Attach 11 - USCP Request for Criminal History.pdf

CP-491

(01/21) UNITED STATES CAPITOL POLICE

REQUEST FOR CHECK OF CRIMINAL HISTORY RECORDS

(Please Type or Print Legibly)

INSTRUCTIONS

• APPLICANT – Complete Sections 1- 17 of this form.

• APPLICANT’S AGENCY – Complete sections 18-24 of this form.

• Bring this form along with a valid (non-expired) government-issued photo identification that officially establishes your identity to the

United States Capitol Police Badging and Credentialing Division located in the Fairchild Building, 499 South Capitol Street, SW, Room 127, Washington, DC 20003.

1. NAME (Last, First, Middle)

2. ADDRESS (Complete Address)

3. EMPLOYER 4. OTHER NAMES EVER USED (e.g. maiden name, nickname, etc.). If you have never used another name write “None”

5. TELEPHONE

NUMBER

6. DATE OF

BIRTH (mm/dd/yyyy)

7. BIRTHPLACE

(City /State/ Country)

8. SOCIAL

SECURITY #

9. COUNTRY OR

CITIZENSHIP

10. GENDER IDENTITY 11. RACE 12. HEIGHT 13. WEIGHT 14. EYE COLOR 15. HAIR COLOR

SIGNATURE AND RELEASE OF INFORMATION: READ THE FOLLOWING CAREFULLY BEFORE SIGNING

• I understand that the information provided above will be used to check the criminal history records of the Federal Bureau of

Investigation.

• I consent to the use of the information provided above in making a security determination concerning me.

• I certify that I am authorized to work in the United States and if requested can provide legal documents supporting my certifications.

• I acknowledge by my signature below that any falsification of the information provided and or the use, possession, or representation of any false identification by me is subject to prosecution and penalties.

• I certify that to the best of my knowledge and belief, all the information provided above is true, correct, complete, and made in good faith.

16. APPLICANT SIGNATURE 17. DATE (mm/dd/yyyy)

AUTHORIZED REQUESTOR

To be filled out by the individual Authorized to Request that the Applicant submit to a Criminal History Records check.

18. NAME (Last, First, Middle) please print 19. AGENCY

20. POSITION/TITLE 21. TELEPHONE NUMBER 22. DATE OF REQUEST

I request that the applicant/employee indicated above be fingerprinted by the United States Capitol Police and that these fingerprints be submitted for a check of the criminal history records of the Federal Bureau of Investigation. This check will be used in making a security determination concerning this applicant/employee. I have verified that the applicant is authorized to legally work within the United States in accordance with the federal government hiring provisions of the Immigration Reform and Control Act of 1986 (Pub. L. 603), as amended, applicable Form I-9 requirements, and any executed Memorandum of Understanding with the United States Capitol Police regarding Requests for Criminal History Record Information by Congressional Employing Offices.

23. SIGNATURE 24. DATE (mm/dd/yyyy)

BADGING AND CREDENTIALING DIVISION

25. INDIVIDUAL CONDUCTING

RECORDS CHECK

26. DATE CHECK

CONDUCTED

27. FBI # (If none, write none”)

28. DOCUMENT

ESTABLISHING IDENTITY