[별지 제22호서식]															(1st page)
PERSONAL QUESTIONNAIRE *THIS INFORMATION IS FOR OFFICIAL USE ONLY															[PHOTO] (3㎝×4㎝)
NAME	Last/First/Middle				DATE OF BIRTH					Month/Day/Year
NATIONALITY (Include any dual nationality)					PLACE OF BIRTH					City/Country
ALIEN REGISTRATION NUMBER					DATE & PLACE OF ENTRY TO KOREA					Month/Day/Year City/Country
ADDRESS											GENDER
WORK PLACE						JOB/POSITION
TELEPHONE NUMBERS (Include Area Code)	HOME : WORK : MOBILE :
BLOOD TYPE		HEIGHT		㎝			WEIGHT		㎏			HAIR COLOR				EYE COLOR
EDUCATION	SCHOOL NAME		PERIOD (MM/YY-MM/YY)					TYPE OF DEGREE					REWARD & PUNISHMENT (MM/YY)				LOCATION (Street Address & City/Country)
210㎜×297㎜ 일반용지 60g/㎡(재활용품)

							(2nd page)
WORK EXPERIENCE AND ACTIVITIES	EMPLOYER/ VERIFIER NAME		PERIOD (MM/YY-MM/YY)		JOB TITLE/ POSITION		LOCATION (Street Address & City/Country)
FAMILY DETAILS	RELATION	NAME Last/First/Middle		DATE OF BIRTH	FINAL ACADEMIC CAREER	CAREER	ADDRESS
RELATIVE & ASSOCIATES IN KOREA	RELATION	NAME Last/First/Middle		DATES KNOWN (MM/YY-MM/YY)	CAREER	JOB TITLE/ POSITION	TELEPHONE NUMBER
I understand that this form may be submitted for checking against the records of police, security and credit agencies in accordance with security policy. I declare that the information I have given is true and complete to the best of my knowledge and belief. I understand that any false statement or deliberate omission in the information I have given in this questionnaire may disqualify me for employment or make me liable to disciplinary action which may include dismissal. DATE : SIGNATURE :
210mm×297mm 일반용지 60g/㎡(재활용품)

Consent to Provision of Personal Information

■ I hereby agree that in the case of being employed as a government employee, where an institution needs to conduct a background check, I confirm that I have read and understood the notes specified below regarding the purpose of collecting personal information, etc. (including sensitive information such as crime history, etc.). I agree that I will provide my personal information, which is protected in accordance with the Personal Information Protection Act, etc., to the institution that performs background checks as per Article 15 of said Act (Collection and Use of Personal Information).

■ I herewith request the heads of institutions that hold my personal information to provide my personal information to the institution performing the background check.

■ I hereby confirm that a photocopy of this consent letter signed by myself (including family members) has equal validity to the original thereof.

Notes (to inform you that you may reject the provision and collection of personal information, and method of managing and the provision of personal information)

￭ Consent regarding the collection and provision of personal information shall only be used for the purpose of background checks, and collected information shall be managed and disposed of in accordance with the Act on the Management of Public Archives. The scope of personal information to be collected is as follows.

￭ You may reject the provision of information based on your intention. However, please note that in such case, a background check cannot proceed properly.

(Month)          / (Day)        /,  (Year)

Name                    (signature)

■ Consent from myself and family members (I may sign on behalf of minors)

	Name	Date of birth DD/MM/YEAR	Signature
			Consent to the provision of personal information	Consent to the provision of sensitive information
me		/ /
spouse		/ /		n.a.
child		/ /		n.a.
child		/ /		n.a.
child		/ /		n.a.

※ List of personal information items to be collected for a background check

Myself	Family members
￭ Resident registration, family relation registration, public employee personnel management record (Ministry of the Interior) ￭ Resident crime history and investigation record (National Police Agency) ￭ Entry and departure data (Ministry of Law) ￭ Land and housing ownership data, and automobile registration register (Ministry of Land, Infrastructure, and Transport) ￭ Income and individual and corporate business registration data (National Tax Service) ￭ Military records (Military Manpower Administration, Defense Security Command) ￭ Loans from financial institutions (Korea Credit Information Service)	￭ Resident registration, family relation registration register (Ministry of the Interior) ￭ Resident data (National Police Agency) ￭ Entry and departure data (Ministry of Law) ￭ Land and housing ownership data, automobile registration register (Ministry of Land, Infrastructure, and Transport) ￭ Income and individual and corporate business registration data (National Tax Service) ￭ Military records (Military Manpower Administration, Defense Security Command) ￭ Loans from financial institutions (Korea Credit Information Service)

To: Head of Institution that holds personal information

개인정보 제공 동의서

■ 본인은 공직임용에 있어 신원조사기관이 본인에 대한 신원조사를 실시할 필요가 있다는 것과  개인정보(범죄경력 등 민감정보 포함. 이하 동일) 수집 목적 등 아래 유의사항을 이해하였으며,

이를 위해 ｢개인정보보호법｣ 등에 의해 보호되고 있는 본인의 개인정보를 동법 제15조(개인정보의 수집ㆍ이용)의 규정 등에 따라 신원조사기관에 제공하는데 동의합니다.

■ 이에 따라, 개인정보 보유기관장은 원활한 신원조사를 위해 본인에 관한 개인정보를 해당 신원조사기관에게 제공하여 줄 것을 요청합니다.

■ 본인(가족 포함)이 서명한 동의서 복사본은 원본과 동일하게 유효하다는 것을 인정합니다.

유의사항 (개인정보 수집 목적ㆍ관리방법, 정보제공 동의 거부 가능 고지)

￭ 수집된 개인정보자료ㆍ개인정보 제공 동의서는 신원조사 목적으로만 사용되고,「공공기록물관리에관한법률」에 따라 관리ㆍ폐기되며 수집하려는 개인정보의 항목은 아래와 같습니다.

￭ 개인의 자유로운 의사에 따라 정보 제공동의를 거부할 수 있습니다. 다만, 이 경우 신원조사를 원활히 진행할 수 없음을 알려드립니다.

년    월    일

성명               (서명)

■ 본인 및 가족 동의 (자녀는 결혼·해외거주 등에 불문하고, 미성년은 본인대리 서명 가능)

구 분	성 명	생년월일	서 명
			개인정보 제공 동의	민감정보 제공 동의
본인			자필서명	자필 서명
배우자			자필서명	해당없음
자녀			자필서명	해당없음
자녀			자필서명	해당없음
자녀			자필서명	해당없음

※ 신원조사를 위해 수집되는 개인정보 항목 (밑줄은 민감정보)

본 인(예시)	가 족(예시)
￭ 주민등록ㆍ가족관계등록부, 공무원인사기록(행자부ㆍ인사처) ￭ 주민·범죄경력ㆍ수사ㆍ수배 조회자료(경찰청) ￭ 출입국자료(법무부) ￭ 토지ㆍ주택자료 및 자동차 등록원부(국토부) ￭ 소득 및 개인ㆍ법인 사업자 자료(국세청) ￭ 병적자료(병무청ㆍ기무사) ￭ 금융기관 대출자료(한국신용정보원)	￭ 주민등록ㆍ가족관계등록부(행자부) ￭ 출입국자료(법무부) ￭ 토지ㆍ주택자료 및 자동차 등록원부(국토부) ￭ 소득 및 개인ㆍ법인 사업자 자료(국세청) ￭ 병적자료(병무청ㆍ기무사) ￭ 금융기관 대출자료(한국신용정보원)

개인정보 보유기관장 귀하