Title 5, U.S. Code, Sections 301 and 1104, Executive Order 9297 and 5 U.S.C. Â§522(a)(2000), Privacy Act of 1974.
This form requests personal information for the purpose of conducting a security clearance process of applicants desiring to become an authorized user of the Seizure System.
This information is provided pursuant to 5 U.S.C 552a (Privacy Act of 1974) for individuals supplying information for inclusion in a system of records.
The primary use of this information is to conduct a modified background check as a condition of granting authorization to access this system.
Information contained in this form may be disclosed to appropriate Federal, state, or local agencies for assistance in completing the security clearance process. Other routine uses include the disclosure to agencies responsible for investigating, prosecuting, enforcing, or implementing statutes, rules, regulations or orders when there is violation or possible violation of civil or criminal law or when conducting an audit of system usage.
Furnishing the information on this form is voluntary; however, non-completion of this form may result in delay or suspension of the authorization process to obtain access to this system.
any investigator, special agent, or other duly accredited representative of the authorized Federal agency conducting my modified background investigation, to obtain any information relating to my activities from criminal justice agencies or other sources of information. This information may include, but is not limited to, criminal history record information. I authorize the Federal agency to conduct my investigation for the purpose of making a determination of my suitability for access to this system.
I Further Authorize
custodians of records and sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.
that the information released by records custodians and sources of information is for official use by the Federal Government only for the purposes provided in this form and may be re-disclosed by the Government only as authorized by law.
Once this statement is received by esp.usdoj.gov, this authorization is valid.
By clicking "I Agree" you agree and consent to (a) the ESP Authorization for Release of Information, (b) the submission of your User Account Request form, and (c) receive required notifications from ESP electronically.