| Public Law 93-579 states in part: |
| "The purpose of this Act is to provide certain safeguards for an individual against invasion of personal privacy by requiring Federal agencies...to permit an individual to determine what records pertaining to him are collected, maintained, used, or dismissed by such agencies." |
| The following questions are based upon that act and are necessary in order that this individual may make a reasonable determination concerning divulgence of information to this agency. |
| 1. Name of public servant: ___________________________________________________________ 2. Residence address ______________________________________________________________ City:________________________________ State:___________________ Zip:_________________ 3. Name of Department of government bureau or agency by which public servant is employed: ________________________________________________________________________________ Supervisor's name:_________________________________________________________________ 4. Department's mailing address:______________________________________________________ City:__________________________________State:____________________Zip:_______________ 5. Will public servant uphold the United States Constitution? Yes No 6. Did public servant furnish proof of identity? Yes No 7. Two pieces of ID are necessary: # 1-Badge No._______________________ # 2-Drivers License___________________ # 3-Credit Card______________________ 8. Will public servant furnish a copy of law or regulations which authorises this investigation? Yes No 9. Will the public servant read aloud that portion of the law which authorises this investigation ? Yes No 10. Are the answers Voluntary? __________ Mandatory? ___________ 11. Are the questions to be asked based upon a specific law or regulation?____________________________ 12. What other uses may be made of this information? ____________________________________________ ________________________________________________________________________________________ 13. What other agencies may have access to this information? _____________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Public Servant Signature _________________________________ Date ___________________________ |
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