2.2.1_Attachment 6 - RecordCheck Form.pdf
PDF 291 KB Posted
- Attached to
- Port Isabel Detention Center Solicitation Federal contract opportunity
- Solicitation number
- 70CDCR21R00000007
- Issued by
- Immigration and Customs Enforcement
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IMMIGRATION AND CUSTOMS ENFORCEMENT
PORT ISABEL DETENTION CENTER
REQUEST FOR RECORD CHECKS
In accordance with ACA ALDF-7B-03 and as part of the Homeland Security efforts to ensure a safe working environment. A criminal record check on the national crime information center(NCIC) is hereby requested for the following person. Also provide a CIS and EARM check for all non-United States Citizens based on the noted *A number. This person is currently requesting access to the facility either as an employee, contractor or volunteer. The criminal check is to ascertain if there are any criminal convictions that have a specific relationship to job performance... E-MAIL REQUESTS: PIC-FACILITYACCESS@ICE.DHS.GOV
(1.) POINT OF CONTACT: (complete all fields) (2.) REQUESTOR INFORMATION: (complete all fields) I hereby state that this criminal record and immigration check request is required in the performance of my official visit and will be kept strictly confidential, per NCIC guidelines...
(3.) RECORD CHECK INFORATION: (agency use only) Upon completion of an NCIC criminal record check and based on the information, the person:
(4.) IMMIGRATION CHECK INFORMATION: (agency use only) Upon completion of immigration checks on the above non-United States Citizen, the immigration status of this person is:
(5) ALL REQUIRED CHECKS WERE CONDUCTED BY OFFICIAL/OFFICER: (agency use only)
ACA-4-ALDF-7B-03/PIDC 1.3.5.
11.0.0.20130303.1.892433.887364 10/11/2018
EDWARD MARTINEZ
REQUEST FOR RECORD CHECKS
| either the name of company the requestor will represent/or ICE department.: |
| Enter full name of CEO, Owner, or manager requesting this individual to get access to facility.: |
| ENTER PHONE NUMBER XXX-XXX-XXXX: |
| Enter company address to include street, city, state, and zip code: |
| a brief reason why the individual requires access to facility & a point of contact in ICE.: |
| enter POC e-mail address that belongs to the CEO/OWNER/Manager.: |
| RequestorFullNameTXT: |
| Enter you date of birth: |
| Enter your height & weight: |
| Enter your Place of birth (city & state): |
| Enter your residential address to include house/apartment number, street, city, state,& zip code: |
| enter your driver's license number and state that issued it.: |
| enter your full social security number in the following format xxx-xx-xxxx: |
| alienRegistrationNoTXT: |
| printNameTXT: |
| If electronically signed no need to date as the electronic signature dates it. if manually signed then date will be required.: |
| enter your job title here...: |
| isClearedCKB1: |
| NotClearedCKB2: |
| clear4CKB: |
| notClear4CKB: |
| print officers full name: |
| officer's title : |
| SignatureField2: |
| EmailSubmitButton1: |
| add the POC you are dealing with in ICE/ERO/Port Isabel Detention Center.: |
| TextFieldStyle1: |
| TextFieldStyle2: |
| TextFieldStyle3: |
| TextFieldStyle4: |
| TextFieldStyle5: |
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