Dhs Form 11000-9 - Disclosure And Authorization Pertaining To Consumer Reports

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U. S. Department of Homeland Security
DISCLOSURE AND AUTHORIZATION
PERTAINING TO CONSUMER REPORTS
PURSUANT TO THE FAIR CREDIT REPORTING ACT
This is a release for the U. S. Department of Homeland Security to obtain one or
more consumer/credit reports about you in connection with your application for
employment or in the course of your employment with the Department. 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 and/or sensitive, but unclassified information.
I, _________________________________________________________, hereby
authorize the U. S. Department of Homeland Security to obtain such report(s) from
any consumer/credit reporting agency for employment purposes. Copies of this
authorization that show my signature are as valid as the original signed by me.
___________________________________
Signature
___________________________________
Date
___________________________________
Social Security Number
___________________________________
Current Organization Assigned
The Privacy Act, 5 U.S.C. 552a, requires that federal agencies inform individuals; at the time information is
solicited from them, whether the disclosure is mandatory or voluntary, by what authority such information is
solicited, and what uses will be made of the information. You are hereby advised that authority for soliciting your
Social Security Number (SSN) is Executive Order 9397. Your SSN will be used to identify you precisely when it is
necessary to conduct and/or obtain a credit report on you. Although the disclosure of your SSN is not mandatory,
your failure to do so may impede the acquisition of a credit report concerning you and possibly result in the denial of
your being approved for access to classified and/or sensitive, but unclassified information.
DHS Form 11000-9 (10-03)

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