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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 usedto determine your suitability for employment. Collection is authorized by 39 USC 401, 410, 1001, 1005, and 1206. Providing the information is voluntary, but if it is not provided, you may not receivefull consideration. We may only disclose your information as follows: in relevant legal proceedings; to law enforcement when the USPS® or requesting agency becomes aware of a violation of law; to acongressional 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 informationregarding our privacy policy visit us at usps.com®.
Applicant's Name (last, first, MI) Date of Birth (MM/DD/YYYY) Home Telephone Number (include area code)

Other Names and Dates When Used: Listthe names you have used in the past, beginning with the most recent (#1) and working backward. You must list all names you have ever used and the dates you used each name. If you need more space toprovide complete information, please continue on the reverse side of this form.
#1 Previous Name Used #2 Previous Name Used From Month/Year (MM/YYYY) To: From Month/Year (MM/YYYY) To: From Month/Year(MM/YYYY) To:

#3 Previous Name Used

Where You Have Lived: List the places where you have lived, beginning with the most recent (#1) and working back 5 years. All periods must be accounted for. Besure 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...