1600/10 Notice and Authorization for Consumer Reports

Federal Deposit Insurance Corporation

NOTICE AND AUTHORIZATION PERTAINING
TO CONSUMER REPORTS PURSUANT TO THE
FAIR CREDIT REPORTING ACT OF 1970,
15 U.S.C. § 1681, et seq.
PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820; 15 U.S.C. § 1681; and
Executive Order 9397 as amended. The FDIC will use this information to obtain one or more consumer reports as part of
a background investigation to determine whether you meet the required fitness and integrity standards for employment or
performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the
requested information in whole or in part may delay or prohibit any further consideration of you for employment or
performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state,
local or foreign agencies and law enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to
contractors, agents and other third parties as authorized by law and in accordance with any of the other routine uses
described in the FDIC Personnel Records (FDIC 30-64-0015) System of Records available at www.fdic.gov/about/
privacy/index. If you have questions or concerns about the collection or use of the information, you may contact the
FDIC's Chief Privacy Officer at Privacy@fdic.gov.

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FDIC 1600/10 (5-18)

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Federal Deposit Insurance Corporation

NOTICE AND AUTHORIZATION PERTAINING
TO CONSUMER REPORTS PURSUANT TO THE
FAIR CREDIT REPORTING ACT OF 1970,
15 U.S.C. § 1681, et seq.
INSTRUCTIONS: This form is to be completed by Applicants seeking employment or Contractor Personnel seeking
positions. Item 4. (Applicant/Contractor Personnel Signature) will require an ink (also known as wet) signature.

Executive Order 9397 (November 22, 1943) asks federal agencies to use Social Security Numbers (SSN) to help identify
individuals in agency records. Your SSN is therefore needed to keep records accurate, because other people may have
the same name. Providing your SSN is voluntary; however, failure to provide the requested information could result in
the FDIC receiving an erroneous credit report.
Please take notice that one or more consumer reports may be obtained for employment purposes. Because a
background investigation will be conducted as part of a determination of your fitness for employment, or for performance
under a contract, you are also entitled to request additional disclosures concerning the nature and scope of the
investigation.
By signing this form, you are giving consent to have your consumer reports furnished by consumer reporting agencies as
part of an investigation to determine your (1) fitness for federal employment, (2) clearance to perform contractual service,
and/or (3) security clearance or access. The information obtained may be re-disclosed to other federal agencies for the
above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law.
This authorization is valid for one (1) year from the date signed or upon my separation of employment/services from the
FDIC.

SECTION I - APPLICANT/CONTRACTOR PERSONNEL INFORMATION
1. Name

2. Last 4 of SSN

SECTION II - AUTHORIZATION AND SIGNATURE

I hereby authorize the FDIC to obtain such report(s) from any consumer-reporting agency for employment purposes.

3. Date

FDIC 1600/10 (5-18)

4. Applicant/Contractor Personnel Signature

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