TENNESSEE VALLEY AUTHORITYmulti.tva.gov/contractor/forms/tva/TVA_Personal_History... · tva 40932...
Transcript of TENNESSEE VALLEY AUTHORITYmulti.tva.gov/contractor/forms/tva/TVA_Personal_History... · tva 40932...
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TVA 40932 (BLUE), INI / UPA / R1Y (12-31-2012) RESTRICTED INFORMATION Page 1 of 26
TENNESSEEVALLEYAUTHORITYNUCLEARPOWERGROUP
PERSONALHISTORYQUESTIONNAIRE(PHQ)
TVALOCATION: BrownsFerry Sequoyah WattsBar
Corporate Bellefonte
Name:
SSN:
Employer:
TodaysDate:
Ifyouhaveneverheldunescortedaccess,oryourlastaccesswasover3yearsago;orifyourlastunescortedaccesswas
deniedorterminatedunfavorably,checkhere: INITIAL
Ifyourlastunescortedaccessendedover365daysago,butlessthan3yrs,checkhere: UPDATE
Ifyourlastunescortedaccessendedover30daysago,butlessthan365days,checkhere: R1Y
**NOTE:Ifyourlastunescortedaccessendedlessthan31daysago,orifyoucurrentlyholdunescortedaccessatanothernuclearpowerplant,pleaseseePlantAccessfordifferentpaperwork.
Dateyoulastheldaccess:
Plantwhereyoulastheldaccess:
TVAUSEONLY: DATEFINGERPRINTSSUBMITTED:
PreHire TVA C/VDatehired:
CriticalGroup
YES NO
BIAgencysentto: DateSent:
ScannedtoAgency FaxedtoAgency
ScannedtoNAS FaxedtoNAS
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AllinformationprovidedwillbetreatedasPERSONALCONFIDENTIALandobservedonlybypersonswithanauthorizedNEEDTOKNOW,orinaccordancewithapplicablelaw.
InordertomeettherequirementsoftheNuclearRegulatoryCommission(NRC)theTennesseeValleyAuthorityNuclearPowerGroup(TVANPG),towhichyouareapplyingforunescortedaccessauthorization(UAA),unescortedaccess(UA)and/oraccesstosafeguardsinformationrequiresthatyouconsenttoundergoabackgroundscreeningprocess.Thepurposeofthescreeningprocessistodetermineyourtrustworthinessandreliabilitytoworkwithintheprotectedandvitalareasofanuclearpowerplant(NPP).InformationfromthisformwillbeusedtoconductabackgroundinvestigationforaccessauthorizationpurposesasrequiredbytheNRC.Youmustprovideallinformationrequestedinacompleteandaccuratemanner.Yoursignatureonthedocumentisyourcertificationthattheinformationyouhaveprovidediscompleteandcorrect.ProvidingdeliberateorwillfulmisleadingstatementstoanyNPPwiththeintenttogainaccessisaviolationofFederalregulations.Anymisrepresentation,deliberatemisstatement,falsificationorwillfulomissionmayconstitutecausefordenialorrevocationofUAA/UAand/oraccesstosafeguardsinformation.Failuretoreportandlistreasonsforanyprevioussuspension,revocationordenialofUAA/UAand/oraccesstosafeguardsinformationataNPPorotherentitysubjecttoeithertheNRCaccessauthorization,FFDorSafeguardsInformationregulationsmaybesufficientcausefordenialorrevocationofUAA/UAand/oraccesstosafeguardsinformation.IfsuchaninstanceisdetectedtheplantisrequiredtoadvisetheNRC.TheNRCmayinvestigateyouand,ifappropriate,criminalandcivilsanctionsmaybeimposedagainstyouifdeemedmaterialbytheNRC.Whensuchinstanceshavepreviouslyoccurred,theresulthasbeenalengthy(fiveyear)orpermanentexclusionfromworkatnuclearpowerplantsintheUnitedStates.
Thefactsconcerningyourcriminalhistoryorfitnessfordutyrecordmaybesubjecttointerpretationduetovaryingcategorizationsofsimilaroffensesbetweenstates.Itisthereforerequiredthatyoudiscloseallinformationthathasanypotentialforbeingconsideredasderogatorytominimizethelikelihoodofdiscrepanciesbetweentheinformationyouprovidedandthatobtainedfromothersources.AllinformationrequestedisneededforthepurposeestablishedbytheNRCregulationorOrders.ResultsoftheinvestigationwillbeavailableasspecifiedinyoursignedConsentform,toentitiesauthorizedbytheNRCpursuanttoUAA/UA,FFDandSafeguardsInformationregulations. InsomeofthesectionsofthePersonalHistoryQuestionnaire(PHQ)youarerequiredtoprovideyourpersonalinformation;inothersectionsyouwillberequiredtoacknowledgethatyouunderstandcertainongoingrequirementsorpersonalresponsibilities.Theinformationrequestedmayincludeanyorallofthefollowingtopics:verificationofidentify,selfdisclosuredata,employment/unemploymenthistory(includingmilitaryserviceand/oreducationinlieuofemployment),criminalhistory,credithistory,characterreferences,residences,andfitnessfordutyhistory.Whennotinuse,yourwritteninformationisstoredinasecureenvironment,whichmayincludebeingelectronicallyplacedinasecuredatabase,topreventunauthorizeddisclosureofpersonalinformation.
InformationfromthisformwillbeusedtoconductabackgroundinvestigationforaccessauthorizationpurposesasrequiredbytheNuclearRegulatoryCommission(NRC).Theinformationyouareaskedtoprovideisspecific,explicitpersonalhistoryinformationincluding:workhistoryandlocations,personalreferences,criminalhistory,andpsychologicalandfitnessfordutyhistory.Youmustprovideallinformationrequestedincompletingthisdocument.NoinformationisrequestedthatisnotneededforthepurposeestablishedbyregulationtoevaluateyourtrustworthinessandreliabilityforUAataNPP.
YOUAREREQUIREDTOREPORTANYLEGALACTIONSBETWEENSIGNINGTHISPHQANDBEINGGRANTED
UNESCORTEDACCESSAUTHORIZATION/UNESCORTEDACCESS.
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Unlessotherwiseinstructed,youarerequiredtocompleteallportionsofthisPHQtobeconsideredforUAA/UAataTVAsite.Pleasetypeorprint(useblackink)thespecificanswerstoallquestionsandrequestsforinformation.Singlelineoutandinitialmistakes.Write"None"orN/Awhenthequestionisnotapplicable.Somequestionsarefollowedbyrequestsforadditionaldata.Enteralldatesintheformattwodigitmonth,twodigitdayandfourdigityear(MM/DD/YYYY).AttachadditionalpagestothePHQifthelengthofanexplanationexceedsthespaceprovided.Aftercompleting,reviewthequestionnairetoensuretherearenoomissionsandyourprintednameandsocialsecuritynumberareincludedoneachpage.WhenaskedYes/No,circleorchecktheapplicableresponse.
IhavereadandunderstandallinstructionsforcompletingthisPHQ ApplicantsSignature
HaveyoueverappliedfororbeengrantedUAA/UAataNPP? YesNoIfYes,lastUAA/UAwasterminatedFavorableorUnfavorable(CircleOne)at on:
PlantName DateHaveyoueverappliedfororbeengrantedaccesstoaNPPunderconstruction? YesNoIfYes,lastperiodofaccesswasterminated FavorableorUnfavorable(CircleOne)at on:
PlantName DateHaveyoueverappliedfororbeengrantedaccesstoSafeguardsInformationataNPPorNPPunderconstruction?YesNoIfYes,lastperiodofSafeguardsAccesswasterminated FavorableorUnfavorable(CircleOne)at on:
PlantName Date NRCESCALATEDENFORCEMENTACTIONNote:Occasionally,theNRCtakesenforcementactionagainstindividualsworkingundertheNRCsjurisdiction.WhentheNRClosesreasonableassurancethatanindividualiswillingorabletocomplywithNRCrequirements,typicallydemonstratedbydeliberatemisconduct,theagencymayissueanenforcementorderthatincludesaprohibitionagainstallorsomeformsofNRClicensedactivities.Inaddition,theNRCmayengageinalternativedisputeresolutionwithanindividualwhotheNRCbelieveshaswillfullyviolatedNRCrequirements.Throughalternativedisputeresolution,theNRCmayissueaconfirmatoryorderthatincludesanagreeduponperiodofprohibitionfromallorsometypesofNRClicensedactivities.Inlesssignificantcases,theagencymayissueanoticeofviolationtoanindividual. HaveyoueverbeenissuedanNRCEscalatedEnforcementAction? YesNo(CircleOne)Ifyes,pleaseprovidedetails.
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SECTIONIPERSONALDATAProvidepersonalinformationinblanksprovided.Ensurethatthetelephonenumberyouprovideiscurrentintheeventyouneedtobecontactedforclarificationorforadditionalinformation,ifnecessary. Writelegiblyplease.
Name: , Last First Middle Sr,Jr,III
OtherNamesUsed: (Maiden,previousmarriages,aliases,nicknamesandwhenused.)
USSSN(SocialSecurity): BirthDate: / /
PermanentAddress: , , NumberandStreet City State Zip
TemporaryAddress: , , (Ifapplicable) NumberandStreet City State Zip
HomePhone: ( ) CellPhone: ( )
Daytime/LocalPhone: ( ) EMailAddress:
BirthPlace:City: State: Country: USA Other:
PERSONALDESCRIPTION:
EyeColor HairColor Height(ft./inch) Weight(lbs) Sex:M/F Race
AreyouaU.S.citizen? Yes No IfNo,whatisyourcountryofcitizenship?
IfyouwereNOTbornintheUnitedStates,providetheapplicableinformationspecifiedbelow:
DateandPortofEntryintoUS: / / , DateofEntry PortofEntry(City) (State)
Nameattimeofentry AlienRegistrationNumber NaturalizationNumber
/ / VisaType VisaNumber ExpirationDate
IfyoudonthaveaUSSSN,providealternatevalid(notexpired)governmentissuedidentification: IdentificationNumber/Type Source(e.g.,Passport)
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SECTIONIPERSONALDATA(contd.)
U.S.DRIVERSLICENSEINFORMATION
Ifnovalidlicense,explain:
DriversLicenseNo.: State:
IssuedDate:/ / ExpirationDate: / /
UNIONINFORMATION: Craft: Home/Local#:
Phone:( ) City: State:
SECTIONIPERSONALDATARESIDENCESIfyouhaveNOTheldUnescortedAccessatanuclearplantwithinthelast3years,listallresidenceswhereyouhavelivedfor
morethan30daysinthepastseven(7)years.
IfyouHAVEheldUnescortedAccesswithinthelast3years,listallresidenceswhereyouhavelivedformorethan30dayssinceyoulastheldunescortedaccess.
From: / / To: Present
NumberandStreet City State Zip
From: / / To: / /
NumberandStreet City State Zip
From: / / To: / /
NumberandStreet City State Zip
From: / / To: / /
NumberandStreet City State Zip
From: / / To: / /
NumberandStreet City State Zip
From: / / To: / /
NumberandStreet City State Zip
X ApplicantsFullPrintedName SocialSecurityNumber
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SECTIONIPERSONALDATAFOREIGNTRAVELInthepast5years,sinceyour18thBIRTHDAY,orsinceyourlastfavorableaccesswhicheverperiodisshorter,haveyoutraveledtoanyforeigncountry?(CircleOne) Yes NoDonotincludetravelwhenintheserviceofanyUSgovernmentagency(e.g.,USMilitary,StateDepartment,etc.)CountryName:________________________________________________________DateDepartedUnitedStates:From:___/___/_____DateReturnedtoUnitedSates:To:___/___/_____PortofDeparture:______________________________________________________PurposeofTravel:______________________________________________________CountryName:________________________________________________________DateDepartedUnitedStates:From:___/___/_____DateReturnedtoUnitedSates:To:___/___/_____PortofDeparture:______________________________________________________PurposeofTravel:______________________________________________________CountryName:________________________________________________________DateDepartedUnitedStates:From:___/___/_____DateReturnedtoUnitedSates:To:___/___/_____PortofDeparture:______________________________________________________PurposeofTravel:______________________________________________________Useadditionalcontinuationsheets,asnecessary.SECTIONIIPERSONALREFERENCESList three individuals who are available for immediate contact and who can comment on your character and reputation. References cannot be related to you and cannot be living in your household. They may be friends, neighbors, or others with whom you have frequent personal and/or business relationships. Provide home address (actual street address), not post office box numbers. List telephone numbers where each reference can be reached.
Name Address PhoneNumbersincludingareacodes Daytime Evening
KnownSince
() ()
() ()
() ()
Closestrelativenotlivingwithyou:
Name: Relationship: PhoneNo:( ) NumberandStreet City State Zip
X ApplicantsFullPrintedName SocialSecurityNumber
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SECTIONIIICREDITHISTORY(NotapplicableifyouhaveheldUnescortedAccessatanuclearplantwithinthelast365days.)Inthepastseven(7)years,haveyouhad: Abankruptcy?............................................................................................. YES NO Afinancialjudgmentagainstyou?............................................................. YES NO Achargeoff?............................................................................................... YES NO Ataxlien?................................................................................................... YES NO Otherfinancialdifficultieswithinthepastseven(7)years?...................... YES NO
Ifyourespondedyestoanyoftheabove,providethereasonorcircumstancesforthesedifficulties:
Note:Ifyouhaveplacedasecurityfreezeonyourcreditfile,thecreditfilemustbeunfrozeninorderfortherequiredcreditchecktobecompleted.Changingthestatusofyourcreditfileisyourresponsibility.
Yourcreditwillbecheckedthroughanationalcreditagency.Ifyoudonothaveanestablishedcredithistory,listasourceofcreditsuchasabankordepartmentstorechargeaccountoranypersonalsourcesofcredit.(Examples:localgasstation,companysalesrepresentative,etc.)
Source: Location: , PhoneNumber:( ) Name City State
SECTIONIVEDUCATIONHISTORYASEMPLOYMENTInthepast5yearswereyouenrolled,witheducationasyourprimaryactivity,inaneducationalinstitutioninlieuofemployment? YES NOIf Yes, complete this section for each enrollment. Ifclaiminganyeducation,acopyofanofficialeducationalinstitutiontranscriptmustbeprovided.
NameofSchool Address(City/State)
DatesAttended(Mo/YrMo/Yr)
CourseofStudy
ReasonforLeaving
Wereyousubjecttoanydisciplinaryactionatanyoftheabovelistededucationalinstitutes? YES NO
Ifyes,providedetails:
SECTIONVMILITARYSERVICEASEMPLOYMENT
Didyouserveinthemilitaryasprimaryjobwithinthelastthree(3)yearsorsinceyour18thbirthday? YES NOIfYescompletethissectionforeachperiodofservice. DoyouhavetheDDForm214youreceivedupondischarge? YES NOIfYes,presenttheOriginalDD214withthisPHQ,acopywillberetainedandtheoriginalreturnedafterauthentication.
DateofService:From: / / To: / /
BranchofService: TypeofService: ActiveDuty NationalGuard/Reservesonactiveduty
LastCommander: LastDutyStation: PhoneNo:( )
ReasonforDischarge:
CharacterofService: Honorable Other,explain:
AnyDisciplinaryaction: YES NO Ifyes,explain:
X ApplicantsFullPrintedName SocialSecurityNumber
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SECTIONVIEMPLOYMENTHISTORYIfyouhaveNOTheldUnescortedAccessatanuclearplantwithinthelast3years,listallemployment/unemploymentforlast5years.IfyouHAVEheldUnescortedAccesswithinthelast3years,listallemployment/unemploymentsincelastaccess.Donotleavegaps.Donotlistunemploymentofficeorlocaluniontoverifyemploymentorunemployment.Haveyoubeenfired,involuntarilyterminated,orforcedtoleaveanyjoborposition,exceptaspartofareductioninforce,withinthepastfive(5)years? YES NOIfYes,explainthecircumstancesandreasonforleavingatbottomofpage12.
Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()JobSiteLocation:(City/State) ReasonforTermination*:
Fired LaidOff QuitEligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
*Iffiredornoteligibleforrehire,provideexplanationatbottomofpage12.
X ApplicantsFullPrintedName SocialSecurityNumber
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EMPLOYMENTHISTORY(continued)Donotleavegaps.Donotlistunemploymentofficeorlocaluniontoverifyemploymentorunemployment.
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()*Iffiredornoteligibleforrehire,provideexplanationatbottomofpage12.
X ApplicantsFullPrintedName SocialSecurityNumber
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EMPLOYMENTHISTORY(continued)Donotleavegaps.Donotlistunemploymentofficeorlocaluniontoverifyemploymentorunemployment.
Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()*Iffiredornoteligibleforrehire,provideexplanationatbottomofpage12.
X ApplicantsFullPrintedName SocialSecurityNumber
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EMPLOYMENTHISTORY(continued)Donotleavegaps.Donotlistunemploymentofficeorlocaluniontoverifyemploymentorunemployment.
Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()Unemployed:From:To:
Nameofpersonwhocanverify:DaytimePhoneNo: Evening:
EmployersName:(Noinitialsorabbreviations) Employed/SelfEmployedFrom:
/ /Employed/SelfEmployedTo:
/ /HomeOfficeAddress: PositionHeld: PhoneNo:
()
JobSiteLocation:(City/State) ReasonforTermination*:Fired LaidOff Quit
EligibleforRehire*: Yes No
If Selfemployedor employeroutofbusiness(checkone),providepersonwhocanverifyactivities:
Name:PhoneNo:()*Iffiredornoteligibleforrehire,provideexplanationatbottomofpage12.
X ApplicantsFullPrintedName SocialSecurityNumber
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ACKNOWLEDGMENTSTATEMENT
Ihaveread,understandandacknowledgethepurposeofthispersonalhistoryquestionnaire(PHQ)andthatIhavefurnishedtherequestedinformationunderthestatedconditions.IhavereadandunderstandtheinformationconcerningNRCrequiredfingerprintsandcriminalhistoryrecord.
IhavebeenadvisedthatanyfalsificationorwillfulomissionofinformationmaybeaviolationofNuclearRegulatoryCommission(NRC)regulations.Thefactsconcerningmycriminalhistoryorfitnessforduty(FFD)recordmaybesubjecttointerpretationbecausedifferentstatesmaycategorizethesameoffensesdifferently.ItisthereforesuggestedthatIdiscloseallpotentiallyderogatoryinformationandreducethelikelihoodofdiscrepanciesbetweentheinformationIhaveprovidedandthatobtainedfromothersources.Failuretolistreasonsforanyprevioussuspension,revocationordenialofUnescortedAccess(UA)toanuclearfacilityorotherentitysubjecttoeitherNRCorFFDregulationmaybesufficientcausefordenialofUAA/UAand/orcivilpenaltiesfromtheNRC.
TheinformationthatIhaveprovidedinthisPHQiscorrectandcompletetothebestofmyknowledgeandbelief.ImakethisstatementwithknowledgethatanyfalseormisleadingstatementoromissionofanyfactmaybesufficientcausefordenialofUAA/UAand/orsafeguardsaccess.IunderstandthattheinformationIhaveprovidedinthisformwillbeverifiedbyauthorizedbackgroundinvestigatorsandwillbeusedonlyforaccessauthorizationpurposes,orotherwiseinaccordancewithapplicablelaw.
IunderstandthatifIamcertifiedUAAorgrantedUA,itismyresponsibility,undertheBehavioralObservationProgram(BOP),toreportanylegalactiontomysupervisorinaccordancewithTennesseeValleyAuthorityNuclearPowerGroup(TVANPG)procedures.ImustalsoreportanylegalactionsfromthetimeIcompletethisPHQuntilIamcertifiedUAAorgrantedUA.AnevaluationwillbemaderegardingtheimpactofthelegalactiononmyUAA/UA.Thedeterminationofwhatconstitutesalegalactionisamatterofstatelawbut,ingeneral,thetermlegalactionmeans:
Aformalactiontakenbyalawenforcementauthorityorcourtoflaw,includingbeingheld,detained,takenintocustody,charged,arrested,indicted,fined,forfeitedbond,cited,orconvictedforaviolationofanylaw,regulationorordinancethisincludesfelony,misdemeanor,serioustrafficoffenses,seriouscivilchargesormilitarychargesbutdoesnotincludeminormisdemeanorssuchasparkingticketsorminorcivilactionssuchaszoningviolationsorminortrafficviolationssuchasmovingviolationswhentheindividualwasnotphysicallytakenintocustody,andincludesthemandatedimplementationofaplanfortreatmentormitigationinordertoavoidapermanentrecordofanarrestorconvictionsinresponsetothefollowing:
(1) theuse,saleorpossessionofillegaldrugs,(2) theabuseoflegaldrugsoralcohol,(3) ortherefusaltotakeadrugoralcoholtest.
Ihavebeenadvisedofmyrighttorequesttoreviewtheinformationdevelopedtoassureitsaccuracyandcompleteness.IunderstandthattheinformationcollectedduringtheconductofthebackgroundinvestigationwillberetainedandmustbemadeavailabletoanyothernuclearpowerplantwhereImayrequestaccess.ItwillonlybeusedindeterminingmyeligibilitytobecertifiedUAA,grantedUAand/orgrantedaccesstosafeguardsinformation.ThisinformationwillberetainedforaperiodoftimeafterthelastterminationofmyUAA/UAordenialofmyUAA/UAand/oraccesstosafeguardsinformation.
ADDITIONALCOMMENTSORNOTES:
TheinformationIhaveprovidedinthisPHQisaccurateandcorrect.
ApplicantsFullPrintedName SocialSecurityNumber
ApplicantsSignature Date
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AUTHORIZATION,CONSENT,ANDACKNOWLEDGMENT
Iherebyacknowledgethatinorderformetoworkwithintheprotectedand/orvitalareasofaTennesseeValleyAuthorityNuclearPowerGroup(TVANPG)site,Iamsubjecttoabackgroundinvestigationtodeterminemytrustworthinessandreliability,andconsenttosuchaninvestigationbyTVANPG,itsinvestigativeagents,oritsapprovedcontractors/vendors(C/Vs).Thisinvestigationmayinclude,butisnotlimitedto,averificationofidentity,selfdisclosuredata,employment/unemploymenthistory(includingmilitaryserviceand/oreducationinlieuofemployment),criminalhistory,credithistory,characterreferences,residences,andfitnessfordutyhistory,aswellasamedical/psychologicalevaluation.Thisinformationmaybeobtainedthroughcontactwithfederal,state,andlocalgovernmentalagencies,educationalinstitutions,previousandcurrentemployers,institutionsandindividuals,andothers,whetherornotspecificallymentionedherein,asmayhaverecordsorpersonalknowledgerelatingtomeormyactivities.IauthorizeTVA,itsinvestigativeagents,oritsapprovedC/VstoreleaseallinformationobtainedconcerningmetoanynuclearfacilityortheU.S.NuclearRegulatoryCommission(NRC)fortheirdeterminationofmyeligibilityforunescortedaccess.
Iacknowledgetheinformationcollected/transferredconcerningmepursuanttothisprocessisconsideredconfidentialandisprotectedfromunauthorizeddisclosure.Disclosureisauthorizedunderthefollowingconditions:otherlicensees,C/VsortheirauthorizedrepresentativesseekingtheinformationforUAAdeterminations;NRCrepresentatives;appropriatelawenforcementofficialsundercourtorder;myselformyrepresentative,whoIhavedesignatedinwriting;thoselicenseerepresentativesorC/Vswhohaveaneedtohaveaccesstotheinformationinperformingassigneddutiesincludingauditsoflicensee,contractor,orvendorprograms,exceptwherespecificallyexcludedbyregulation;personsdecidingmattersonrevieworappeal;or,otherpersonspursuanttocourtorderorotherwiseinaccordancewithapplicablelaw.Thesewillbereviewedonacasebycasebasis.IacknowledgethattheresultsofthisinvestigationwillbemaintainedbyTVANPGoritsC/Vsthroughmyperiodofemploymentandforatleastfiveyearsfollowingterminationofmyunescortedaccess.
Iacknowledgethat,uponmyproperrequest,IhavetherighttoreviewtheinformationcollectedduringthebackgroundinvestigationprocessandmaintainedattheTVANuclearAccessServicesofficetoensureitsaccuracyandcompleteness.
Iherebyauthorizeanyperson,agency,organization,orinstitutiontoreleasetoTVANPG,itsinvestigativeagents,orapprovedC/Vssuchinformationasmayberequestedaboutme,basedonadeterminationthattheinformationisnecessaryorappropriateinconnectionwithinvestigatingmeforunescortedaccess.Thisauthorizationspecificallyincludesreleaseofanyandallinformationbymypresentandpreviousemployers,lawenforcementagencies,educationalinstitutions,teachers,professors,landlords,friends,familymembers,andothers,whetherornotspecificallymentionedherein.Theinformationcoveredbythisauthorizationmayinclude,butisnotlimitedto,academic,residential,achievement,performance,attendance,disciplinary,financial,arrestandconvictionrecords,andrecordsrelatingtomymoralcharacterandmentalstability.
IherebywaiveanyandallclaimsagainsttheUnitedStates,TVA,theiremployees,theirC/Vs,theirauthorizedinvestigativeagents,TVAsapprovedC/Vs,andanyperson,agency,organization,orinstitution(includingrecordcustodians)whichprovidesinformationtoTVA,TVAsemployees,orauthorizedinvestigativeagents,forlossordamageofwhateverkindornaturewhichmayatanytimeresultonaccountofcompliance,oranyattemptstocomply,withthisauthorization.
IacknowledgethatdisclosureofinformationisvoluntaryandthatImaywithdrawmyauthorization/consentatanypoint;but,indoingso,Iwillnotbeeligibleforunescortedaccess.
Iacknowledgemyresponsibilitytoreportanylegalactions,includinglegalactionswhichoccurbetweensigningthisformandbeinggrantedUAA/unescortedaccess,toNuclearAccessServicesPlantAccessorCorporateNuclearAccessServices,aswellasmysupervisor,thenextbusinessdayafteranysuchlegalaction.
IhavereadandunderstandallofthetermscontainedinthisAuthorization,Consent,andAcknowledgment.
ApplicantsFullPrintedName SocialSecurityNumber
ApplicantsSignature Date
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PrivacyActStatement
Subsection(e)(3)of5U.S.C.552a(Section3ofthePrivacyAct))requiresthatTVAinformyouofitsauthoritytorequestinformationandtheuseswhichTVAmaymakeoftheinformationrequested.ThatsubsectionfurtherrequiresTVAtoinformyouoftheeffectsofnotprovidinganyoralltherequestedinformation.
TVAsauthoritytorequesttheinformationyouwillprovideisderivedfromtheTVAAct(16U.S.C.831831ee),ExecutiveOrderNo.10450,theAtomicEnergyActof1954,asamended,andanumberofotherstatutesandPresidentialExecutiveorders.Informationprovidedonthisformmaybefurnishedtopeople,agencies,organizations,orinstitutionsinordertoobtaininformationregardingyouinconnectionwithaninvestigationtodetermine:(1)fitnessforTVAemployment;(2)clearancetoperformservicesforTVAunderpersonalservices,consultant,orothercontracts;or(3)securityclearanceorclearanceforaccesstoTVAinstallations.
Furnishingtherequestedinformationisvoluntary;however,failuretoprovideallorpartoftheinformationmayresultinalackoffurtherconsiderationforemployment,clearanceoraccess,orintheterminationofyouremployment.
InformationprovidedonthisformisnormallyusedonlytodeterminefitnessforemploymentorsecurityclearanceforaccesstoTVAinstallations.Informationobtainedonthisformmaybefurnishedtothirdpartiesasauthorizedbylaw.Forexample,shouldadisputeariseoracongressionalinquirybemaderegardingTVAemploymentpractices,theinformationmaybemadeavailableoutsideofTVAinthecourseofthatdisputeorinquiry.Further,informationprovidedmaybeprovidedtoanotherfederalagencyifrelevanttoadecisiontobemadebythatagency.Inaddition,informationonthisformmaybemadeavailabletolawenforcementagenciesintheexerciseoftheirduties,ortoaprospectiveemployerorTVAcontractoruponproperrequest.
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FAIRCREDITREPORTINGACT
DISCLOSUREANDAUTHORIZATIONSTATEMENT
Forthepurposeofevaluatingmyapplicationforormaintenanceofnuclearpowerplantaccessauthorization,IunderstandTVAoritscontractors/vendorsmayobtainorhavepreparedaconsumerreportorinvestigativeconsumerreportconcerningmyprioremployment,militaryrecord,education,creditworthiness,creditstanding,creditcapacity,character,generalreputation,personalcharacteristics,criminalbackgroundrecord,ormodeofliving.
IunderstandthatuponwrittenrequesttoTVA,Iwillbeinformedwhetheraninvestigativeconsumerreportwasrequested,andgivenfullinformationastothenatureandscopeofthisinvestigation.Iunderstandthataninvestigativeconsumerreportisareportinwhichinformationconcerningmycharacter,generalreputation,personalcharacteristics,ormodeoflivingisobtainedthroughpersonalinterviewswithneighbors,friends,orassociateswithwhomIamacquainted.
Bysigningbelow,IamauthorizingTVA,itscontractors/vendorsoritsinvestigativeagentstoobtainaconsumerorinvestigativeconsumerreportonmeaspartofthescreeningprocessforaccessauthorization.DuringtheperiodinwhichIretainaccessauthorization,Ifurtherauthorizetheobtainingofadditionalconsumerorinvestigativeconsumerreportsonmetoevaluatemytrustworthinessandreliabilityforpurposesofdeterminingandmaintainingcontinuedunescortedaccessauthorization.
Bymysignaturebelow,IalsoacknowledgethatIhavebeenprovidedasummaryofmyrightsundertheFederalFairCreditReportingAct(attachedcopypreparedbytheConsumerFinancialProtectionBureau).
IhavereadandunderstandthisConsentandauthorizeTVAand/oritscontractors/vendorstotakesuchactionsasaredescribedherein.
NameofApplicant:
SocialSecurityNumber:
DateofBirth:
SignatureofApplicant:
Date:
Ifnamechangedbymarriageorotherwise,printformername(s)here:
PrivacyActStatement
Subsection(e)(3)of5U.S.C.552a(Section3ofthePrivacyAct))requiresthatTVAinformyouofitsauthoritytorequestinformationandtheuseswhichTVAmaymakeoftheinformationrequested.ThatsubsectionfurtherrequiresTVAtoinformyouoftheeffectsofnotprovidinganyoralltherequestedinformation.
TVAsauthoritytorequesttheinformationyouwillprovideisderivedfromtheTVAAct(16U.S.C.831831ee),ExecutiveOrderNo.10450,theAtomicEnergyActof1954,asamended,andanumberofotherstatutesandPresidentialExecutiveorders.Informationprovidedonthisformmaybefurnishedtopeople,agencies,organizations,orinstitutionsinordertoobtaininformationregardingyouinconnectionwithaninvestigationtodetermine:(1)fitnessforTVAemployment;(2)clearancetoperformservicesforTVAunderpersonalservices,consultant,orothercontracts;or(3)securityclearanceorclearanceforaccesstoTVAinstallations.
Furnishingtherequestedinformationisvoluntary;however,failuretoprovideallorpartoftheinformationmayresultinalackoffurtherconsiderationforemployment,clearanceoraccess,orintheterminationofyouremployment.
InformationprovidedonthisformisnormallyusedonlytodeterminefitnessforemploymentorsecurityclearanceforaccesstoTVAinstallations.Informationobtainedonthisformmaybefurnishedtothirdpartiesasauthorizedbylaw.Forexample,shouldadisputeariseoracongressionalinquirybemaderegardingTVAemploymentpractices,theinformationmaybemadeavailableoutsideofTVAinthecourseofthatdisputeorinquiry.Further,informationprovidedmaybeprovidedtoanotherfederalagencyifrelevanttoadecisiontobemadebythatagency.Inaddition,informationonthisformmaybemadeavailabletolawenforcementagenciesintheexerciseoftheirduties,ortoaprospectiveemployerorTVAcontractoruponproperrequest.
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PERSONNELACCESSDATASYSTEM(PADS)CONSENTTheTennesseeValleyAuthority(TVA)hasmyconsentto:
a. Collectpersonalinformationaboutmeinordertoverifytheinformationsaccuracy;b. Conductabackgroundinvestigation(BI)inaccordancewithU.S.NuclearRegulatoryCommission(NRC)regulationsto
verifyinformationIhaveprovidedonaPersonalHistoryQuestionnaireandotherinformation,asnecessary;c. Takemyfingerprintsandassociatedbiographicidentifierstoconductacheckofthecriminalhistoryinformation
recordscontainedwithintheFederalBureauofInvestigations(FBIs)IntegratedAutomatedFingerprintInformationSystem(IAFIS).
d. Retainpersonalinformationprovidedforinvestigation;ande. Transferinformationfromotherlicensees,asnecessary,including:(i)informationpertainingtothedenialof
unescortedaccessauthorization(UAA)orunescortedAccess(UA),ordenialofaccesstoanuclearpowerplantunderconstruction,todeterminewhethertocertifyUAA,grantUAtoaU.S.NRClicensedfacilityandtoallowmetomaintainsuchaccess;or(ii)informationpertainingtodenialofaccesstoSafeguardsInformation.
Withtheexceptionofcriminalhistoryrecordinformation(CHRI)collectedunder10CFR73.57,theinformationcollectedwillonlybeusedforthepurposesofdeterminingUAA/UAinaccordancewith10CFR73.56,PersonnelAccessAuthorizationRequirementsforNuclearPowerPlants,separatefitnessforduty(FFD)authorizationinaccordancewith10CFRPart26,FitnessforDutyPrograms,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguardsInformationinaccordancewith10CFR73.21,73.22or73.23,ProtectionofSafeguardsInformation,unlessIprovideaseparatereleasetothelicenseeforanotherpurpose.CHRImayonlybeusedforthepurposesofdeterminingwhetherapersonissuitableforunescortedaccesstoanuclearpowerplantorforaccesstoSafeguardsInformation,andmaynotbeusedforanyotherpurpose.IunderstandthatevidenceofcriminalconductdetectedduringtheconductofaBImustbereportedtotheappropriatelawenforcementagencybythelicenseeorcontractor/vendor(C/V).Iauthorizetheuseofsignedcopiesofthisconsenttobeusedinplaceofanoriginallysignedconsentdocument.TheNRCrequiresthattheinformationcollectedbeusedindeterminingthatanindividualistrustworthy,reliable,andfitfordutypriortocertifyingUAA,grantingUA,whilemaintainingUAA/UA;grantingaccesstoanuclearpowerplantunderconstruction;andbeforegrantingaccesstosafeguardsinformation.TheresultsofthisdeterminationmustbeavailabletootherNRClicensedfacilities.AnyofthefollowingactionsrelatedtotheprovidingandsharingofpersonalinformationissufficientcausefordenialorunfavorableterminationofUAA/UA,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguardsInformation:
a. Refusaltoprovidewrittenconsentforthebackgroundinvestigationand/orsuitableinquiry;b. Refusaltoprovideinformationorthefalsificationofanypersonalinformationrequiredunder10CFR73.56,Personnel
AccessAuthorizationRequirementsforNuclearPowerPlants,10CFR26,FitnessforDutyPrograms,and/or10CFR73.21,73.22or73.23,ProtectionofSafeguardsInformation,including,butnotlimitedto,thefailuretoreportanypreviousdenialorunfavorableterminationofauthorization;
c. Refusaltoprovidewrittenconsentforthesharingofpersonalinformationwithotherlicenseesorotherentitiesrequiredunder10CFR73.56,PersonnelAccessAuthorizationRequirementsforNuclearPowerPlants,10CFR26,FitnessforDutyPrograms,and/or10CFR73.21,73.22or73.23,ProtectionofSafeguardsInformation;and
d. Failuretoreportanylegalactionsinaccordancewith10CFR73.56(g).
Iunderstandthatthedomesticcommercialnuclearindustryusesacomputerized,restrictedaccessdatasystem,thePersonnelAccessDataSystem(PADS),toshareinformationnecessarytoprocessapplicationsofworkersforUAA/UAtonuclearfacilities,accesstonuclearfacilities,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguardsInformation.Ifurtherunderstandthatthissystemisintendedtopermitnuclearfacilitylicenseesandtheiracceptedcontractors/vendorstomeetregulatoryrequirementsmandatingthatcertaininformationbeavailabletoanyfacilitylicenseebyretainingcertainaccessinformationinacentralcomputerdatabase.Iunderstandthattheinformationmaybetransferred,electronicallyorotherwise,tootherlicenseesandcontractor/vendorsortheagentsofeach.Thisinformationwillinclude,butisnotlimitedto:
a. NameandSocialSecurityNumber;b. Placeofbirthandphysicalcharacteristics;
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PERSONNELACCESSDATASYSTEM(PADS)CONSENT(continued)c. Dateswhenanyofthefollowingarecompleted:backgroundinvestigation,psychologicalevaluation,fitnessforduty
testing,suitableinquirychecks;d. DateswhenUAA/UA,accesstoanuclearpowerplantconstructionsite,and/oraccesstoSafeguardsInformationhas
beenauthorizedorterminated;e. DateofanydenialofUAA/UA,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguards
Informationandthecompanyholdingtherelevantinformation;f. DatesassociatedwithFFDtesting(preaccess,postevent,forcauseandfollowup)andtreatment;g. Annualradiationexposurehistory;h. Respiratoryequipmentqualification/fittesting;i. Medicalqualificationforrespiratoruse;j. DataconcerningtrainingrequiredforUAA/UA,accesstoanuclearpowerplantconstructionsite,accesstoSafeguards
Informationandworkqualification;andk. Directiontoseekadditionalinformationdirectlyfromanotherlicensee.
Iauthorizeanyindividual,organization,institution,orentitythatnowhas,orobtainsinthefuture,accessrelatedinformationaboutme(examplesofwhichareprovidedintheaboveparagraph),whetherornotsuchinformationisincludedinthePADSdatabase,toreleaseanysuchinformationinordertoperformtheinvestigationandevaluationrequiredforUAA/UA,accesstoanuclearpowerplantconstructionsiteand/oraccesstoSafeguardsInformation.IunderstandthatinformationcontainedwithinanFBIcriminalhistoryrecordwillberestrictedtotheNRC,nuclearlicenseefacilitiesregulatedbytheNRC,andmyself,andthatthecriminalhistoryinformationwillnotbereleasedtocontractor/vendorsortheiragents.IauthorizetheentryintothePADScomputerdatabaseofanyinformationcollectedforthepurposeofprocessingmyapplicationfor,orcontinuedmaintenanceof,UAA/UA,accesstoanuclearpowerplantconstructionsite,and/oraccesstoSafeguardsInformation.Iauthorizethetransferofsuchinformation,electronicallyorotherwise,tootherNRCnuclearfacilitylicenseesandcontractors/vendors.Iauthorizesuchlicenseesandcontractors/vendorstousethedatabaseinformationforthepurposeofdeterminingmyeligibilityforUAA/UA,foraccesstoanuclearpowerplantconstructionsite,and/orforaccesstoSafeguardsInformation.IunderstandthatinformationobtainedpursuanttothisConsentshallbetreatedasconfidential.ThereleaseofaccessrelatedinformationaboutmeshallbelimitedtoregulatoryagenciesandsuchemployeesofNRCfacilitylicenseesandtheircontractors/vendorswhohavebeendesignatedashavinganeedtoknowtheinformationinordertodotheirjobs.Thefollowingisalistingofindividualsthatmayaccessinformationwithoutmyconsentinordertoperformtheirofficialduties:
a. Myselformyrepresentative,whenIhavedesignatedtherepresentativeinwritingforspecifiedUAA/UA,nuclear
powerplantconstructionsiteaccess,safeguardsinformationaccessand/orFFDmatters;b. AssignedMedicalReviewOfficers(MROs)andMROstaff;c. NRCrepresentatives;d. Appropriatelawenforcementofficialsundercourtorder;e. licensee,contractor/vendor,ortheiragentswhohaveaneedtohaveaccesstotheinformationtoperformtheir
assigneddutiesundertheUAA/UA,nuclearpowerplantconstructionsiteaccess,safeguardsaccess,and/orFFDprograms,includingdeterminationsoffitness,accessauthorizationorFFDprogramaudits,andsomehumanresourcesfunctions;
f. Thepresidingofficerinajudicialoradministrativeproceedingthatisinitiatedbythesubjectindividual;g. PersonsdecidingmattersunderaccessauthorizationorFFDprogramappealprocess;andh. Otherpersonspursuanttocourtorder.
Iunderstandthatallinformationaboutmeinthedatabasewillbemaintainedassecurelyasreasonablypracticableforaperiodofatleast5yearsafterUAA/UA,accesstoanuclearpowerplantconstructionsite,and/oraccesstoSafeguardsInformationislastterminated.ThetypesofrecordsmaintainedincludedocumentationcollectedduringtheadministrationoftheaccessauthorizationandFFDprograms.Alldocumentspertainingtoa5yearorpermanentdenial
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PERSONNELACCESSDATASYSTEM(PADS)CONSENT(continued)ofUAA/UArequiredby10CFR26willberetainedbyalicenseemakingthedenialorunfavorableterminationofUAA/UAfor40yearsortheNRCdeterminesthattherecordsarenolongerneeded.TherecordsofFFDtrainingandexaminationsconductedunder10CFR26and10CFR73.21,73.22,or73.23willbemaintainedforatleast3years.RecordsidentifiedarenormallymaintainedattheTVANuclearAccessServicesoffice.IunderstandthatifIdeterminethatinaccordancewith28CFR16.34,Proceduretoobtainchange,correctionorupdatingofidentificationrecordsIf,afterreviewingmyidentificationrecord,Ibelievethatitisincorrectorincompleteinanyrespectandwishchanges,correctionsorupdatingoftheallegeddeficiency,Imaymakeapplicationdirectlytotheagencywhichcontributedthequestionedinformation.ImayalsodirectmychallengeastotheaccuracyorcompletenessofanyentryonyourrecordtotheFBI,CriminalJusticeInformationServices(CJIS)Division,ATTN:SCU,Mod.D2,1000CusterHollowRoad,Clarksburg,WV26306.TheFBIwillthenforwardthechallengetotheagencywhichsubmittedthedatarequestingthatagencytoverifyorcorrectthechallengedentry.Uponthereceiptofanofficialcommunicationdirectlyfromtheagencywhichcontributedtheoriginalinformation,theFBICJISDivisionwillmakeanychangesnecessaryinaccordancewiththeinformationsuppliedbythatagency.IunderstandthatIhavearighttoreviewinformationcollectedandmaintainedbyTVAtoassureitisaccurateandcompleteandtocorrectanyinaccurateorincompleteinformation.Iunderstandthat,uponmywrittenrequesttoTVA,andatnocosttome,Iwillbeprovided,within10businessdays,withaprintedcopyoftheinformationaboutmewhichisrecordedinthedatabase.If,aftermyreviewofsuchinformation,Icanshowthatanyoftheinformationisincorrectorincomplete,suchinformationwillbecorrectedand/orcompletedassoonasisreasonablypractical.IunderstandthatatanytimeanduponwrittennoticetoTVA,ImaywithdrawthisConsent,butthiswillalsoconstituteawithdrawalofmyrequestforaccess.Iunderstandthatanyprocessingactivitiesthatwereinitiatedbeforereceiptofmywithdrawalofconsentshallcontinueandtheresultinginformationwillberetainedinthedatabase.Nonewinquiriesshallbeinitiatedafterreceiptofmywithdrawalofconsent.Thereafter,PADSparticipantsarenotpermittedtoretrieveinformationfromthedatabaseotherthanmyname,dateofbirth,identificationnumber,andthefactthatmyconsenthasbeenwithdrawn,unlessIprovideacurrentlyvalidConsentortheinformationsoughtisrequiredbyNRCregulation.IherebyreleaseTVA,otherPADSparticipants,NEI,andtheofficers,employees,representatives,agents,andrecordscustodiansofeachaswellastheofficers,employees,representatives,agents,andrecordscustodiansofanyentityorindividualsupplyingorusingsuchinformationfromanyandallliabilitybasedontheirauthorizedreceipt,disclosure,oruseoftheinformationobtainedpursuanttothisConsentandtodeterminemyeligibilityforUAA/UAtonuclearfacilities,accesstoanuclearpowerplantunderconstruction,and/oraccesstoSafeguardsInformation.IunderstandthatthisConsentisnotintendedtoanddoesnotaffectanyrightorresponsibilitythatI,myemployer(ifnotTVA),orTVAmayhaveunderSection211oftheEnergyReorganizationActof1974,asamended.Ifurtherunderstandthatnothingherein(1)affectsmyrightormyresponsibilitytobringpotentialsafetyconcernstomyemployer(ifnotTVA),TVA,ortheNRC;or(2)prohibitsmefromparticipatinginanyproceedingorinvestigationregardingsuchapotentialsafetyconcern.IhavereadandunderstandthisConsentandauthorizeTVAtotakesuchactionsasaredescribedhereinorspecifiedbyPADSprocedures.WhileIunderstandthatUAA/UA,accesstoanuclearpowerplantconstructionsiteand/oraccesstoSafeguardsInformationisdependentuponmyacceptingtheregulatoryrequirementsofthisprogram,thestatementsmadebymeinthisConsentandmydecisiontosignthisConsentarevoluntary.ThestatementswerenotinducedbyanypromisenorhaveIbeensubjectedtoanythreat,duressorcoerciontosignthisConsent.
ApplicantsFullPrintedName SocialSecurityNumber
ApplicantsSignature Date
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PrivacyActStatement
Subsection(e)(3)of5U.S.C.552a(Section3ofthePrivacyAct))requiresthatTVAinformyouofitsauthoritytorequestinformationandtheuseswhichTVAmaymakeoftheinformationrequested.ThatsubsectionfurtherrequiresTVAtoinformyouoftheeffectsofnotprovidinganyoralltherequestedinformation.
TVAsauthoritytorequesttheinformationyouwillprovideisderivedfromtheTVAAct(16U.S.C.831831ee),ExecutiveOrderNo.10450,theAtomicEnergyActof1954,asamended,andanumberofotherstatutesandPresidentialExecutiveorders.Informationprovidedonthisformmaybefurnishedtopeople,agencies,organizations,orinstitutionsinordertoobtaininformationregardingyouinconnectionwithaninvestigationtodetermine:(1)fitnessforTVAemployment;(2)clearancetoperformservicesforTVAunderpersonalservices,consultant,orothercontracts;or(3)securityclearanceorclearanceforaccesstoTVAinstallations.
Furnishingtherequestedinformationisvoluntary;however,failuretoprovideallorpartoftheinformationmayresultinalackoffurtherconsiderationforemployment,clearanceoraccess,orintheterminationofyouremployment.
InformationprovidedonthisformisnormallyusedonlytodeterminefitnessforemploymentorsecurityclearanceforaccesstoTVAinstallations.Informationobtainedonthisformmaybefurnishedtothirdpartiesasauthorizedbylaw.Forexample,shouldadisputeariseoracongressionalinquirybemaderegardingTVAemploymentpractices,theinformationmaybemadeavailableoutsideofTVAinthecourseofthatdisputeorinquiry.Further,informationprovidedmaybeprovidedtoanotherfederalagencyifrelevanttoadecisiontobemadebythatagency.Inaddition,informationonthisformmaybemadeavailabletolawenforcementagenciesintheexerciseoftheirduties,ortoaprospectiveemployerorTVAcontractoruponproperrequest.
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SELFDISCLOSURE
TheNuclearRegulatoryCommissionrequiresthatthecompanyinvestigateyourpreviousemploymenthistoryandmakeinquiriesofemployerstodeterminewhetherornotthereareanyfitnessforduty(FFD)concernsthatmustbeexploredandevaluatedpriortocertifyingUAAorgrantingUA.
AnswereachquestionbycheckingeitherYesorNoasitpertainstoyou.ForeachYesanswerincludethespecifictypeofissue,durationandresolution,including,butnotlimitedtothereasonforanunfavorableterminationordenialofUAA/UA.Detailsmayinclude,butarenotlimitedto,date,nameandlocationoftheemployerorpotentialemployerinvolved(towhomyouappliedforemployment),natureoftheviolation,anyhearing,penaltyimposedorotherdisposition.
InitialWithinthelastfive(5)years,orsinceyour18thBIRTHDAY(whicheverisshorter),haveyou:Update/ReinstatementSinceyourlastUA/UAAiffavorablyterminatedwithinthepast3years,haveyou: (CheckYesorNo)
1. violatedalicenseeoremployersfitnessfordutypolicy? Yes No
2.beendeniedorhadunescortedaccessauthorizationterminatedunfavorablyatanyplaceofemploymentoratanynuclearpowerplantforanyreasonincludingfitnessfordutypolicyviolationorbeenunfavorablyterminatedfromanyemploymentforafitnessfordutyreason?
Yes No
3. used,sold,orpossessedillegaldrugs? Yes No
4. abusedlegaldrugsoralcohol? Yes No
5. eversubvertedorattemptedtosubvertadrugoralcoholtestingprogram? Yes No
6. refusedtotakeadrugoralcoholtest? Yes No
7. beensubjecttoaplan(exceptselfreferral)fortreatingsubstanceabuse? Yes No
8.beensubjecttoalawenforcementauthorityorcourtoflawactionforalcoholordruguserelatedtoanyofthefollowing:
(a)Theuse,saleorpossessionofillegaldrugs? Yes No
(b)Theabuseoflegaldrugsoralcohol? Yes No
(c)Therefusaltotakeadrugoralcoholtest? Yes No
9. beensubjecttoemploymentactiontakenforalcoholordrugabuseinvolvinganyofthefollowing:
(a)Achangeinjobresponsibilitiesorremovalfromajob? Yes No
(b)Mandatedimplementationofaplanforsubstanceabusetreatmentinordertoavoidachangeinorremovalfromajob?
Yes No
10. Areyoucurrentlyinafitnessfordutyfollowuptestingprogram? Yes No
ExplainanyYESanswers,includingdate(s),location(s),anddescriptionofincident(s):
ApplicantsFullPrintedName SocialSecurityNumber
ApplicantsSignature Date
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PrivacyActStatement
Subsection(e)(3)of5U.S.C.552a(Section3ofthePrivacyAct))requiresthatTVAinformyouofitsauthoritytorequestinformationandtheuseswhichTVAmaymakeoftheinformationrequested.ThatsubsectionfurtherrequiresTVAtoinformyouoftheeffectsofnotprovidinganyoralltherequestedinformation.
TVAsauthoritytorequesttheinformationyouwillprovideisderivedfromtheTVAAct(16U.S.C.831831ee),ExecutiveOrderNo.10450,theAtomicEnergyActof1954,asamended,andanumberofotherstatutesandPresidentialExecutiveorders.Informationprovidedonthisformmaybefurnishedtopeople,agencies,organizations,orinstitutionsinordertoobtaininformationregardingyouinconnectionwithaninvestigationtodetermine:(1)fitnessforTVAemployment;(2)clearancetoperformservicesforTVAunderpersonalservices,consultant,orothercontracts;or(3)securityclearanceorclearanceforaccesstoTVAinstallations.
Furnishingtherequestedinformationisvoluntary;however,failuretoprovideallorpartoftheinformationmayresultinalackoffurtherconsiderationforemployment,clearanceoraccess,orintheterminationofyouremployment.
InformationprovidedonthisformisnormallyusedonlytodeterminefitnessforemploymentorsecurityclearanceforaccesstoTVAinstallations.Informationobtainedonthisformmaybefurnishedtothirdpartiesasauthorizedbylaw.Forexample,shouldadisputeariseoracongressionalinquirybemaderegardingTVAemploymentpractices,theinformationmaybemadeavailableoutsideofTVAinthecourseofthatdisputeorinquiry.Further,informationprovidedmaybeprovidedtoanotherfederalagencyifrelevanttoadecisiontobemadebythatagency.Inaddition,informationonthisformmaybemadeavailabletolawenforcementagenciesintheexerciseoftheirduties,ortoaprospectiveemployerorTVAcontractoruponproperrequest.
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CRIMINALHISTORY
CAUTION:Providingfalseordeliberatemisleadingstatementsoromissionoffactsmaybesufficientgroundsfordenialofunescortedaccess.Ifyouwerefingerprinted,reporttheoccurrence.Ifyoucurrentlyhaveanycriminalchargespending,reportthecharge.Youmustlistfelony,misdemeanor,trafficormilitarycriminalhistorytoincludecourtmartialornonjudicialpunishmentincludingguiltypleasandnolocontendere(meaningnocontest);anysuspendedsentences,pretrialdiversions,dismissals,nolleprosequi(meaningnotprosecuted).(Youmayomitnoninjurytraffic,parkingoffensesoflessthan$200orminorcivilactionssuchaszoningviolations,whenyouwerenotphysicallytakenintocustody,butyoumustincludeanyalcohol/drugrelatedtrafficoffensesregardlessofamountoffine.)
InitialSinceyour18thBIRTHDAY,haveyou:Update/ReinstatementSinceyourlastUA/UAAifwithin3years,haveyou: (Check Yes or No)
1. Beenheld,detained,takenintocustody,charged,arrested,indicted,fined,forfeitedbond,cited,orconvictedforaviolationofanylaw,regulationorordinance(e.g.,felony,misdemeanor,trafficormilitarycriminalhistory,etc.)ordoyounowhavesuchacasepending? Yes No
2. Beencharged,arrestedorconvictedofanalcoholoracontrolledsubstancerelatedoffense,whichincludes:drivingunder
theinfluence/whileintoxicated(DUI/DWI),orhavesuchacasepending? Yes No
3. Beencharged,arrestedorconvictedofaninfractionofthelawforwhichyouwerefinedmorethan$200? Yes No
4. Failedtoappearincourtforanyoffense(s)? Yes No
5. Areyoucurrentlyunderindictment,onprobation,parole,workrelease,orsubjecttoanyothercontrolofacourt(includingrestrainingorders,ordersofprotection)? Yes No
IfyouansweredYestoanyquestionabove,listalloccurrencesbelowandprovidespecificdetailsinthespaceprovidedonthenextpage.Addcontinuationpagesasnecessary.
Date(Mo/Day/Yr) Offense CityandStateofOffense
Misdemeanor Felony
Disposition/CurrentStatus(i.e.,guilty,
dismissed,fined,pending(listamount))
TheNuclearRegulatoryCommissionrequiresthatindividualswithUAA/UAatNuclearPowerPlantsreportLegalActions.Alegalactionwillbejudgedbaseduponitspotentialtoimpactuponyourtrustworthiness.ThisispartoftheBehavioralObservationProgram.YoumustalsoreportanylegalactionsfromthetimeyoucompletethisPHQuntilgrantedUAA.SuchlegalactionswillbeconsideredindeterminingyourreliabilityandtrustworthinessandTVAsdecisionwhethertograntormaintainyourUnescortedAccess.
ApplicantsFullPrintedName SocialSecurityNumber
ApplicantsSignature Date
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FINGERPRINTINFORMATIONFORFBICRIMINALHISTORYTheNuclearRegulatoryCommissionregulation(10CFR73.57)whichimplementsPublicLaw99399"OmnibusDiplomaticSecurityAndAntiTerrorismActOf1986"requireslicenseestotakethefingerprintsofpersonsseekingunescortedaccesstonuclearpowerfacilitiesoraccesstosafeguardsinformationandsubmitthoseprintstotheFBIrequestingcriminalhistorychecks.Inaccordancewith28CFR16.34,Proceduretoobtainchange,correctionorupdatingofidentificationrecordsIf,afterreviewingyouridentificationrecord,youbelievethatitisincorrectorincompleteinanyrespectandwishchanges,correctionsorupdatingoftheallegeddeficiency,youshouldmakeapplicationdirectlytotheagencywhichcontributedthequestionedinformation.YoumayalsodirectyourchallengeastotheaccuracyorcompletenessofanyentryonyourrecordtotheFBI,CriminalJusticeInformationServices(CJIS)Division,ATTN:SCU,Mod.D2,1000CusterHollowRoad,Clarksburg,WV26306.TheFBIwillthenforwardthechallengetotheagencywhichsubmittedthedatarequestingthatagencytoverifyorcorrectthechallengedentry.Uponthereceiptofanofficialcommunicationdirectlyfromtheagencywhichcontributedtheoriginalinformation,theFBICJISDivisionwillmakeanychangesnecessaryinaccordancewiththeinformationsuppliedbythatagency.Yourcriminalrecordorpersonalinformationcollectedandmaintainedasaresultofthefingerprintsmaynotbedisclosedtopersonsotherthanyourself,yourauthorizedrepresentative,ortothosewhohaveaneedtoknowtheinformationinperformingassigneddutiesintheprocessofgrantingordenyingunescortedaccesstothenuclearpowerfacilityoraccesstosafeguardsinformation.TheinformationobtainedfromacriminalhistoryrecordcheckwillbemadeavailabletoanyotherNRClicenseepursuanttoanaccessclearanceforyouatanotherfacility.Inaccordancewith28CFR16.32,Proceduretoobtainanidentificationrecord,youmayobtainacopythereofbysubmittingawrittenrequestviatheU.S.mailsdirectlytotheFBI,CriminalJusticeInformationServices(CJIS)Division,ATTN:SCU,Mod.D2,1000CusterHollowRoad,Clarksburg,WV26306.Suchrequestmustbeaccompaniedbysatisfactoryproofofidentity,whichshallconsistofname,dateandplaceofbirthandasetofrolledinkedfingerprintimpressionsplaceduponfingerprintcardsorformscommonlyutilizedforapplicantorlawenforcementpurposesbylawenforcementagencies.CriminalhistoryinformationobtainedthroughtheFBImayalsobemadeavailableforexaminationbyauthorizedrepresentativesoftheNRCinthecourseoftheirdutiestodeterminecompliancewithregulationsandlaws.ThecriminalhistoryrecordinformationwillberetainedasrequiredbyregulationafterUAA/UAtothenuclearpowerfacilityortosafeguardsinformationhasbeendeniedorterminated. Ihavethefollowingadditionalcommentsconcerningcriminalhistory:
ApplicantsFullPrintedName SocialSecurityNumber
ApplicantsSignature Date
PrivacyActStatement
Subsection(e)(3)of5U.S.C.552a(Section3ofthePrivacyAct))requiresthatTVAinformyouofitsauthoritytorequestinformationandtheuseswhichTVAmaymakeoftheinformationrequested.ThatsubsectionfurtherrequiresTVAtoinformyouoftheeffectsofnotprovidinganyoralltherequestedinformation.
TVAsauthoritytorequesttheinformationyouwillprovideisderivedfromtheTVAAct(16U.S.C.831831ee),ExecutiveOrderNo.10450,theAtomicEnergyActof1954,asamended,andanumberofotherstatutesandPresidentialExecutiveorders.Informationprovidedonthisformmaybefurnishedtopeople,agencies,organizations,orinstitutionsinordertoobtaininformationregardingyouinconnectionwithaninvestigationtodetermine:(1)fitnessforTVAemployment;(2)clearancetoperformservicesforTVAunderpersonalservices,consultant,orothercontracts;or(3)securityclearanceorclearanceforaccesstoTVAinstallations.
Furnishingtherequestedinformationisvoluntary;however,failuretoprovideallorpartoftheinformationmayresultinalackoffurtherconsiderationforemployment,clearanceoraccess,orintheterminationofyouremployment.
InformationprovidedonthisformisnormallyusedonlytodeterminefitnessforemploymentorsecurityclearanceforaccesstoTVAinstallations.Informationobtainedonthisformmaybefurnishedtothirdpartiesasauthorizedbylaw.Forexample,shouldadisputeariseoracongressionalinquirybemaderegardingTVAemploymentpractices,theinformationmaybemadeavailableoutsideofTVAinthecourseofthatdisputeorinquiry.Further,informationprovidedmaybeprovidedtoanotherfederalagencyifrelevanttoadecisiontobemadebythatagency.Inaddition,informationonthisformmaybemadeavailabletolawenforcementagenciesintheexerciseoftheirduties,ortoaprospectiveemployerorTVAcontractoruponproperrequest.
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NOTIFICATIONOFLEGALACTION
Individualsapplyingfor,certifiedfor,grantedormaintainingUnescortedAccessAuthorization(UAA),orUnescortedAccess(UA),orFitnessforDutyAuthorization(FFDA)atnuclearpowerplantsmustreportlegalactionsfromthetimetheindividualsignsthePersonalHistoryQuestionnaire(PHQ)uptoandincludingthetimethattheindividualUAA/UA/FFDAisterminated.Legalactionswillbejudgedbaseduponthepotentialtoimpactuponyourtrustworthiness.ThisispartoftheBehavioralObservationProgram(BOP).
Tocomplywithregulatoryrequirements,youarerequiredtoreportANYlegalaction(youmayomitnoninjurytrafficorparkingoffensesoflessthan$200butyoumustincludeanyalcohol/drugrelatedtrafficoffensesregardlessofamountoffine)inwriting,toNuclearAccessServicesPlantAccessorNuclearAccessServicesCorporateandyoursupervisornolaterthanthenextbusinessdayafterthelegalactionoccurred.YoumustalsoreportanylegalactionsfromthetimeyoucompletethisPHQuntilgrantedUnescortedAccess.Youarealsorequiredtoreportanychangesinthestatusofanylegalactionbythenextbusinessday(i.e.,changesincourtdate,chargesdropped,arrestresultinginconviction,placedonprobation,parole,workrelease,orsubjecttoanyothercontrolofthecourt.)Alegalactionisdefinedas:
Aformalactiontakenbyalawenforcementauthorityorcourtoflaw,includingbeingheld,detained,takenintocustody,charged,arrested,indicted,fined,forfeitedbond,cited,orconvictedforaviolationofanylaw,regulationorordinance.
Thisincludesfelony,misdemeanor,serioustrafficoffenses,seriouscivilchargesormilitarychargesbutdoesnotincludeminormisdemeanorssuchasparkingticketsorminorcivilactionssuchaszoningviolationsorminortrafficviolationssuchasmovingviolationswhentheindividualwasnotphysicallytakenintocustody,
Italsoincludesthemandatedimplementationofaplanfortreatmentormitigationinordertoavoidapermanentrecordofanarrestorconvictionsinresponsetothefollowing:(1)Theuse,saleorpossessionofillegaldrugs;(2)Theabuseoflegaldrugsoralcohol;or(3)Therefusaltotakeadrugoralcoholtest.
Thisdoesnotincludeminormisdemeanorssuchasparkingtickets,minorcivilactions,suchaszoningviolations,orminortrafficviolationssuchasmovingviolationswhentheindividualwasnotphysicallytakenintocustody,providedthelegalactiondidnotincludeuse.Sale,orpossessionofillegaldrugs;abuseoflegaldrugsoralcohol;orrefusaltotakeadrugoralcoholtest.
Failuretoreportalegalactionasrequiredmayresultindenial,suspension,revocation,orwithdrawalofUAA/UAorFFDA,anddisciplinaryactionuptoandincludingdischarge.Bymysignaturebelow,IcertifythatIhavereadthisnotificationandunderstandmyobligationtoreportlegalactionsfromthesigningofthisdocumentuntilauthorizationisterminated.
ApplicantsFullPrintedName SocialSecurityNumber
ApplicantsSignature Date
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Parainformacionenespanol,visitewww.consumerfinance.gov/learnmoreoescribealaConsumerFinancialProtectionBureau,1700GStreetN.W.,Washington,D.C.20552.
ASummaryofYourRightsUndertheFairCreditReportingAct
ThefederalFairCreditReportingAct(FCRA)promotestheaccuracy,fairness,andprivacyofinformationinthefilesofconsumerreportingagencies.Therearemanytypesofconsumerreportingagencies,includingcreditbureausandspecialtyagencies(suchasagenciesthatsellinformationaboutcheckwritinghistories,medicalrecords,andrentalhistoryrecords).HereisasummaryofyourmajorrightsundertheFCRA.Formoreinformation,includinginformationaboutadditionalrights,gotowww.consumerfinance.gov/learnmoreorwriteto:ConsumerFinancialProtectionBureau1700GStreetN.W.,Washington,D.C.20552. YoumayhaveadditionalrightsunderMainesFCRA,ME.Rev.Stat.Ann.10,Sec1311etseq.
Youmustbetoldifinformationinyourfilehasbeenusedagainstyou.Anyonewhousesacreditreportoranothertypeofconsumerreporttodenyyourapplicationforcredit,insurance,oremploymentortotakeanotheradverseactionagainstyoumusttellyou,andmustgiveyouthename,address,andphonenumberoftheagencythatprovidedtheinformation.
Youhavetherighttoknowwhatisinyourfile.Youmayrequestandobtainalltheinformationaboutyouinthefilesofaconsumerreportingagency(yourfiledisclosure).Youwillberequiredtoprovideproperidentification,whichmayincludeyourSocialSecuritynumber.Inmanycases,thedisclosurewillbefree.Youareentitledtoafreefiledisclosureif:
o apersonhastakenadverseactionagainstyoubecauseofinformationinyourcreditreport;o youarethevictimofidentitytheftandplaceafraudalertinyourfile;o yourfilecontainsinaccurateinformationasaresultoffraud;o youareonpublicassistance;o youareunemployedbutexpecttoapplyforemploymentwithin60daysInaddition,allconsumersareentitledtoonefreedisclosureevery12monthsuponrequestfromeachnationwidecreditbureauandfromnationwidespecialtyconsumerreportingagencies.Seewww.consumerfinance.gov/learnmoreforadditionalinformation.
Youhavetherighttoaskforacreditscore.Creditscoresarenumericalsummariesofyourcreditworthinessbasedon
informationfromcreditbureaus.Youmayrequestacreditscorefromconsumerreportingagenciesthatcreatescoresordistributescoresusedinresidentialrealpropertyloans,butyouwillhavetopayforit.Insomemortgagetransactions,youwillreceivecreditscoreinformationforfreefromthemortgagelender.
Youhavetherighttodisputeincompleteorinaccurateinformation.Ifyouidentifyinformationinyourfilethatisincompleteorinaccurate,andreportittotheconsumerreportingagency,theagencymustinvestigateunlessyourdisputeisfrivolous.Seewww.consumerfinance.gov/learnmoreforanexplanationofdisputeprocedures.
Consumerreportingagenciesmustcorrectordeleteinaccurate,incomplete,orunverifiableinformation.Inaccurate,incompleteorunverifiableinformationmustberemovedorcorrected,usuallywithin30days.However,aconsumerreportingagencymaycontinuetoreportinformationithasverifiedasaccurate.
Consumerreportingagenciesmaynotreportoutdatednegativeinformation.Inmostcases,aconsumerreportingagencymaynotreportnegativeinformationthatismorethansevenyearsold,orbankruptciesthataremorethan10yearsold.
Accesstoyourfileislimited.Aconsumerreportingagencymayprovideinformationaboutyouonlytopeoplewithavalidneedusuallytoconsideranapplicationwithacreditor,insurer,employer,landlord,orotherbusiness.TheFCRAspecifiesthosewithavalidneedforaccess.
Youmustgiveyourconsentforreportstobeprovidedtoemployers.Aconsumerreportingagencymaynotgiveoutinformationaboutyoutoyouremployer,orapotentialemployer,withoutyourwrittenconsentgiventotheemployer.Writtenconsentgenerallyisnotrequiredinthetruckingindustry.Formoreinformation,gotowww.consumerfinance.gov/learnmore.
Youmaylimitprescreenedoffersofcreditandinsuranceyougetbasedoninformationinyourcreditreport.Unsolicitedprescreenedoffersforcreditandinsurancemustincludeatollfreephonenumberyoucancallifyouchoosetoremoveyournameandaddressfromtheliststheseoffersarebasedon.Youmayoptoutwiththenationwidecreditbureausat18885678688).
Youmayseekdamagesfromviolators.Ifaconsumerreportingagency,or,insomecases,auserofconsumerreportsorafurnisherofinformationtoaconsumerreportingagencyviolatestheFCRA,youmaybeabletosueinstateorfederalcourt.
Identitytheftvictimsandactivedutymilitarypersonnelhaveadditionalrights.Formoreinformation,visitwww.consumerfinance.gov/learnmore.
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StatesmayenforcetheFCRA,andmanystateshavetheirownconsumerreportinglaws.Insomecases,youmayhavemorerightsunderstatelaw.Formoreinformation,contactyourstateorlocalconsumerprotectionagencyoryourstateAttorneyGeneral.Forinformationaboutyourfederalrights,contact: TYPEOFBUSINESS: CONTACT:
1.a,Banks,savingsassociations,andcreditunionswithtotalassetsofover$10billionandtheiraffiliates.b,Suchaffiliatesthatarenotbanks,savingsassociations,orcreditunionsalsoshouldlist,inadditiontotheBureau:
a,BureauofConsumerFinancialProtection1700GStreetNWWashington,DC20006b,FederalTradeCommission:ConsumerResponseCenterFCRAWashington,DC20580(877)3824357
2.Totheextentnotincludedinitem1above:
a.Nationalbanks,federalsavingsassociations,andfederalbranchesandfederalagenciesofforeignbanks
b.Statememberbanks,branchesandagenciesofforeignbanks(otherthanfederalbranches,federalagencies,andinsuredstatebranchesofforeignbanks),commerciallendingcompaniesownedorcontrolledbyforeignbanks,andorganizationsoperatingundersection25or25AoftheFederalReserveAct
c.NonmemberInsuredBanks,InsuredStateBranchesofForeignBanks,andinsuredstatesavingsassociationsd.FederalCreditUnions
a. OfficeoftheComptrolleroftheCurrencyCustomerAssistanceGroup1301McKinneyStreet,Suite3450Houston,TX770109050b. FederalReserveConsumerHelpCenterP.O.Box1200Minneapolis,MN55480c. FDICConsumerResponseCenter1100WalnutStreet,Box#11KansasCity,MO64106
d,NationalCreditUnionAdministrationOfficeofConsumerProtection(OCP)DivisionofConsumerComplianceandOutreach(DCCO)1775DukeStreetAlexandria,VA22314
3.Aircarriers Asst.GeneralCounselforAviationEnforcement&ProceedingsDepartmentofTransportation400SeventhStreetSWWashington,DC20590
4.CreditorsSubjecttoSurfaceTransportationBoard OfficeofProceedings,SurfaceTransportationBoardDepartmentofTransportation1925KStreetNWWashington,DC20423
5.CreditorsSubjecttoPackersandStockyardsAct
NearestPackersAndStockyardsAdministrationareasupervisor
6.SmallBusinessInvestmentCompanies..
AssociateDeputyAdministratorforCapitalAccess
UnitedStatesSmallBusinessAdministration
406ThirdStreet,SW,8thFloor
Washington,DC20416
7.BrokersandDealers
SecuritiesandExchangeCommission
100FStNE
Washington,DC20549
8.FederalLandBanks,FederalLandBankAssociations,FederalIntermediateCreditBanks,andProductionCreditAssociations
FarmCreditAdministration1501FarmCreditDrive
McLean,VA221025090
9.Retailers,FinanceCompanies,andAllOtherCreditorsNotListedAbove
FTCRegionalOfficeforregioninwhichthecreditoroperatesorFederalTradeCommission:ConsumerResponseCenterFCRA
Washington,DC20580
(877)3824357