W9127827QA001_Attachment_1_SAM_Form_36_APRIL_2021_(FINAL)_.pdf

SAM FORM 36, APR 2021 PREVIOUS EDITIONS ARE OBSOLETE.

U.S. Army Corps of Engineers, Mobile District (SAM) QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS (Campground Attendants and Volunteers)

For use of this form, see EP/ER/EC 1130-2-550; the proponent agency is CESAM-OP-TR.

AGENCY USE ONLY:

Project: Park Attendant Volunteer Coordinator:

UIC: Volunteer Time Period: Less than 6 months More than 6 months

Branch of Service:

Fingerprints Submitted (Date): FEDEX Tracking:

Requesting Official:

Name Date Signature

PURPOSE: The Mobile District conducts background investigations to establish that applicants or incumbents either employed by the Government or working for the Government under contract, are suitable for the job. Information from this form is used primarily as the basis for this investigation.

Provision of this information is voluntary.

AUTHORITY: The Mobile District is authorized to ask for this information under Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code and parts 5, 731, and 736 of Title 5, Code of Federal Regulations.

PENALTIES FOR INACCURATE OR FALSE STATEMENTS: The U.S. Criminal Code, Title 18, Section 1001, provides that knowingly falsifying or concealing a material fact is a felony which may result in fines up to $10,000, and/or 5 years imprisonment, or both. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified information, and this remains a part of the permanent record for future placement.

DISCLOSURE OF INFORMATION: Our collection, maintenance, use and dissemination of your personally identifiable information gathered for our background investigation is governed by the Privacy Act (5 U.S.C. § 552a, as amended). The information you give us is for the purpose of determining your suitability to serve as a Campground Attendant or Volunteer and will be protected from misuse and unauthorized disclosure as provided by the Act.

SUBJECT INFORMATION:

(Mr./Mrs./etc.) First Name Middle Name or NMN Last Name (Jr./Sr./II ect.)

Date of Birth Place of Birth - City, State and Country

Primary Phone Number (Area code +)

Home

Cell Secondary Phone Number (Area code +)

Home

Cell E-mail Address

U.S. Citizen ? (Necessary Documentation to be provided under separate/secure cover.) Yes No

AUTHORIZATION:

I authorize any investigator, special agent, or duly accredited representative of the U.S. Army Corps of Engineers, Mobile District, conducting my background investigation to obtain any information relating to myself for said purpose. I understand that the information released to the authorized party is for official use only for the purposes provided herein. This authorization is valid for one (1) year from the date signed.

Full Name Date Signature

SOI: IPAC Code:SON:

SAM FORM 36, APR 2021

PREVIOUS EDITIONS ARE OBSOLETE.

U.S. Army Corps of Engineers, Mobile District (SAM) QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS (Campground Attendants and Volunteers) For use of this form, see EP/ER/EC 1130-2-550; the proponent agency is CESAM-OP-TR.

AGENCY USE ONLY:

Volunteer Time Period:

Requesting Official:

PURPOSE: The Mobile District conducts background investigations to establish that applicants or incumbents either employed by the Government or working for the Government under contract, are suitable for the job. Information from this form is used primarily as the basis for this investigation. Provision of this information is voluntary.

AUTHORITY: The Mobile District is authorized to ask for this information under Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code and parts 5, 731, and 736 of Title 5, Code of Federal Regulations.

PENALTIES FOR INACCURATE OR FALSE STATEMENTS: The U.S. Criminal Code, Title 18, Section 1001, provides that knowingly falsifying or concealing a material fact is a felony which may result in fines up to $10,000, and/or 5 years imprisonment, or both. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified information, and this remains a part of the permanent record for future placement.

DISCLOSURE OF INFORMATION: Our collection, maintenance, use and dissemination of your personally identifiable information gathered for our background investigation is governed by the Privacy Act (5 U.S.C. § 552a, as amended). The information you give us is for the purpose of determining your suitability to serve as a Campground Attendant or Volunteer and will be protected from misuse and unauthorized disclosure as provided by the Act.

SUBJECT INFORMATION:

U.S. Citizen ? (Necessary Documentation to be provided under separate/secure cover.)

AUTHORIZATION:

I authorize any investigator, special agent, or duly accredited representative of the U.S. Army Corps of Engineers, Mobile District, conducting my background investigation to obtain any information relating to myself for said purpose. I understand that the information released to the authorized party is for official use only for the purposes provided herein. This authorization is valid for one (1) year from the date signed.

2019-10-02 Forms Design Team

QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS

Darwin Chen last updat M.HERRICK SAM Form 36 APRIL 2021 QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS 20210405 darwin.chen@usace.army.mil