Form 2181 C – Fill Out and Use This PDF

P r i v a c y A c t S t a t e m e n t : The collection of this information is authorized by 39 USC 404, 18 USC 3061, and 5 USC, App. 3. This authorization will be used to obtain information from organizations and individuals pertaining to your character, personal history, credit standing, educational claims, current or prior employment, military service, and other information which may be relevant and necessary to determine your fitness and suitability to perform services under contract with the Postal Service, including a security clearance and evaluation of your loyalty to the United States. This authorization does not consent to the collection of information by the Postal Service except as otherwise permitted by law. Nor does it waive any remedy you may have against the Postal Service in the event of a violation of the Privacy Act or other rights established by law. As a routine use, this information may be disclosed to an agency for which information is requested in the course of a background check; to an appropriate government agency, domestic or foreign, for law enforcement purposes; where pertinent, in a legal proceeding in which the USPS is a party or has an interest; to a government agency in order to obtain information relevant to a USPS decision concerning employment, security clearances, contracts, licenses, grants, permits or other benefits; to a government agency upon its request when relevant to its decision concerning employment, security clearances, security or suitability investigations, contracts, licenses, grants or other benefits; to a congressional office at your request; to an expert, consultant, or other person under contract with the USPS to fulfill an agency function; to th e F e d e ra l R e c o rd s C e n te r fo r s to ra g e ; to th e O ffic e o f Management and Budget for review of private relief legislation; to an

independent certified public accountant during an official audit of USPS finances; to an investigator, administrative judge or complaints e x a m i n e r a p p o i n t e d b y t h e E q u a l E m p l o y m e n t O p p o r t u n i t y Commission for investigation of a formal EEO complaint under 29 CFR 1614; to the Merit Systems Protection Board or Office of Special Counsel for proceedings or investigations involving personnel practices and other matters within their jurisdiction; and to a labor organization as required by the National Labor Relations Act; to an appropriate foreign or international law enforcement agency, an organization, or individual for investigative or prosecutorial purposes, to assist in crime prevention or detection, to obtain information relating to a pending investigation, trial or hearing, to obtain the cooperation of a witness or informant or to notify of the status of the case; to a party or his attorney to discuss settlement, plea bargaining, or discovery proceedings; to an agency or individual concerned with maintenance, extradition, or release of a person held in custody; to a foreign country pursuant to an international treaty, conventions, or executive agreement; to the public, news, media trade associations or organized groups if it is information of interest on accomplishments of the Postal Service or its employees; to a foreign country when apprehending and/or returning a fugitive to a jurisdiction seeking return; to American Insurance Association Index System members if it is information relating to accidents or injuries.

Completion of this form is voluntary; however, if consent to obtain this information is not given, it may have an adverse effect on your opportunities to perform services under contract with the USPS.

Applicant's Name (Last, First, Middle)

Mailing Address

Date of Birth (Month, Day, Year)

Home Phone Number

This constitutes my consent and authorization to the dis- closure or furnishing of any relevant and necessary infor- mation or records to any duly authorized official of the USPS by any person, corporation, agency, or associa- tion concerning my character, personal history, credit standing, educational claims, current or prior employ- ment, military service, and other information which may be relevant and necessary to determine my fitness and suitability to perform services under contract with the USPS.

This authorization is executed with full knowledge and understanding that the USPS will take measures to pro- tect the aforementioned information against unautho- rized disclosure to any parties not having a legitimate

need for it in the discharge of official business of the United States, or its agencies and instrumentalities.

I hereby RELEASE the aforementioned persons, corpo- rators, agencies, associations and their employees, agents and representatives from any and all liability for damages resulting from a decision by the USPS not to contract for my services on account of compliance with this authorization, except for any damages resulting from knowingly providing false or misleading information or records about me.

A copy of this authorization shall be as effective and val- id as the original. This authorization shall be valid for 12 months from the date it is signed.

Date Signed

Signature of Applicant