ATTENTION: PLEASE READ PRIOR TO COMPLETION OF ANY FORMS
PRIVACY ACT OF 1974 NOTICE
In accordance with the Privacy Act of 1974 (Public Law 93-579, 5 U.S.C. 552a), you are hereby notified
that:
(1) Public Law 86-36, Public Law 88-290, Title 5 U.S.C.; Executive Order 10450, Executive Order
12958, and Executive Order 12333; Director of Central Intelligence Directive 1/14; NSA/CSS PMM
Chapter 808 authorize the National Security Agency/Central Security Service to receive and maintain
personal information on applicants and employees.
(2) The information is required to determine and assess your qualifications and suitability for
NSA/CSS employment and for access to sensitive cryptologic information and NSA/CSS facilities.
(3) The information is to be furnished to officials of NSA/CSS and of other Federal Agencies
charged with investigating and evaluating the applicant’s qualifications and suitability.
Information
provided by you, including information on possible or actual violations of criminal laws, will be
disseminated as appropriate to Federal, state and local authorities with law enforcement responsibilities.
NSA’s Blanket Routine Uses, found at 58 Fed. Reg. 10,531 (1993) apply.
(4) Disclosure of the requested information is voluntary. If you do not provide the requested
information, this may result in processing delays or the inability of the Agency to reach a final
determination with respect to employment, clearance, and access to NSA/CSS spaces and information.
The request for your social security number is authorized by Executive Order 9397.
Providing it is
voluntary. It will be used to identify you during the investigations and evaluations referred to above.
Failure to provide it will delay your processing.
A COPY OF THIS NOTICE IS AVAILABLE FOR YOUR RETENTION UPON YOUR REQUEST
SIGNATURE
I certify that I have read and understand the above.
FORM P1613A REV NOV 98 (Supersedes P1613A REIN NOV 90 which is obsolete)
NSN: 7540-FM-001-0262
FOR USE WITH FORM FD-258, FINGERPRINT CARD, ONLY
DATE