13. BP-A0660.012_NCIC Form.pdf
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- Solicitation number
- 15BPCC26R00000001
- Issued by
-
Department of Justice Bureau of Prisons
About this file
This is a federal background check authorization form used by the U.S. Department of Justice Federal Bureau of Prisons. The form BP-A0660.012, issued in March 1999, authorizes representatives of the Federal Bureau of Prisons to conduct National Crime Information Center (NCIC) checks on individuals seeking entry, employment, or volunteer/contract status at Bureau facilities. The form collects personal identification information including name, address, telephone number, aliases, citizenship, Social Security number, date of birth, physical descriptors (sex, race, height, weight, eye color, hair color), and place of birth. Applicants must certify that the information provided is true and correct by signing and dating the form.
The authorization is grounded in Executive Order 10450 and various U.S. Code sections (5 USC 1303-1305, 42 USC 2165 and 2455, 22 USC 2585 and 2519, and 5 USC 3301). Information collected is used to determine fitness for federal employment, clearance to perform contractual services, and security clearance eligibility. The form notes that furnishing information is voluntary, but failure to provide complete information may result in denial of entry, employment, volunteer status, or contract clearance, or termination of existing employment. The information obtained may be shared with third parties as necessary to fulfill official responsibilities.
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Text version
BP-A0660.012 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. Date of Birth (Month, day, year):
8a. Sex: 8b. Race:
8c. Height: 8d. Weight:
8e. Color of Eyes: 8f. Color of Hair:
9. Place of Birth (City, State, County), (List city, county and country if outside the U.S.A)
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 the fulfillment of official responsibilities.
Effects of Non-disclosures: Furnishing the requested information is voluntary, but failure to provide all or of part the information may result in lack of further consideration for employment, clearance or access, or in the termination of your employment.
(This form may be replicated via WP)
| Name: |
| Address: |
| Telephone: |
| Aliases: |
| Citizenship: |
| SSN: |
| DOB: |
| Sex: |
| Race: |
| Height: |
| Weight: |
| Color of Eyes: |
| Color of Hair: |
| Place of Birth: |
| Date: |
File details come from the government source that posted it. Updated .