Pre-Employment Screening —
Authorization and Release
Applicant: Carefully read the following information before you complete and sign this form
Privacy Act Statement: Your information will be used to determine your suitability for employment. Collection is authorized by
39 U.S.C. 401, 410, 1001, 1005, and 1206. Providing the information is voluntary, but if it is not provided, you may not receive full
consideration. We may only disclose your information as follows: in relevant legal proceedings; to law enforcement when the
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USPS or requesting agency becomes aware of a violation of law; to a congressional office at your request; to entities or individuals
under contract with USPS; to entities authorized to perform audits; to labor organizations as required by law; to federal, state, local,
or foreign government agencies regarding personnel matters; to the Equal Employment Opportunity Commission; and to the Merit
Systems Protection Board or Office of Special Counsel. For more information regarding our privacy policy visit us at usps.com
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Applicant’s Name (last, first, MI)
Date of Birth (MM/DD/YYYY)
Home Telephone Number (include area code)
Email Address
Other Names and Dates Used: List all the names you have used in the past, beginning with the most recent (#1) and working
backward (#2, #3, etc.). You must list all names you have ever used and the dates you used each name.
If you need more space to provide complete information, please continue on the reverse side of this form.
#1 Previous Name Used
From Month/Year (MM/YYYY)
To:
#2 Previous Name Used
#3 Previous Name Used
To:
To:
From Month/Year (MM/YYYY)
From Month/Year (MM/YYYY)
Where You Have Lived: List the places where you have lived, beginning with the most recent (#1) and working back 5 years
(#2, #3, ect.). You must account for all periods. Be sure to indicate the actual physical location of your residence; do not list a
permanent address when you were actually living at a school address. Use the two letter Postal Service™ abbreviation code for
the state. If you need more space to provide complete information, please continue on the reverse side of this form.
.
#1 From Month/Year (MM/YYYY)
Street Address
City
County State
ZIP Code™
To: Present
#2 From Month/Year (MM/YYYY)
Street Address
City
County
State
ZIP Code
To:
#3 From Month/Year (MM/YYYY)
Street Address
City
County
State
ZIP Code
To:
#4 From Month/Year (MM/YYYY)
Street Address
City
County State ZIP Code
To:
#5 From Month/Year (MM/YYYY)
Street Address
City
County
State
ZIP Code
To:
This constitutes my consent and authorization to the disclosure or furnishing of any relevant and necessary information or records
to any duly authorized employment official or to a contractor acting on behalf of the United States Postal Service by any person,
corporation, agency, or association concerning my character, employment, criminal records, driving records, or military service as
may be relevant and necessary for a determination of my suitability for employment with the United States Postal Service.
This authorization is executed with full knowledge and understanding that the United States Postal Service will take measures to
protect the mentioned information against unauthorized disclosure to any parties not having a legitimate need for it in the discharge
of official business of the United States, or its agencies and instrumentalities.
I hereby release the mentioned persons, corporations, agencies, associations and their employees, agents, and representatives
from any and all liability for damages resulting from a decision by the United States Postal Service not to employ me on account of
compliance, or any attempts at compliance with this authorization, except for any damages resulting from knowingly providing false
or misleading information or records about me.
A copy of this authorization is as effective and valid as the original. If hired, this authorization is valid for the duration of my
employment to demonstrate continued suitability for employment with the United States Postal Service.
Date Signed Signature of Applicant
Printed Name of Applicant
PS Form
2181-A, October 2015 (PSN 7530-02-000-7401)
click to sign
signature
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