c.BackgroundCheck.doc

U.S. Forest Service

PROSPECTIVE CONTRACTOR LIMITED BACKGROUND CHECK

Read the following instructions carefully before you complete this form. Type or print clearly in dark ink.

Prospecitive contractors must pass a limited background check to be authorized entry into federal facilities. This check includes a criminal history inquiry for employment purposes. Prospective contractors may be disqualified if they meet one or more of the following criteria: (a) criminal records consisting of felony or serious misdemeanor conviction(s), (b) a showing of a current drug or alcohol dependency, or (c) a finding of a current mental or emotional instability.

Answer all questions truthfully and completely. A false statement on any part of this declaration or attached forms or sheets may be grounds for disqualification. Also, intentionally providing false information on this form is a violation of law and regulation and could result in fine, imprisonment or both (18 U.S.C. 1001, 36 CFR 261.3(b)).

BIOGRAPHICAL INFORMATION

1. Name (Last, First, Middle):

2. Present Home Address:

Street:

City:

State:

Zip:

3. Present Home Phone Number:

4. Other names Used:

Maiden name:

5. Birth Date (Month, Day, Year):

6. Drivers License Number:

State:

BACKGROUND INFORMATION

7. In the last 7 years, have you been arrested for, charged with, or convicted of any offense(s)? (You may leave out traffic fines of less than $150.)

If yes, please explain each violation. Give date and place of occurrence and name/address of police/court involved.

8. In the last year, have you illegally used any controlled substance?

If yes, Please specify:

Signature, Certification, and Release of Information Read the following authorization carefully before you sign to release information about yourself. You must sign and date this form. Electronic signatures are not acceptable.

I authorize U.S. Forest Service personnel to obtain information relating to my activities which would have a direct relationship to the janitor position. This information may include, but is not limited to, employment history, driving records, and criminal history record information for employement purposes.

I authorize custodians of records and sources of such information pertaining to me to release that information upon request of the Forest Service regardless of any previous agreement to the contrary.

I understand that the information released by records custodians and sources of information is for official use by the Forest Service only for the purposes provided on this form and may only be disclosed by the Agency as authorized by law.

Copies of the authorization that show my signature are as valid as the original release signed by me. This authorization is valid for 60 days from the date signed.

I certify that, to the best of my knowledge and belief, all of the statements are true, correct, complete, and made in good faith.

SIGNATURE OF APPLICANT (Sign in dark ink): ___________________________________________

FULL NAME (Type or Print): _______________________________________________________________ DATE SIGNED (Month, Day, Year): __________________________________________

Background Authorization Form