NOTIFICATION OF DEROGATORY INFORMATION & WRITTEN STATEMENT
Selectee Name:
Purpose: As a result of a routine background investigation, which is conducted on all Non-Appropriated Funds/Appropriated Funds applicants and employees by this office, we have been furnished information regarding a past record which requires further clarification. Specifically, we have been provided information that must be addressed to determine if you are suitable for employment.
You are being asked to provide a written statement regarding the incident from your point of view, any mitigating circumstances, and the disposition of the case. This information will be shared with the hiring manager and all individuals in the process of determining your suitability for employment with the United States Government. You do not have to provide a statement if you do not believe it is in your best interest. If you do not want to provide a statement simply indicate such and sign and date below. Additional pages may be used if you require more space. You may contact the agency which ran the background check and provided the results to our office, and request a copy of the investigation results to dispute the charges. A statement is still required if this is your course of action so the hiring process may proceed.
Actionable Issues/Offenses are as follows:
a. DA form 3433-1 Self-disclosed, Speeding, Stoddard County Missouri, Disposition: “Paid Ticket”
Written Statement:
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SELECTEE SIGNATURE DATE
NOTIFICATION OF DEROGATORY INFORMATION & WRITTEN STATEMENT
SUPPLEMENTAL PAGE
Selectee Name:
Written Statement:...