Your completion of this form will be appreciated. Submission of this Information is
voluntary and it will have no effect on the review
of your application. The data collected will be used only for statistical and program management purposes. The OMB control number for
this collection is 0648-0568.
PRIVACY ACT INFORMATION
GENERAL - This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 31, 1974, for individuals completing Federal
records and forms that solicit personal information. AUTHORITY - Section 7201 of title 5 of the U.S. Code and Section 2000e-16 of title 42 of the U.S. Code.
PURPOSE AND ROUTINE USES
The information is used only for management and assessment of program performance. Your response will not affect the review of your application.