PRIVACY ACT STATEMENT AND DISCLOSURE CONSENT FORM The authority for obtaining information on this form is 5 USC 301 and 44 USC 3101. Executive AUTHORITY: Order 9397 of 22 November 1943 authorizes use of your Social Security Number. To screen applicants who want to volunteer as a Youth Sports Coach. PRINCIPAL PURPOSE: This form will be utilized by the civilian and military members of the Provost Marshall on a ROUTINE USE(S): need to know to check Provost Marshall records for history or indications of conditions which could deem applicants unsuited for coaching Youth Sports. Disclosure is voluntary. However, failure to do so may result in denial of DISCLOSURE OF INFORMATION: permission to coach Youth Sports. Information collected will be submitted to the Youth Sports Director. ______________________________ __________________________________________ DATE APPLICANT APPLICANT SPONSOR Name: _____________________________ Name: _____________________________ SSN: _____________________________ SSN: _____________________________ DOB: _____________________________ DOB: _____________________________ Driver’s license No. & State Driver’s license No. & State ___________________________________ ___________________________________
PRIVACY ACT STATEMENT AND DISCLOSURE CONSENT FORM AUTHORITY: The authority for obtaining information on this form is 5 USC 301 and 44 USC 3101. Executive Order 9397 of 22 November 1943 authorizes use of your Social Security Number. PRINCIPAL PURPOSE: To screen applicants who want to volunteer as a Youth Sports Coach. ROUTINE USE(S): This form will be utilized by the civilian and military members of the Provost Marshall on a need to know to check Provost Marshall records for history or indications of conditions which could deem applicants unsuited for coaching Youth Sports. DISCLOSURE OF INFORMATION: Disclosure is voluntary. However, failure to do so may result in denial of permission to coach Youth Sports. Information collected will be submitted to the Youth Sports Director. ______________________________ __________________________________________ DATE APPLICANT APPLICANT SPONSOR Name: _____________________________ Name: _____________________________ SSN: _____________________________ SSN: _____________________________ DOB: _____________________________ DOB: _____________________________ Driver’s license No. & State Driver’s license No. & State ___________________________________ ___________________________________
Back%20Ground%20Check%20form(1).docx