Application to Serve on Advisory Board

OMB Control #3170-0037
Expiration Date: 07/31/2016

APPLICATION TO SERVE ON
ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau
You are being considered for a position as a representative on an Advisory Board, Body, Panel, Committee
or other similar group (generally, “Advisory Group”) of the Consumer Financial Protection Bureau (CFPB).
Please complete and submit this questionnaire as part of the application and selection process for the
Advisory Group. CFPB will use this information to perform a background check, conduct a conflict of
interest review, and perform other similar due diligence activities associated with your application and
possible selection as a representative on the Advisory Group. CFPB will use the information you provide
only for these purposes or other purposes authorized by law, or as outlined under the attached Privacy Act
Statement. Please ensure that the information you provide is complete and accurate.
Select Advisory Group to which you are applying to be a representative.
Consumer Advisory Board

o

Community Bank Advisory
Council

o

Credit Union Advisory Council

Name (Print last, first, middle initial)

E-mail Address

Position/Title

How long at employer?

Employer

Address

Work Phone

Cell Phone

Other

Place of Birth

Date of Birth

Gender – M of F

List your business or professional experience not listed on your resume.

Identify the statutory membership categories that are
applicable to you.
Consumer protection
Financial services

Depository institution primarily serving underserved
communities

Community development

Representing communities that have been significantly
impacted by higher-priced mortgage loans

Fair lending and civil rights

Other

Consumer financial products or services
Identify your area of expertise.
Payday & Auto Loans Expertise
Overdraft & Deposits
Mortgage – Origination, Compliance
Credit Reporting, Cards, Payments

Financial Education
Mortgage – Underserved Populations, Niche Products
Debt Collection
Underserved Populations, Consumer Protection

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-0037
Expiration Date: 07/31/2016
List other affiliations and/or service as a community leader that would benefit you in your role as a member of the advisory
group.

List any Federal advisory committee or any board on which you are currently a member and the number of years you have
served on that committee or board.

1.

Have you ever been convicted of a felony? (A felony is defined as any violation of law punishable by
imprisonment longer than one year).
Yes – Please explain on the attached continuation sheet.
No

2.

Are you a US citizen?
Yes
No
If no, do you have permanent residency status?
Yes
No

3.

Have you been a party to a civil or criminal action involving a financial institution or service provider?
Yes – Please explain on the attached continuation sheet.
No

4.

Are you now or have you in the last year been subject to the registration and reporting requirements of the
Lobbying Disclosure Act (2 U.S.C. 1605)?
Yes – Please explain on the attached continuation sheet.
No

5.

Are you currently engaged in any business before the CFPB?
Yes – Please explain on the attached continuation sheet.
No

6.

Have you failed to pay any tax, penalty, or interest liability during the current or last three calendar years within
forty-five (45) days of the date of which the IRS gave notice of the amount due and request for payment?
Yes – Please explain on the attached continuation sheet.
No

7.

Have you now or ever been under investigation by the IRS for possible criminal offenses?
Yes – Please explain on the attached continuation sheet.
No

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-0037
Expiration Date: 07/31/2016

Part I: Affiliations,
Representations, and/or
Positions with Boards,
Advisory Councils, or Similar
Groups
Please list all relationships outside your current employer, in which you
represent the interests of a party, or you or your affiliates receive from a
party a fee, income, or any other benefit from a party
Additionally, please list all positions and relationships you currently hold or held at
any time during the past two years, whether or not you were compensated and
whether or not you currently hold that position. Positions include an officer,
director, employee, trustee, general partner, proprietor, representative, executor,
member, or consultant of any of the following:
• Corporation, partnership, trust, or other business entity
• Non-profit or volunteer organization
• Educational institution
• Any government or industry advisory board or council
Do not list any position with a
o Religious entity
o Social entity
o Fraternal entity
o Political entity
o Any position held by your spouse or dependent child
Positions You Hold or Have Held (List up to 8 relevant positions starting with the most recent)
Organization
(include city and state where organization is

Type of organization

Position

Years Held

Brief
Description

1

2

3

4

5

6

7

8

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-0037
Expiration Date: 07/31/2016
Privacy Act Statement
The information that you provide will be used by the Consumer Financial Protection Bureau (CFPB)
to determine qualifications, suitability, and availability for service on advisory boards, bodies,
panels, committees or other similar groups. The information will be used to conduct background
clearances and/or for annual reports on advisory boards, bodies, panels, committees or other
similar groups. The information will be used by and disclosed to employees, contractors, agents,
and others authorized by the CFPB to receive this information to assist in related activities. The
information may also be disclosed to:
(1) Appropriate agencies, entities, and persons when: (a) the CFPB suspects or has confirmed that
the security or confidentiality of information in the system of records has been compromised;
(b) the CFPB has determined that, as a result of the suspected or confirmed compromise, there
is a risk of harm to economic or property interests, identity theft or fraud, or harm to the
security or integrity of this system or other systems or programs (whether maintained by the
CFPB or another agency or entity) that rely upon the compromised information; and (c) the
disclosure made to such agencies, entities, and persons is reasonably necessary to assist in
connection with the CFPB’s efforts to respond to the suspected or confirmed compromise and
prevent, minimize, or remedy such harm;
(2) Another federal or state agency to (a) permit a decision as to access, amendment or correction
of records to be made in consultation with or by that agency, or (b) verify the identity of an
individual or the accuracy of information submitted by an individual who has requested access
to or amendment or correction of records;
(3) To the Office of the President in response to an inquiry from that office made at the request of
the subject of a record or a third party on that person’s behalf;
(4) Congressional offices in response to an inquiry made at the request of the individual to whom
the record pertains;
(5) Contractors, agents, or other authorized individuals performing work on a contract, service,
cooperative agreement, job, or other activity on behalf of the CFPB or Federal Government and
who have a need to access the information in the performance of their duties or activities;
(6) The U.S. Department of Justice (“DOJ”) for its use in providing legal advice to the CFPB or in
representing the CFPB in a proceeding before a court, adjudicative body, or other
administrative body before which the CFPB is authorized to appear, where the use of such
information by the DOJ is deemed by the CFPB to be relevant and necessary to the litigation,
and such proceeding names as a party or interests:
(a) The CFPB;
(b) Any employee of the CFPB in his or her official capacity;
(c) Any employee of the CFPB in his or her individual capacity where DOJ has agreed to
represent the employee; or
(d) The United States, where the CFPB determines that litigation is likely to affect the CFPB or
any of its components;
(7) To the public in the form of names, affiliations, and other pertinent biographical information of
board or committee members; and
(8) Appropriate agencies, entities, and persons to the extent necessary to obtain information
relevant to making a determination of whether an individual is eligible to serve on a CFPB
board or committee.
The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011, 1012,
1014, codified at 12 U.S.C. §§ 5491, 5492, 5494. Providing your identifying information is voluntary,
but not doing so may result in non-selection of a prospective advisory board, body, panel,
committee, or other similar group membership. However, failure to provide your Social Security
number may not be the reason for non-selection.
APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-0037
Expiration Date: 07/31/2016
The Bureau has a special interest in ensuring that women, minority groups, and individuals with
disabilities are adequately represented on the Board and Councils, and therefore, encourages
applications from qualified candidates from these groups. In furtherance of this interest, the
Bureau invites applicants to the Board and Councils to voluntarily self-identify their race or
ethnicity. Submission of this information is voluntary and refusal to provide it will not disqualify you
from consideration for service on the Board or Councils. The information obtained will be kept
confidential and will only be used for internal management purposes. There have been occasions
when members of the public and/or Congress have requested information regarding the
demographic composition of the Board and Councils. If the Bureau receives and responds to such a
request, data provided will not identify any specific individual."

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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OMB Control #3170-0037
Expiration Date: 07/31/2016
Paperwork Reduction Act

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a valid OMB control number. The OMB
control number for this collection is 3170-0037. It expires on 07/31/2016. The time required to complete this
information collection is estimated to average approximately 45 minutes per response, including the time for
reviewing any instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. The obligation to respond to this collection of
information is voluntary. Comments regarding this collection of information, including the estimated response
time, suggestions for improving the usefulness of the information, or suggestions for reducing the burden to
respond to this collection should be submitted to Bureau at the Consumer Financial Protection Bureau
(Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to PRA@cfpb.gov.

The Bureau will not disclose any personally identifiable information collected except to the extent that it is
required to do so by law and as provided in the Privacy Act Statement listed below. Additionally, the Bureau
will treat the information collected consistent with its confidentiality regulations at 12 C.F.R. Part 1070, et seq.

I certify that the statements I have made on this form and all attached statements are true,
complete, and correct to the best of my knowledge.
Signature

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

Date (mm/dd/yy)

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OMB Control #3170-0037
Expiration Date: 07/31/2016
Continuation Sheet to Form
If you need more space for an answer, use this sheet. Please number each answer
to correspond to the number on this form. When you have completed your
answers, attach to this form.
Name (Last, First, Middle)
__________________________________________________________

APPLICATION TO SERVE ON ADVISORY BOARD, BODY, PANEL, COMMITEE, OR GROUP
Consumer Financial Protection Bureau

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