Attachment 5 - Police Check.pdf

11. If foreign born, provide the type and number for one of the following: alien registration, naturalization certificate, U.S passport, or employment authorization card.

Police Check Inquiry U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives

ATF E-Form 8620.42 Revised May 2007

This form must be completed by all individuals requiring escorted access to ATF facilities, access to ATF unsensitive information, and/or an ATF construction site, for the purpose of performing Low Risk-Nonsensitive duties.

1. Mark one of the following: Contractor Vendor Other

5. Social Security Number4. Middle Name3. First Name2. Last Name To be Completed by Subject

9. Sex8. Citizenship7. Place of Birth (State/Country)6. Date of Birth

10. Other Names Used (Maiden, Nickname, etc.)

Type Number

12. Home Address (provide residential history for past 5 years-use additional sheet(s) if necessary) From: To: Address City State

13. Employment History (for past 5 years-use additional sheet(s) if necessary) From: To: Employment Name City StateAddress

14. Mark One or More of the Following Categories

American Indian or Alaska Native A person having origin in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliations or community attachment.

Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American A person having origins in any of the black, Haitian, or Negro racial groups of Africa.

Hispanic or Latino A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.

Native Hawaiian or Other Pacific Island

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

A person having origins in any of the original peoples of Hawaii, Guam, Somoa, or other Pacific Islands.

White

I, , give my consent and permission for the Bureau of Alcohol , Tobacco, Firearms and Explosives (ATF) to conduct a police check inquiry for the purpose of escorted access to ATF facilities and/or access to ATF unsensitive information, or access to an ATF construction site. I understand that a felony may automatically disqualify me. Any incident(s) involving firearms or explosives are grounds for disqualification from consideration to perform work in ATF facilities or access to ATF unsensitive data. I understand that additional forms may be required by ATF for a more in-depth background investigation. I attest that the information provided is true.

Date:Signature

OMB No. 1140-0068 (04/30/2010)

From: To: Address City State

From: To: Address City State

From: To: Address City State

From: To: Employment Name City StateAddress

From: To: Employment Name City StateAddress

From: To: Employment Name City StateAddress

To be Completed by COTR/ATF POC

16. Subject's ATF Job Title15. Subject's Assigned ATF office 17. Assignment Duration Dates

Beginning Ending

18. Subject's duties will require the following access:

Escorted Facilities ATF Unsensitive Information Construction Site

20. COTR/POC Address 21. Phone Number19. COTR/POC Name

23. Date22. Signature

24. See Remarks

To be Completed by the Physical Security Programs Branch/Field Division

25. NCIC Conducted:

N/R R

26. TECS Conducted:

N/R R

27. State(s):

N/R R

N/R

N/R

N/R

R

R

R

28. Allied Nations Policy:

N/A Compliant Non-Compliant

29. Residency Requirement:

N/A Compliant Non-Compliant

Access Granted

Access Denied

Title DateAuthorized Signature

ATF Form 8620.42 should be intiated by the COTR or ATF Point of Contact (POC) prior to granting escorted access to ATF facilities. Examples of positions that could be escorted are janitorial, short-term construction contractors who may be performing electrical or plumbing duties. The Physical Security Programs Branch or Field Division is responsible for conducting the required records and inquiry checks. The Physical Security Programs Branch or Field Division is also responsible for ensuring that individuals are in compliance with the Allied Nations and residency policies.

Instructions

Items 1-14. Applicant contractors are responsible for completion of items 1 through 14 in their entirety. No item may be left unanswered.

Items 15-24. To be completed by COTR or ATF POC.

Item 15. Please include both branch or division and physical location. (for example): Phoenix FD, Denver Field Office; or ISD, Software Mgt. Branch, BHQ)

Item 16. Describe the job the contractor is to perform.

Items 25-29. To be completed by the Physical Security Programs Branch or Field Division.

Paperwork Reduction Act Notice

This request is in accordance with the Paperwork Reduction Act of 1995. The information collected is used by ATF to screen prospective contractors for escorted access to ATF facilities and/or unsensitive information.

The estimate average burden associated with this collection of information is 5 minutes per respondent, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Report Management Officer, Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information that does not display a currently valid OMB control number.

ATF E-Form 8620.42 Revised May 2007

Privacy Act Statement

You are requested to furnish information regarding your race under the authority of 42 U.S.C. § 2000e - 16, which requires that Federal employment practices be free from discrimination and provide equal opportunities for all. Solicitation of this information is in accordance with Department of Commerce Directive 15, "Race and Ethnic Standards for Federal Statistics and Administrative Reporting."

You are further requested to furnish your social security number (SSN) under authority of E.O. 9397, published 11/22/1943. That Order requires agencies to use the SSN for the sake of economy and orderly administration in the maintenance of records. Your race, as well as your SSN will be used as a means to positively identify you in the Federal criminal justice records system.

Your furnishing your race and SSN is voluntary; however, your failure to provide the requested information may negatively impact ATF's ability to postively identify you in the Federal criminal justice records system.

Solicitation of this information is authorized as part of our investigative authorities devolving from E.O. 10450 and E.O. 12968. This information will eb used by ATF to begin preliminary screening/investigation for security and/or suitability purposes.

ATF E-Form 8620.42 Revised May 2007

11. If foreign born, provide the type and number for one of the following: alien registration, naturalization certificate, U.S passport, or employment authorization card.

Police Check Inquiry U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives ATF E-Form 8620.42 Revised May 2007 This form must be completed by all individuals requiring escorted access to ATF facilities, access to ATF unsensitive information, and/or an ATF construction site, for the purpose of performing Low Risk-Nonsensitive duties.

1. Mark one of the following:

To be Completed by Subject

12. Home Address (provide residential history for past 5 years-use additional sheet(s) if necessary)

13. Employment History (for past 5 years-use additional sheet(s) if necessary)

14. Mark One or More of the Following Categories A person having origin in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliations or community attachment.

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

A person having origins in any of the black, Haitian, or Negro racial groups of Africa.

A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

A person having origins in any of the original peoples of Hawaii, Guam, Somoa, or other Pacific Islands.

I, , give my consent and permission for the Bureau of Alcohol , Tobacco, Firearms and Explosives (ATF) to conduct a police check inquiry for the purpose of escorted access to ATF facilities and/or access to ATF unsensitive information, or access to an ATF construction site. I understand that a felony may automatically disqualify me. Any incident(s) involving firearms or explosives are grounds for disqualification from consideration to perform work in ATF facilities or access to ATF unsensitive data. I understand that additional forms may be required by ATF for a more in-depth background investigation. I attest that the information provided is true.

OMB No. 1140-0068 (04/30/2010) To be Completed by COTR/ATF POC

17. Assignment Duration Dates

18. Subject's duties will require the following access:

To be Completed by the Physical Security Programs Branch/Field Division

25. NCIC Conducted:

26. TECS Conducted:

27. State(s):

28. Allied Nations Policy:

29. Residency Requirement:

ATF Form 8620.42 should be intiated by the COTR or ATF Point of Contact (POC) prior to granting escorted access to ATF facilities. Examples of positions that could be escorted are janitorial, short-term construction contractors who may be performing electrical or plumbing duties. The Physical Security Programs Branch or Field Division is responsible for conducting the required records and inquiry checks. The Physical Security Programs Branch or Field Division is also responsible for ensuring that individuals are in compliance with the Allied Nations and residency policies.

Instructions

Items 1-14. Applicant contractors are responsible for completion of items 1 through 14 in their entirety. No item may be left unanswered.

Items 15-24. To be completed by COTR or ATF POC.

Item 15. Please include both branch or division and physical location. (for example): Phoenix FD, Denver Field Office; or ISD, Software Mgt. Branch, BHQ)

Item 16. Describe the job the contractor is to perform.

Items 25-29. To be completed by the Physical Security Programs Branch or Field Division.

Paperwork Reduction Act Notice

This request is in accordance with the Paperwork Reduction Act of 1995. The information collected is used by ATF to screen prospective contractors for escorted access to ATF facilities and/or unsensitive information.

The estimate average burden associated with this collection of information is 5 minutes per respondent, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Report Management Officer, Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information that does not display a currently valid OMB control number.

ATF E-Form 8620.42 Revised May 2007 Privacy Act Statement

You are requested to furnish information regarding your race under the authority of 42 U.S.C. § 2000e - 16, which requires that Federal employment practices be free from discrimination and provide equal opportunities for all. Solicitation of this information is in accordance witrh Department of Commerce Directive 15, "Race and Ethnic Standards for Federal Statistics and Administrative Reporting."

You are further requested to furnish your social security number (SSN) under authority of E.O. 9397, published 11/22/1943. That Order requires agencies to use the SSN for the sake of economy and orderly administration in the maintenance of records. Your race, as well as your SSN will be used as a means to positively identify you in the Federal criminal justice records system.

Your furnishing your race and SSN is voluntary; however, your failure to provide the requested information may negatively impact ATF's ability to postively identify you in the Federal criminal justice records system.

Solicitation of this information is authorized as part of our investigative authorities devolving from E.O. 10450 and E.O. 12968. This information will eb used by ATF to begin preliminary screening/investigation for security and/or suitability purposes.

ATF E-Form 8620.42 Revised May 2007 Standard Formats