Attachment 1: SAM Form

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U.S. Army Corps of Engineers, Mobile District (SAM)
QUESTIONNAIRE FOR NON-SENSITIVE POSITIONS (Campground Attendants and Volunteers) For use of this form, see EP/ER/EC 1130-2-550; the proponent agency is CESAM-OP-TR.

AGENCY USE ONLY:

Project: choose from drop down list

UIC: W2SR04

SOI:

Park Attendant

Volunteer Time Period:

Volunteer

Coordinator:

Less than 6 months

More than 6 months

IPAC Code:

SON:

Fingerprints Submitted (Date):

Branch of Service: U.S. ARMY
FEDEX Tracking:

Requesting Official:
Name

Date

Signature

PURPOSE: The Mobile District conducts background investigations to establish that applicants or incumbents either employed by the Government or working for the Government under contract, are suitable for the job. Information from this form is used primarily as the basis for this investigation. Provision of this information is voluntary.

AUTHORITY: The Mobile District is authorized to ask for this information under Executive Order 10577, sections 3301 and 3302 of title 5, U.S. Code and parts 5, 731, and 736 of Title 5, Code of Federal Regulations.

PENALTIES FOR INACCURATE OR FALSE STATEMENTS: The U.S. Criminal Code, Title 18, Section 1001, provides that knowingly falsifying or concealing a material fact is a felony which may result in fines up to $10,000, and/or 5 years imprisonment, or both. In addition, Federal agencies generally fire, or disqualify individuals who have materially and deliberately falsified information, and this remains a part of the permanent record for future placement.

DISCLOSURE OF INFORMATION: Our collection, maintenance, use and dissemination of your personally identifiable information gathered for our background investigation is governed by the Privacy Act (5 U.S.C. § 552a, as amended). The information you give us is for the purpose of determining your suitability to serve as a Campground Attendant or Volunteer and will be protected from misuse and unauthorized disclosure as provided by the Act.

SUBJECT INFORMATION:

(Mr./Mrs./etc.)

First Name

Date of Birth

Middle Name or NMN

Last Name

(Jr./Sr./II ect.)

Place of Birth - City, State and Country
Home

Primary Phone Number (Area code +)

Cell

Home
Secondary Phone Number (Area code +)

U.S. Citizen ? (Necessary Documentation to be provided under separate/secure cover.)

E-mail Address

Cell
Yes

No

AUTHORIZATION:

I authorize any investigator, special agent, or duly accredited representative of the U.S. Army Corps of Engineers, Mobile District, conducting my background investigation to obtain any information relating to myself for said purpose. I understand that the information released to the authorized