SpecialAgentApplicant..docVIP

Special Agent Applicant Drug Use Statement Privacy Act Statement Authority: Title 5, U.S. Code, Sections 301 and 1104; and Executive Order 12564, September 15, 1986. Principal Purpose: This form requests information about personal history of use, trafficking, or other activities involving illegal drugs and drug paraphernalia. Its purpose is to determine suitability for employment with the DEA, after a conditional offer of employment has been made, and as part of DEA’s applicant screening program. Completion of this form is voluntary; however, non-completion of the form may result in the withdrawal of a conditional offer of employment. Routine Uses: Information contained in this form may be disclosed to other federal agencies for assistance in completing the security clearance process. Other routine uses include disclosure to foreign, federal, state and local law enforcement and regulatory agencies, for referral to avoid duplication of the investigative process and where the appropriate agency is charged with the responsibility of investigating or prosecuting potential violations of law. Additional routine uses are set forth in the Systems Record Notice for DEA-018, DEA Applicant Investigations, published and updated in the Federal Register. Name: Last____________________ First___________________ Middle___________ Division ____________ SSN: ________________ Date of Birth _____________ As an applicant for a Special Agent position with the Drug Enforcement Administration (DEA) any prior drug use, attempted use, and/or experimentation must be disclosed before you can be considered for further processing. Do not include instances in which substances were prescribed, administered, or dispensed by a duly licensed physician for treatment of a legitimate medical condition. Please read the following instructions very carefully before answering the drug questions and initial your acknowledgment: ______ Initials I understand that I must provide truthful informati