Form PC-0005 Peace Corps Questionaire for Peace Corps Volunteer Backg

Questionnaire for Peace Corps Volunteer Background Investigation

OMB Control Number: 0420-0001

PC-0005

Expires 07/31/2017

Peace Corps policy and federal law requires the completion of a background investigation before you can depart for service. The information you provide is a crucial step in initiating your background check.

Enter your full name below. If you have initials only, enter each initial in the appropriate field, skip one space, and type "(IO)" after the initial for INITIAL ONLY. If you are a "Sr.", "Jr.", "III", etc., skip one space after your Middle Name and enter the appropriate designation. If you have no middle name, enter "NMN" in the Middle Name field.

*Last Name:

*First Name:

*Middle Name:

*Date of Birth:

*Place of Birth: City

Place of Birth: County (if born outside of the U.S., leave blank)

*Place of Birth: State (if born outside of the U.S., select "N/A")

*Place of Birth: Country

*Social Security Number: (###-##-####)

Enter other names you have used and the dates (month and year) the names were used, such as maiden names, names by former marriages, aliases, nicknames, or former names changed legally or otherwise. Type "NEE" before maiden names.

*Have you ever used a different name? Yes No

*Sex: Male Female

Certification: I certify that all information given by me in this form is true and complete to the best of my knowledge and belief and is provided in good faith. I authorize this information to be provided to an investigator or other duly authorized representative of the Peace Corps for the purpose of undertaking a background investigation. I also authorize such investigator or representative to obtain information from the Office of Personnel Management, the Federal Bureau of Investigation, the Defense Security Service or any other relevant agency relating to my qualifications, eligibility or suitability for Peace Corps service or whether assignment to the Peace Corps would be consistent with the national interest.

*Name:

*Date:

Privacy Act Statement: The Peace Corps, an agency of the U.S. government, is required by the Privacy Act of 1974 (5 U.S.C. §552a) to advise you of the following information regarding this form. The Privacy Act addresses the federal government’s use of certain personal information in agency files.

1. This form is authorized by the Peace Corps Act (22 U.S.C. 2501 et seq.) as amended.

2. The information you provide will be used to determine whether you are qualified, eligible, and suitable to be a Peace Corps Volunteer. It will be used by the Peace Corps or a contractor to conduct a background investigation, which may include a check of records at the Office of Personnel Management, the Federal Bureau of Investigation, the Defense Security Service and other agencies which might have pertinent records relating to your activities. Signature on the form provides your consent for such a check.

3. C. This information may be used for the routine uses described in the Privacy Act, 5 U.S.C. 552a, and the Peace Corps' published Routine Uses, summarized in Peace Corps' System of Records. The Peace Corps asks for your Social Security number because it is required to conduct a background investigation.

4. Completion of this form is voluntary, but without it the Peace Corps will be unable to process your background investigation, which is a requirement for Volunteer service.

Paperwork Reduction Act Burden Statement: Public reporting burden for this information collection is estimated to average two minutes. This includes the time for reviewing instructions and completing the information. This is a voluntary information collection. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: the FOIA Officer, Peace Corps, 1111 20th Street NW, 2nd Floor, Washington, D.C. 20526.