3 NCICRlease.pdf

U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

BP-A660.012

MAR 1999 NCIC CHECK

1. Name (Last, First, Middle)

AUTHORIZATION FOR RELEASE OF INFORMATION

NCC (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 a ny Bureau facility. I also understand that refusal to provide all necessary information may result in 1) denial of entry into a Burea u facility and 2) denial of volunteer/contract status.

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):

8a. Sex:

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

6. Social Security Number:

8b. Race:

8d. Weight:8c. Height:

8f. Color of Hair:8e. Color of Eyes:

9. Place of Birth (City, State, County), (List city, county and country if outs ide 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 Fed eral employment, (2) clearance to perform contractual service for the Federal Government, (3) security clearance or access. The infor mation obtained may be furnished to third parties as necessary in the 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.