A07 - SOC Form 271 - NCIC III.PDF

SOC Form 271 R2, May 2018

Request for Access to Hawthorne Army Depot

Use in accordance with "Directive Type Memorandum (DTM) "09-012" Interim Policy Guidance for DoD Physical Access Control" Dated 22 APR 14

Proponent Office is HWAD Security

Privacy Act Statement AUTHORITY: Title 10 United States Code, Section 3013

PRINCIPAL PURPOSE(S): In conjunction with "Directive Type Memorandum (DTM)" 09-012 "Interim Policy Guidance for DoD Physical Access Control", dated 22

Apr 14, this form is intended to ensure that force protection measures are implemented for all non - DoD - credentialed personnel who request access to the installation.

ROUTINE USES: To control and maintain force protection requirements.

DISCLOSURES: Voluntary civilian. Failure to provide information deemed "mandatory" may result in a processing delay of your request for access or a denial of your request.

Application Date: Expiration Date:

1 year from date of application Areas to be Visited:

Reason for Request for Criminal History Background Check:

Access to Hawthorne Army Ammunition Depot

First Name: Middle Name: Last Name:

Other Names Used:

Street Address: City: State: Zip Code:

Home Telephone Number:

Sex: Race: Country of Birth State of Birth (if not born within the U.S.) Provide U.S.

Passport/card, or Naturalization Certificate.

Date of Birth: Social Security Number:

Driver’s License State of Issuance: Driver’s License Number:

Employee POC: Employee POC Phone Number: Employee POC E-Mail Address:

This Area To Be Completed Only If You Are A Contractor Or Vendor Name of Company (No Abbreviations):

Company POC: Company Address: City: State: Zip Code:

Company POC Phone Number: Company POC Fax Number: Company POC E-Mail Address:

CRIMINAL HISTORY BACKGROUND CHECK RELEASE AND CONSENT

I hereby authorize the Hawthorne Army Depot Security Branch to receive any criminal history/background information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency/organization. I understand that a criminal history background check will be used to determine access to Hawthorne Army Depot and that access to Hawthorne Army Depot can be revoked at any time.

PLEASE TAKE NOTICE THAT ONE OR MORE CRIMINAL BACKGROUND REPORTS PURSUANT TO

THE FAIR CREDIT REPORTING ACT, AS AMENDED, 15 U.S.C. 1681 ET SEQ, MAY BE OBTAINED FOR

THE PURPOSES OF ACCESS TO HAWTHORNE ARMY DEPOT. SHOULD A DECISION TO DENY

ACCESS BE MADE BASED EITHER IN PART OR IN WHOLE ON THAT REPORT, THE REPORTING

AGENCY THAT PROVIDED THE INFORMATION PLAYED NO ROLE IN THE DECISION.

Information provided by you on this form will be furnished to Hawthorne Army Depot's Security Branch to obtain information in connection with an investigation to determine access to Hawthorne Army Depot. This information is collected for national security and force protection purposes. Use of this form does not relieve any contractor of any requirement to perform a criminal background check or drug test.

SOC Form 271 R2, May 2018

Please answer the following questions and report information truthfully; regardless of whether your case has been "sealed", expunged or otherwise stricken from the court record. The single exception to this requirement is certain convictions under the Federal Controlled Substances

Act-cases for which the court has issued an expungement order under the authority of 21 U.S.C. 844 or 18 U.S.C. 3607.

If the answer is “yes” to any of these questions, please list the actual offense or violation (for example: theft, DUI, battery, etc).

YES NO

1. Are you currently barred from ANY military installation?

If Yes, for what offense(s):

Offense:

2. Have you ever been arrested for, charged with, or convicted of a sex offense? Are you a registered sex offender?

If Yes, List the offense, date, and jurisdiction.

Offense: Date: Jurisdiction:

3. Have you ever been charged with or convicted of a felony?

If Yes, List the offense, date, and jurisdiction.

4. Have you ever been charged with or convicted of a firearms, weapons, or explosive offense?

If Yes, List offense, date, and jurisdiction.

5. Have you ever been charged with or convicted of any offense related to alcohol or drugs?

If yes, List offense, date, and jurisdiction.

6. In the last 7 years, have you been subject to a court martial, or other disciplinary proceedings under the Uniform Code of Military Justice? (include non-Judicial, Captain’s mast, etc.)

If yes, list offense, date, and jurisdiction.

7. In the last 10 years, have you been arrested for, charged with, or convicted of any other offense not listed above? (include misdemeanors) Leave out traffic fines of less than $150 unless the violation was alcohol or drug related.

If yes, list offense, date, and jurisdiction.

8. Are you on parole or probation?

If Yes, for what offense(s).

Offense:

9. Are you a United States Citizen?

If NO, please list you country of citizenship, registration number, and the expiration date of your work permit.

Country of Citizenship: Registration or Visa Number: Expiration of your work permit:

10. Do you currently have or have you ever been issued a security clearance by the United States Government?

If YES, please provide details on where the clearance was issued and the status of the clearance

Clearance Issued: Status of Clearance:

APPLICANT CERTIFICATION

I certify that, to the best of my knowledge and belief, all of the information provided on this request for access to HWAD Depot is true, correct, and complete and made in good faith. I understand that false, fraudulent, or incomplete information may be grounds for the denial of my request or for the revocation of access to HWAD Depot and may be punishable by fine or imprisonment. I understand that any information I provide may be investigated.

NAME OF APPLICANT (PRINT): ________________________________ DATE:________________________

SIGNATURE:_______________________________________________