PS 2181-A

Pre-Employment Screening — Authorization and Release (4/2006)

Download and Print the PS 2181-A

TO: POSTMASTER

Applicant: Carefully read the following information before you complete and sign this form.

Applicant's Name (last, first, MI) Date of Birth (MM/DD/YYYY) Home Telephone Number (include area
code)

This constitutes my consent and authorization to the disclosure or furnishing of any relevant and necessary information or records to any duly authorized employment official or to a contractor acting on behalf of the USPS by any person, corporation, agency, or association concerning my character, employment, criminal records, driving records, or military service as may be relevant and necessary for a determination of my suitability for employment with the USPS.

This authorization is executed with full knowledge and understanding that the USPS will take measures to protect the aforementioned information against unauthorized disclosure to any parties not having a legitimate need for it in the discharge of official business of the United States, or its agencies and instrumentalities.

I hereby RELEASE the aforementioned persons, corporations, agencies, associations and their employees, agents, and representatives from any and all liability for damages resulting from a decision by the USPS not to employ me on account of compliance, or any attempts at compliance with this authorization, except for any damages resulting from knowingly providing false or misleading information or records about me.

A copy of this authorization shall be as effective and valid as the original. This authorization shall be valid for 12 months from the date it is signed.

Date Signed Signature of Applicant
PS Form 2181-A, April 2006 (PSN 7530-02-000-7401)

Privacy Act Statement: Your information will be used to 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 receive full 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 a congressional 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 information regarding our privacy policy visit us at usps.com®.

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