Fillable Printable Authorization To Obtain Credit Report

Authorization To Obtain Credit Report

AUTHORIZATION TO OBTAIN CREDIT REPORT

NAME OF EMPLOYEE (Please print or type)

SOCIAL SECURITY NUMBER

JR., II, ETC.

MIDDLE

FIRST

LAST

SIGNATURE OF EMPLOYEE DATE SIGNED

PRIVACY ACT NOTICE

The Fair Credit Reporting Act, as amended (15 U.S. C. § 1681, et seq.) allows GSA to get one or more credit reports on you for employment purposes. Should a

decision to take any adverse action against you be made, based ether in whole or in part on the credit report, you should know that the consumer or credit

reporting agency that provided the report has played no role in the decision to take action.

GSA is requesting an investigation to determine your(1) fitness for Federal employment, (2)clearance to perform contractual service for the Federal Government,

or (3) security clearance. The information in this authorization will be given to the consumer or credit reporting agency so that the agency will release information

about you and your credit history. This information may be redisclosed to other Federal agencies (for the above three purposes) and to fulfill official

responsibilities, to the extent that the disclosure is permitted by law.

Disclosure of your Social Security Number (SSN) is voluntary. We need your SSN to keep records accurate, because other people may have the same name.

Executive Order 9397 also asks Federal agencies to use the SSN to help identify individuals in agency records.

GENERAL SERVICE ADMINISTRATION

GSA FORM 3665 (5-98)

Prescribed by ADM P9732.1C

As part of qualifying for a GSA position or contract, I am undergoing a personal background investigation in order to receive a public trust

certification or national security clearance, or a periodic renewal certification or security clearance.

I hereby authorize GSA and its authorized agents to obtain my credit reports from any consumer or credit reporting agency for employment

purposes.