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Application to serve on the
Community Bank Advisory Council
or Credit Union Advisory Council
OMB No: 3170-0037
Expiration: 07/31/2016
Thank you for your interest in a position as a representative on the Community
Bank Advisory Council or Credit Union Advisory Council of the Consumer Financial
Protection Bureau (CFPB). Any interested person may apply for membership on
the advisory council.
Please complete and submit this questionnaire as
part of the application and selection process for
the advisory group.
To evaluate potential sources of conflicts of interest,
the Bureau will ask potential candidates to provide
information related to financial holdings and/or
professional affiliations, and to allow the Bureau
to perform a background check. CFPB will use the
information you provide only for these purposes or
other purposes authorized by law, or as outlined
under the attached Privacy Act Statement. The
Bureau will not review applications and will not
answer questions from internal or external parties
regarding applications until the application period
has closed.
A complete application packet must include:
1. A recommendation letter from a third party
describing the applicant’s interests and
qualifications to serve on the Board or Council;
2. A cover letter explaining your interest and
qualifications.
3. A résumé or curriculum vitae for the applicant;
4. A complete application; and
5. A typed signature which will serve as an
electronic signature.
The Bureau will not entertain applications of
federally registered lobbyists and individuals who
have been convicted of a felony for a position on the
Board and Councils.
Only complete applications will be given
consideration for review of membership on the
Board and Councils.
Consumer Financial
Protection Bureau
1 of 11
ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
General information
1
Credit Union
Advisory Council
Community Bank
Advisory Council
Select advisory group to which you
are applying to be a representative
* Choose one
2
Please provide
your personal
information
FIRST NAME
* Select all that
apply
EMAIL
LAST NAME
M.I.
POSITION/TITLE
HOW LONG AT EMPLOYER
YR
EMPLOYER
MO
EMPLOYER‘S ADDRESS
CITY
STATE
WORK PHONE
CELL PHONE
PLACE OF BIRTH
DATE OF BIRTH
ZIP CODE
RACE/ETHNICITY
WHITE
BLACK, AFRICAN AMERICAN
HISPANIC, LATINO
AMERICAN INDIAN, ALASKA NATIVE
ASIAN AMERICAN, PACIFIC ISLANDER
GENDER
MALE
FEMALE
PREFER NOT TO ANSWER
RECOMMENDER NAME (LAST, FIRST, MI)
Consumer Financial
Protection Bureau
OTHER
ORGANIZATION
2 of 11
ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Experience
3
4
5
List your business
or professional
experience not
listed on your
résumé/CV
Identify the
statutory
membership
category that is
most applicable
to you
Consumer protection
Financial services
Community development
Fair lending and civil rights
Consumer financial products or
services
Depository institution primarily
serving underserved communities
* Choose one
Representing communities that
have been significantly impacted
by higher-priced mortgage loan
Other
What are the
products that your
institution offers
Card Services (Credit cards,
Debit cards, and Prepaid cards)
Consumer Loans (Collateral Loans,
Debt consolidation, Home Equity
Lines, Personal Loans/Small Dollar,
Overdraft Protection, Personal Lines
of Credit)
Checking & Savings
Commercial Banking
Loans (Auto Loans, Boat Loans,
RV Loans, Student Loans)
6
Credit reporting, cards, payments
Mobile banking
Mortgages
Mobile payments
Wealth Management (Bonds,
CD’s, Money market, Stock)
Other
What is your institution’s asset size
$
Ex: 3.5 million
Consumer Financial
Protection Bureau
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ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Experience (continued)
7
8
List other affiliations and/or
service as a community leader that
would benefit you in your role as a
member of the advisory group
List any Federal advisory committee
or any board on which you are
currently a member and the number
of years you have served on that
committee or board
Consumer Financial
Protection Bureau
4 of 11
ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Personal history
9
10
Are you a US citizen?
YES
NO
If no - are you a permanent resident (i.e. possess a green card)?
YES
NO
Have you ever been convicted of a felony (a felony is defined as any violation of
law punishable by imprisonment longer than one year)?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
If yes - please explain on the attached continuation sheet.
11
Have you been a party to a civil or criminal action involving a financial institution
or service provider?
If yes - please explain on the attached continuation sheet.
12
Are you now or have you in the last year been subject to the registration and
reporting requirements of the Lobbying Disclosure Act (2 U.S.C. 1605)?
If yes - please explain on the attached continuation sheet.
13
14
Are you currently engaged in any business before the CFPB?
If yes - please explain on the attached continuation sheet.
Have you failed to pay any tax, penalty, or interest liability during the current or
last three calendar years within forty-five (45) days of the date of which the IRS
gave notice of the amount due and request for payment?
If yes - please explain on the attached continuation sheet.
15
Have you now or ever been under investigation by the IRS for possible
criminal offenses?
If yes - please explain on the attached continuation sheet.
Consumer Financial
Protection Bureau
5 of 11
ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Continuation sheet to form
If you need more space for an answer, use this sheet. Please number each answer to correspond to the
number on this form. When you have completed your answers, attach to this form.
FIRST NAME
LAST NAME
M.I.
CONTINUATION FIELD (IF NEEDED)
Consumer Financial
Protection Bureau
6 of 11
ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Affiliations, representations, and/or positions with boards,
advisory councils, or similar groups
List all positions and relationships you currently
hold or held at any time during the past two
years, whether or not you were compensated and
whether or not you currently hold that position.
Positions include an officer, director, employee,
trustee, general partner, proprietor, representative,
executor, member, or consultant of any of the
following:
§§ Corporation, partnership, trust, or other
business entity
§§ Non-profit or volunteer organization
§§ Educational institution
§§ Any government or industry advisory board
or council
Do not list any position with a:
§§ Religious entity
§§ Social entity
§§ Fraternal entity
§§ Political entity
§§ Any position held by your spouse or
dependent child
List all relationships outside your current employer,
in which you represent the interests of a party, or
you or your affiliates receive from a party a fee,
income, or any other benefit from a party, if the
information is not listed on your résumé/CV.
Positions you hold or have held
1
ORGANIZATION
CITY
TYPE OF ORGANIZATION
POSITION
STATE
YEARS HELD
BRIEF DESCRIPTION
Consumer Financial
Protection Bureau
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ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Positions you hold or have held (continued)
2
ORGANIZATION
CITY
TYPE OF ORGANIZATION
POSITION
STATE
YEARS HELD
BRIEF DESCRIPTION
3
ORGANIZATION
CITY
TYPE OF ORGANIZATION
POSITION
STATE
YEARS HELD
BRIEF DESCRIPTION
4
ORGANIZATION
CITY
TYPE OF ORGANIZATION
POSITION
STATE
YEARS HELD
BRIEF DESCRIPTION
Consumer Financial
Protection Bureau
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ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Positions you hold or have held (continued)
5
ORGANIZATION
CITY
TYPE OF ORGANIZATION
POSITION
STATE
YEARS HELD
BRIEF DESCRIPTION
6
ORGANIZATION
CITY
TYPE OF ORGANIZATION
POSITION
STATE
YEARS HELD
BRIEF DESCRIPTION
7
ORGANIZATION
CITY
TYPE OF ORGANIZATION
POSITION
STATE
YEARS HELD
BRIEF DESCRIPTION
Consumer Financial
Protection Bureau
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ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Privacy Act Statement
The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011, 1012, 1014,
codified at 12 U.S.C. §§ 5491, 5492, 5494. Providing your identifying information is voluntary, but not doing so
may result in non-selection of a prospective advisory board, body, panel, committee, or other similar group
membership. The Bureau has a special interest in ensuring that women, minority groups, and individuals with
disabilities are adequately represented on the Board and Councils, and therefore, encourages applications
from qualified candidates from these groups. In furtherance of this interest, the Bureau invites applicants
to the Board and Councils to voluntarily self-identify their race or ethnicity. Submission of this information
is voluntary and refusal to provide it will not disqualify you from consideration for service on the Board or
Councils. The information obtained will be kept confidential and will only be used for internal management
purposes. There have been occasions when members of the public and/or Congress have requested
information regarding the demographic composition of the Board and Councils. If the Bureau receives and
responds to such a request, data provided will not identify any specific individual.”
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, a Federal 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 OMB control number for this collection is 3170-0037. It expires on 12/30/2015. The time required
to complete this information collection is estimated to average approximately 60 minutes per response.
Responding to this information collection is voluntary; however, a completed application is required for
an LEA to be considered for participation in the TTI. Comments regarding this collection of information,
including the estimated response time, suggestions for improving the usefulness of the information, or
suggestions for reducing the burden to respond to this collection should be submitted to Bureau at the
Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G Street NW, Washington, DC 20552,
or by email to CFPB_PRA@cfpb.gov.
The Bureau will not disclose any personally identifiable information collected except to the extent that it is
required to do so by law and as provided in the Privacy Act Statement listed below. Additionally, the Bureau
will treat the information collected consistent with its confidentiality regulations at 12 C.F.R. Part 1070, et seq.
Consumer Financial
Protection Bureau
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ADVISORY GROUP APPLICATION
OMB No: 3170-0037
Expiration: 07/31/2016
Signature
16
I certify that the statements I have made on this form and all attached statements are true,
complete, and correct to the best of my knowledge.
* Typing your name works as your signature.
SIGNATURE
DATE
Please note the following before submission:
§§ We strongly encourage electronic submission.
§§ Once you have completed the application
save the document as “LASTNAME_
FIRSTNAME_ DATE”. Once saved please click
the blue “Submit application” button below.
If you experience issues with the submit
function, please email the application, letter
of recommendation and your resume to
CFPB_BoardandCouncilapps@cfpb.gov.
§§ To complete the application package, you must
also attach a copy of your cover letter, résumé/
CV and one (1) letter of recommendation. If
you prefer not to submit electronically, please
mail your complete application package, which
includes this form as well as a copy of your
cover letter, résumé/CV and one (1) letter of
recommendation, to:
Attn: Advisory Board and Council Office
Consumer Financial Protection Bureau
1275 1st Street NE, Washington, DC 20002.
§§ Applications submitted electronically must
be received on or before 5:00 p.m. EST
February 28, 2017.
Attach necessary and/or required
documents to this application
§§ Cover Letter
§§ Resume
§§ Letter of Recommendation
To attach files, click on the attach file button
below. You can upload multiple files, but
only one file can be attached per click.
To confirm that your files have attached
properly follow the navigation path below:
View > Show/Hide > Navigation Panes >
Attachments
Attach file
Save the pdf application before submitting
* Submission will be sent via email
Submit application
§§ Mailed applications must be postmarked on or
before 5:00 p.m. EST February 28, 2017.
Consumer Financial
Protection Bureau
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| File Type | application/pdf |
| File Title | CFPB Community Bank Advisory or Credit Union Advisory Council application |
| Author | Consumer Financial Protection Bureau |
| File Modified | 2016-04-06 |
| File Created | 2016-04-06 |