1092 Personnel Security Data Form-Employee

PERSONNEL SECURITY DATA FORM
EMPLOYEE

OMB Control Number: XXXX-XXXX

National Credit Union Administration
Office of Continuity and Security Management

Last Name (Legal Family)
Social Security Number

Section A: Applicant Information

First Name (Legal Given)
Date of Birth MM/DD/YYYY

Middle (or NMN if none)

Place of Birth (City and State)

Other Names Used

Suffix

Country

Gender
M

Home Street Address (P.O. Box not accepted)

U.S Citizen?
Yes

Naturalized U.S. Citizen
Yes

No

Email Address

Physical Working Location

Central Office

Southern

No

Phone Number

Section B: Position and OHR Information

Position Description Number

Eastern

F

Office/Region Supporting (i.e. OCSM)

Dates of Internship, if applicable

NCUA OHR Points of Contact

Hiring Manager

Western

Field or Remote

NOTES

INSTRUCTIONS

Use: This form, in its entirety, must be submitted for any applicant requiring access to NCUA information, systems, or facilities.
Submission: A typed document is preferred to avoid delays and incorrect information. The applicant's full legal name is required. All
documentation must be submitted by the OHR/DMS representative to Personnel Security at PersonnelSecurity@NCUA.gov.
Privacy Act: AUTHORITY: 5 CFR § 731 and 736; Executive Order 13467; Executive Order 12968/SEAD 4. Disclosure of the
requested information is not mandatory. PURPOSE: To assist NCUA personnel in making an informed decision regarding suitability
for federal employment, fitness for contract employment, and/or granting of a security clearance. ROUTINE USE(S): In addition to the
disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act, the information contained herein may specifically be used
to document the outcome of adjudicative determination for the issuance of the HSPD-12 PIV card or the local agency access badge,
and to document the outcome of adjudicative determinations for suitability, fitness, and/or national security clearances. Contact
information is used for communication and authentication purposes. A complete list of Routine Uses is available at NCUA-1,
Personnel Access and Security System (81 FR 12748). EFFECTS OF NOT PROVIDING INFORMATION: The requested information
is needed to process your claim for employment and/or access. Disclosure of your personal information is voluntary. However, failure
to provide the requested information may result in removal from the hiring process. SORN: NCUA-1, Personnel Access and Security
System (81 FR 12748), Office of Personnel Management OPM/Central-9.
Paperwork Reduction Act Statement: This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget (OMB) control number. The OMB control number for this collection is XXXX-XXXX. We estimate that it will
take 10 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time
estimate, including suggestions for reducing this burden, or any other aspects of this collection of information to: NCUA, Office of
Continuity and Security Management,1775 Duke Street, Alexandria, VA 22314-3428.

NCUA 1092

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