Personnel Evaluation Form Page 4

I acknowledge that I have read and understand the information and instructions, and that the

collection, maintenance, use, and disclosure of the information provided on this form is governed by

applicable provisions of the Privacy Act of 1974, section 552a of title 5 of the U.S. Code, as

amended, and other applicable law.

I acknowledge that my statements on this form, and any attachments to it, are true, complete, and

correct to the best of my knowledge and belief and are made in good faith, and that a knowing and

willful false statement on this form can be punished by fine or imprisonment or both. (See Section

1001 of Title 18, United States Code.)

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