183WG Form 1705.pdf

CONSENT FOR BACKGROUND CHECK

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44 -10 United States Code (U.S.C.) 8013 Executive Order 9397, USC 552A.

PRINCIPLE PURPOSE: Criminal History Background Checks on individuals working on Federal Installations DISCLOSURE: Voluntary. However, refusal to provide required information or sign this form will prevent the individual from gaining access to Federal Installations NOTICE: The information on this form is being collected in accordance with federal law permitting the installation commander to limit access to the installation for security reasons (50 U.S.C. Section 797 and DoD Directive 5200.8). This data will be used to screen individuals who have, or are seeking access to, the 183d FW, Springfield, Illinois. Failure to provide truthful, complete and accurate responses may be used as a basis to deny entry to the installation and is also punishable as a criminal offense.

Section 1.

I have been advised and I understand the United States Air Force has an obligation to require a criminal history background check as a condition prior to allowing unescorted access to the installation in order to provide security for personnel and property under its' control. I also understand that random criminal history background checks will be conducted on me while I am working on Federal Installations. I have been further advised that I have a right to obtain a copy of any report and to challenge the accuracy and completeness of any information included in the criminal history report.

Section 2.

I understand that the record checks may include the following:

A State Criminal History Repository Check in the state where I currently reside and in states where I have formerly resided.

A National Agency Check with Inquiries, which includes a Federal Bureau of Investigation, fingerprint check as required.

Section 3.

I hereby authorize any Federal, State, or Local agency or office to release any record relating to me, which is necessary to complete the record checks, described above.

Section 4. PERSONAL IDENTIFICATION (Print or Type) Last Name: First Name: Full Middle Name:

Date of Birth: (mm/dd/year) Gender: (Check One) Driver’s License Number: State of Issue:

Male Female

License Plate Number: Vehicle Make: Model: Year: / Bldg Number:

HOME ADDRESS

Street Address:

City: State: Zip Code:

CONTRACTOR ADDRESS

Street Address:

City: State: Zip Code:

Phone #: Supervisor:

* Employees operating their personal vehicles on base must have current proof of insurance, driver's license and vehicle registration.

Section 5. Employee Certification THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNDER TITLE 18, UNITED STATES CODE, SECTION 1001 OR OTHER APPLICABLE LAWS AND REGULATIONS.

EMPLOYEE SIGNATURE: DATE:

** Contractor and employee shall return their Contractor Access Badge to SFS Pass & Registration Office upon expiration or termination.

Section 6. To be completed by Security Forces NCIC Check Date: Badge Area: Badge Type: Date Issued: Date Expires:

Contractor:

Other:

183WG Form 1705, 20150619 Prescribing Directive, 183WGI 31-08

ILANG CONTRACTOR’SCONSENT FORM Page 1 of 1

Last Name: First Name: Full Middle Name:

Date of Birtrr h: (mm/dd/year) Gender: (Check One) Driver’s License Number: State of Issue:

/ Bldg Number:

HOME ADDRAA ESS

Street AddresAA s:

CONTRACAA TOR ADDRAA ESS

State: Zip Code:

Zip Code:State:

City:

Street AddresAA s:

City:

Phone #: Supervisor:

EMPLOYEE SIGNATAA URE: DATAA E: