AUTHORIZATION FOR RELEASE OF INFORMATION
PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)
STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE
I Authorize the Department of Veterans Affairs (VA), and authorized agents, to obtain my credit reports
from any consumer or credit reporting agency for employment purposes.
The Fair Credit Reporting Act, as amended (15 U.S.C. § 1681, et seq.) allows VA to get one or more credit
reports on you for employment. Should a decision to take any adverse action against you be made, based
either in whole or in part on the credit report, you should know that the consumer or credit reporting agency
that provided the report has played no role in the decision to take action.
VA is requesting an investigation to determine your fitness to work for, or on behalf of, the Federal
Government. The information in this authorization will be given to the consumer or credit reporting agency
so that the agency will release information about you and your credit history. This information may be
disclosed to other Federal Agencies to fulfill official responsibilities, to the extent that the disclosure is
permitted by law.
I Understand that the information released by records custodians and sources of information is for official
use by the Department of Veterans Affairs, all affiliated agencies and departments, to determine suitability
and/or fitness for employment on the behalf of the Federal Government.
Copies of this authorization that show my signature are as valid as the original release signed by me. This
authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the
Department of Veterans Affairs, whichever is sooner.
SIGNATURE OF EMPLOYEE (Sign in ink)
TYPE OR PRINT LEGIBLY FULL NAME DATE SIGNED
OTHER NAMES USED
HOME TELEPHONE NUMBER
(Include Area Code)
CURRENT ADDRESS (Include Street, City, State, and ZIP Code)
VA FORM
OCT 2017
0710
