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Pre-Employment Screening —

Authorization and Release

Applicant: Carefully read the following information before you complete and sign this form

Privacy Act Statement: Your information will be used to determine your suitability for employment. Collection is authorized by

39 U.S.C. 401, 410, 1001, 1005, and 1206. Providing the information is voluntary, but if it is not provided, you may not receive full

consideration. We may only disclose your information as follows: in relevant legal proceedings; to law enforcement when the

USPS

or requesting agency becomes aware of a violation of law; to a congressional ofﬁce at your request; to entities or individuals

under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local,

or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; and to the Merit

Systems Protection Board or Ofﬁce of Special Counsel. For more information regarding our privacy policy visit us at

Home Telephone Number (include area code)

Applicant’s Name (last, first, MI)

Date of Birth (MM/DD/YYYY)

Email Address

Other Names and Dates Used: List all the names you have used in the past, beginning with the most recent (#1) and working

backward (#2, #3, etc.). You must list all names you have ever used and the dates you used each name.

If you need more space to provide complete information, please continue on the reverse side of this form.

#1 Previous Name Used

From Month/Year (MM/YYYY)

To:

#2 Previous Name Used

From Month/Year (MM/YYYY)

To:

#3 Previous Name Used

From Month/Year (MM/YYYY)

To:

Where You Have Lived: List the places where you have lived, beginning with the most recent (#1) and working back 5 years

(#2, #3, ect.). You must account for all periods. Be sure to indicate the actual physical location of your residence; do not list a

permanent address when you were actually living at a school address. Use the two letter Postal Service™ abbreviation code for

the state. If you need more space to provide complete information, please continue on the reverse side of this form.

#1 From Month/Year (MM/YYYY) Street Address

County

State

City

ZIP Code™

To: Present

#2 From Month/Year (MM/YYYY) Street Address

County

State

City

ZIP Code

To:

ZIP Code

#3 From Month/Year (MM/YYYY) Street Address

City

County

State

To:

#4 From Month/Year (MM/YYYY) Street Address

City

County

State

ZIP Code

To:

#5 From Month/Year (MM/YYYY) Street Address

County

City

State

ZIP Code

To:

This constitutes my consent and authorization to the disclosure or furnishing of any relevant and necessary information or records

to any duly authorized employment ofﬁcial or to a contractor acting on behalf of the United States Postal Service by any person,

corporation, agency, or association concerning my character, employment, criminal records, driving records, or military service as

may be relevant and necessary for a determination of my suitability for employment with the United States Postal Service.

This authorization is executed with full knowledge and understanding that the United States Postal Service will take measures to

protect the mentioned information against unauthorized disclosure to any parties not having a legitimate need for it in the discharge

of ofﬁcial business of the United States, or its agencies and instrumentalities.

I hereby release the mentioned persons, corporations, agencies, associations and their employees, agents, and representatives

from any and all liability for damages resulting from a decision by the United States Postal Service not to employ me on account of

compliance, or any attempts at compliance with this authorization, except for any damages resulting from knowingly providing false

or misleading information or records about me.

A copy of this authorization is as effective and valid as the original. If hired, this authorization is valid for the duration of my

employment to demonstrate continued suitability for employment with the United States Postal Service.

Printed Name of Applicant

Date Signed

Signature of Applicant

2181-A,

PS Form

October 2015 (PSN 7530-02-000-7401)

Ps Form 2181-A -

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