Va Form 0710 - Authorization For Release Of Information
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1AUTHORIZATION 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 Security Office to obtain Credit Reports from the Credit
Bureau and other Consumer Reporting Agencies, Collection Agencies, and Retail Business Establishments
which hold financial and credit information.
The Security Office will not take adverse action against the subject of investigation, based in whole or in part
upon the results of the credit report. Should adverse action occur, the VA will provide a copy of the report
and a written description of the subject's rights as described by the FTC under Section 1681g (c)(3) of Title
15. Any information from the consumer report, in violation of any applicable equal employment opportunity
law or regulation, will not be used in the adjudication of the investigation.
I Authorize custodians of records and other sources of information pertaining to me to release such
information upon the request of the investigator, special agent, or other duly accredited representative of any
Federal agency authorized above regardless of any previous agreement to the contrary.
I Understand that the information released by records custodians and sources of information is for official
use by the Department of Veterans Affairs, Office of Security and Law Enforcement, only for the purposes
of the adjudication and establishment of eligibility/security clearance.
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.
(Sign in ink)
SIGNATURE OF EMPLOYEE
TYPE OR PRINT LEGIBLY FULL NAME
DATE SIGNED
(Include Area Code)
OTHER NAMES USED
HOME TELEPHONE NUMBER
(Include Street, City, State, and ZIP Code)
CURRENT ADDRESS
VA FORM
0710
MAY 1998
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