Form DOL-PIV-II Contract Employee Data Submission

OMB Control No. 1225-0xxx

Expiration Date: xx/xx/2xxx

I nstructions

The information collected on this form is used to determine suitability for the issuance of DOL credentials. You may be asked to complete this form at any time. Providing this information is voluntary; however, failure to submit this information may result in denial of a DOL credential. The information will be used to identify proof and register applicants as part of the Personal Identity Verification (PIV) process.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11"). Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

P rivacy Act Statement

The Department of Labor is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: The information collected on this form is used to determine suitability for the issuance of DOL credentials (PIV card). DOL and other agencies will use the information on the PIV card and may use some of the stored information about you to prove your identity and your right of access when you access federal facilities, computers, applications, or data. This information will be kept for as long as you have a valid PIV card. Use of the card is limited to that identified by the Government guidelines (HSPD-12 Directive noted above) and to that identified in the Privacy Act system of records notices that cover each system for the PIV Card process.

P ublic Burden Statement

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1225-0xxx. We estimate that it will take an average of twelve (12) minutes to complete this collection of information, including time for reviewing instructions, researching exiting data sources, and entering the data onto the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of the Chief Information Officer, Department of Labor, Room N-1301, 200 Constitution Avenue NW, Washington, DC 20210, Paperwork Reduction Project (1225-0xxx), Washington, DC 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE.

+	U.S. DEPARTMENT OF LABOR	Contract Employee Data Submission
		Date:	Friday, February 05, 2021

1. Contactor Company Information		2. COTR Information
Contractor Company Name		First Name				Last Name
3. Contract Employee Information
First Name	Last Name		Former Names				SSN (xxx-xx-xxxx)
			1. 2. 3.
Date of Birth (mm/dd/yyyy)	Place of Birth		Country of Citizenship
DOL HR Servicing Office				DOL Agency
DOL Facility Name	DOL Facility Street Address				City		State	Zip Code

Form No. DOL-PIV II

Revised: May 2007