and ZIP Code)
VA FORM
OCT 2017
V A Form 0 7 1 0, OCTOBER 2017 VA Form 0710, AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
0710, Authorization, Release, Information, Protected, Fair, Credit, Reporting, Act Missie Vaccaro-Palomaki
MAY 1998
OCTOBER 2017
Trish Moore (07)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE.
I Authorize the Department of Veterans Affairs (V A), and authorized agents, to obtain my credit reports from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows V A to get one or more credit reports on you for employment. Should a decision to take any adverse action against you be made, based either in whole or in part on the credit report, you should know that the consumer or credit reporting agency that provided the report has played no role in the decision to take action.
V A is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal Government. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information about you and your credit history. This information may be disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is permitted by law.
I understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.
Signature of Employee (Sign in ink):
| TYPE OR PRINT LEGIBLY FULL NAME: |
| DATE SIGNED: |
| OTHER NAMES USED: |
| HOME TELEPHONE NUMBER (Include Area Code): |
| CURRENT ADDRESS (Include Street, City, State, and ZIP Code): |
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