ncicform.rtf

BP-S660.012 NCIC CHECK CDFRM

MAR 99

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

AUTHORIZATION FOR RELEASE OF INFORMATION

NCIC (National Crime Information Center) CHECK

I hereby authorize a representative of the Federal Bureau of Prisons to obtain any information on my criminal history background. I understand that this check must be done before I am allowed to enter/serve at any Bureau facility. I also understand that refusal to provide all necessary information may result in 1) denial of entry into a Bureau facility and 2) denial of volunteer/contract status.

1. Name (Last, First, Middle)

2. Address (Street address) (City, State, County, Zip Code)

3. Home Telephone Number (Area Code, Number):

4. Aliases/Nickname:

5. Citizenship (List the country you are a citizen of):

6. Social Security Number:

7. Driver’s License Number:

7a. Date of Birth (Month, day, year):

8a. Sex:

8b. Race:

8c. Height:

8d. Weight:

8e. Color of Eyes:

9f. Color of Hair:

9. Place of Birth (City, State, County), (List city, county and country if outside the U.S.A) _______________________________________________________________________________________ 9a. Company Name: _ 9b. Department to be Visited:__________________________________________________________

10. The above listed information is true and correct. Applicant’s Signature

10a. Date

PRIVACY ACT NOTICE

Authority for Collecting Information: E.O. 10450; 5 USC 1303-1305; 42 USC 2165 and 2455; 22 USC 2585 and 2519; and 5 USC 3301

Purposes and Uses: Information provided on this form will be furnished to individuals in order to obtain information regarding activities in connection with an investigation to determine (1) fitness for Federal employment, (2) clearance to perform contractual service for the Federal Government, (3) security clearance or access. The information obtained may be furnished to third parties as necessary in te fulfilment of official responsibilities.

Effects of Non-disclosures: Furnishing the requested information is voluntary, but failure to provide all or part the information may result in lack of further consideration for employment, clearance or access, or in the termination of your employment.