FBI Citizens Academy ApplicationFBI New Haven — 2016
Fields marked in red are mandatory. You must enter N/A if not applicable.
Authorization to Conduct Law Enforcement Checks
By typing my name and dating the above, I acknowledge that I
authorize the FBI to conduct law enforcement checks as noted above. Further, I certify that my statements on this form are true, complete,
and correct to the best of my knowledge.
Privacy Act Statement and Consent
This is to advise you, in conformance with the Privacy Act of 1974,
that the collection of this information is authorized under Title 28 U.S.C.533;
28 C.F.R. 0.85; Executive Order 12958, as amended by 13292; 5
U.S.C.552a(e)(10); 44 U.S.C. chapters 21 and 33; 40 U.S.C. chapter 318a; and
Title 41 CFR 102-81.10 and 81.15. The furnishing of this information, including
your Social Security number, is voluntary on your part and will be used for the
purpose of providing clearance to participate in the FBI’s Citizens Academy
program. Information you provide will be protected and used in strict
compliance with the Privacy Act and the routine uses most recently published in
the Federal Register for the FBI’s Central Records System (Justice/FBI-002) and
the FBI’s Blanket Routine Uses (Justice/ FBI-BRU). You are not required to
execute this form; however, if you do not, this refusal may result in your
application for participation in the FBI Citizens Academy program being
rejected. Knowingly falsifying or concealing information required on this form
will result in your application being rejected. In addition, Title 18 Section
1001 of the U.S. Code provides that knowingly falsifying or concealing a
material fact may under certain circumstances constitute a felony resulting in
fines and/or imprisonment.
By typing my name and
dating the above, I acknowledge that I authorize and agree with the execution
of the above Privacy Act Statement and Consent form.
Citizens Academy Photograph Consent/Release Form
During your participation in an FBI Community Outreach Program event or activity, an FBI photographer may photograph the event or activity. By signing this consent/release form, you agree that your image appearing in any such photograph may be used by the FBI and the community outreach program for public affairs purposes.
For questions, please contact the FBI New Haven community outreach specialist at (203) 777-6311.
Deadline for Spring 2016
Applications: Sunday, November 15, 2015