Form 12333 – Fill Out and Use This PDF

Consent For Fingerprint Check

Part A

I hereby authorize any investigator, special agent, or other duly appointed representative of the authorized Federal agency conducting my background investigation to receive any criminal history record information pertaining to me, which may be in the files of any Federal, state or local criminal justice agency. I understand my fingerprint form may be provided to other Federal, state or local agencies in conjunction with the application process, and I consent to such disclosure.

Name (Last, first, middle initial) (Please print)

Privacy Act Statement

The Privacy Act Statement of 1974 requires that when we ask you for information, we state our legal right to do so, why we are asking for the information, and how it will be used. We must also tell you what could happen if you do not provide it and whether your response is voluntary, required to obtain a benefit or mandatory.

Our legal right to ask for the information is 5 USC 301, and Executive Order 9397. We are asking for this information to investigate your background and determine your suitability for employment.

Disclosure of the information may be made to Federal, state and local agencies, and judicial authorities as authorized by law. Violations or potential violations of law, whether civil, criminal or regulatory in nature may be reported to appropriate agencies that have the responsibility for investigating or prosecuting such violations or are charged with enforcing or implementing such laws.

Your failure to complete the pre-appointment/post-appointment information on this form may mean that the required information cannot be obtained to determine your suitability and/or conduct an investigation. Without this information, a determination as to your suitability for Federal employment cannot be made and may result in you not being considered for employment; or a determination may be made that you are unsuitable for your position.

Part B	Live Scan Screen Information

Name (Last, First, Middle) (Please spell out complete full Legal Name)

Middle Name (Full Legal Middle Name. Do not use initials. If no middle name, indicate by printing "NMN".

Maiden Name should be listed in Aliases block)

Last name			First name				Middle name
Social Security Number			Date of birth (mm/dd/yyyy)				Position applying for:
							Clerk	Revenue Agent
							Data Transcriber	TRR/TSS
Aliases (for example maiden name or other last names used)					Sex		Tax Examiner	Other (specify)
					Male	Female	Contact
							Representative
Race			Eye color (excluding colored contacts)				Hair color
A - Asian	W - White/Latino		BLK - Black		HAZ - Hazel		BAL - Bald	RED - Red
B - Black	U - Unknown		BLU - Blue		MAR - Maroon		BLK - Black	SDY - Sandy
I - Indian (Native American, Eskimo)			BRO - Brown		PNK - Pink		BLN - Blond	WHI - White
			GRN - Green		XXX - Unknown		BRO - Brown	XXX - Unknown
			GRY - Gray				GRY - Gray
Height (feet and inches)		Weight (pounds)	Place of Birth (City, State, Country - if born in Mexico or Canada include state or
			province where born)
Resident address (street number and name; do not use P.O. Box)

Form 12333 (Rev. 7-2011)

Catalog Number 28289L

publish.no.irs.gov

Department of the Treasury-Internal Revenue Service

Security Entry and Tracking System (SETS) Activity Log

	(For Personnel Office Use Only)
Name (Applicant/Employee)	Reason for fingerprinting*
EOD (or date entered new position)	POD

Business Unit (i.e. AWSS, SBSE, WAGE, etc.)

Live Scan number

Ink and Roll

SOI

SON

* If courtesy print - please FAX servicing personnel

office consent form within 24 hours

Fingerprints

Forms

Entered into Live

Entered into

Action

Date

Scan or SETS

Action

Date

SETS

(EE initials)

(EE initials)

FP Taken by:

EE Name

Investigation package EE

SOI

Phone number

Returned by EE

FP Taken by Courtesy Personnel

Office:

EE Name

Follow-up (if applicable)

SOI

Phone number

Review by QR

BIO entered into live scan by

SETS Applicant Record Built

Investigation initiated

Transmitted/Mailed

and type of investigation

SETS update not allowed

Return unaccept

Returned

Resubmitted

Resubmitted

CCT Received

Investigation complete/

Prior Investigation

New investigation not required

Date

Comments

Form 12333 (Rev. 7-2011)

Catalog Number 28289L

publish.no.irs.gov

Department of the Treasury-Internal Revenue Service