Fillable PRIVACY ACT AUTHORIZATION AND WAIVER , (last 4 (Department of Labor)

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PRIVACY ACT AUTHORIZATION AND WAIVER , (last 4 (Department of Labor)

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PRIVACY ACT AUTHORIZATION AND WAIVER
, (last 4 digits of social I,
security number), (date of birth), authorize the U.S. Department of
Labor and the Office of Job Corps to disclose any information regarding my records at the
(Job Corps
This authorization is effective on the date it is signed, and is effective until specifically
revoked by me in writing.
A copy of this authorization shall have the same force and effect as the signed original.
Printed Name
Signature
Separation Year
Date
Address
Phone Number
E-mail Address
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that I am
the claimant named above.
Signature
Date
Center in
Center Address) to the following individuals and/or entities:
Select Job Corps Center
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PRIVACY ACT AUTHORIZATION AND WAIVER , (last 4 (Department of Labor)

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Completed 20 May 2022

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