Tsa Form 2811 – Fill Out and Use This PDF

Please read the instructions below before completing Form 2811, the Fair Credit Reporting Act

THE FOLLOWING ARE REQUIRED FIELDS THAT MUST BE COMPLETED:

•Full Name - Include your irst name, middle name, and last name. If you do not have a middle name write “NMN” for “no middle name.” Or if your middle name is an initial only, write “(IO)” for “initial only.”

•Mother’s Maiden Name - Please do not skip this box

•Social Security Number

•U.S. Citizenship

•Date of Birth

•Place of Birth – provide City/State if born in the U.S. or City/Country if born outside the U.S.

•Current Address

•City, State, Zip

•Signature

•Date Signed

THE FOLLOWING ARE FIELDS THAT MUST BE COMPLETED IF THESE CONDITIONS APPLY:

•County of Birth is a required ield if you were born in the U.S.

•Former Address is to be completed only if you have been living at your current address for less than two years.

DHS - Transportation Security Administration

Transportation Security Oficer Application Form

Fair Credit Reporting Act Authorization

INSTRUCTIONS: Carefully read this authorization to release information about you, then type or print legibly and complete all applicable sections. Return original completed form to TSA Ofice of Security, Personnel Security Division.

Information provided by you on this form will be furnished to a consumer reporting agency in order to obtain information in connection with an investigation to determine your (1) itness for Federal employment, (2) clearance to perform contractual

service for the Federal Government, and/or (3) security clearance or access. The information obtained may be disclosed to other Federal agencies for the above purposes and in fulillment of oficial responsibilities to the extent that the law

permits such disclosure.

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

If at current address less than 2 years, please enter former address.

Note: Please take notice that one or more consumer credit reports may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, as amended,15 U.S.C., § , et seq. Should a decision to take any adverse action against you be made based either in whole or in part on the consumer credit report, the consumer reporting agency that provided the report played no role in the agency’s decision to take such adverse action.

PRIVACY ACT STATEMENT: Authority: 49 U.S.C. § 114 (n); 15 U.S.C. § 1681b; E.O. 9397. Principal Purpose(s): To obtain a copy of your

credit report in order to determine your suitability for employment in the position for which you are being considered. Routine Use(s): This information will be shared with consumer reporting agencies for the purpose of obtaining your credit report, or for routine uses listed in the

applicable system of records notice. Disclosure: Disclosure of the requested information is voluntary in the sense that no criminal penalties

will follow from a failure to provide the information. However, failure to provide the requested information may affect your employment prospects, eligibility for continued employment, ability to obtain a security clearance, or ability to work on a government contract. Disclosure of your SSN is also voluntary, but failure to provide your SSN may result in a delay in determining your suitability for employment.

TSA Form 2811, February 2007

DHS - Transportation Security Administration

Transportation Security Oficer Application Form

Authorization for Release of Information

INSTRUCTIONS: Carefully read this authorization to release information about you, then type or print legibly and complete all applicable sections. Return original completed form to TSA Ofice of Security, Personnel Security Division.

I authorize the Transportation Security Administration (TSA), through its employees, agents, or contractors, to obtain any information relating to my activities from criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, or other relevant sources of information. This information may include, but is not limited to, any criminal history record information, and inancial and credit information.

I understand that the purpose of this authorization is to permit TSA to conduct a background investigation for the purpose of making a determination of suitability or eligibility for employment and/or a security clearance, or for work on a Government contract. I authorize the custodians of records and other sources of information pertaining to me to release such information upon request of TSA, regardless of any previous agreement to the contrary. I understand that the information released by custodians of records and other sources of information is for oficial use by the Federal

Government only for the purposes stated above. This information may be re-disclosed by the Government only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for ive (5) years from the date signed or upon the termination of my afiliation with the Federal Government,

whichever is sooner.

PRIVACY ACT STATEMENT: Authority: 49 U.S.C. § 114 (n); E.O. 9397. Principal Purpose(s): To establish that applicants and incumbents either employed by TSA or working under contract are suitable for the job and/or eligible for a public trust or sensitive position, and/or a security

clearance. Routine Use(s): This information may be shared with to any potential source from which information is requested in the course of this background investigation to the extent necessary to identify you, inform the source of the nature and purpose of the investigation, and to

identify the type of information, or for routine uses listed in the applicable system of records notice. Disclosure: Disclosure of the requested

information is voluntary in the sense that no criminal penalties will follow from a failure to provide the information. However, failure to provide the requested information may affect your employment prospects, eligibility for continued employment, ability to obtain a security clearance, or ability to work on a government contract. Disclosure of your SSN is also voluntary, but failure to provide your SSN may result in a delay in determining your suitability for employment.

TSA Form 2812, February 2007