Attachment 0007 - NCIC_III_Release.pdf
PDF 42 KB Posted
- Attached to
- Digital X-Ray Computed Tomography (CT) Equipment Federal contract opportunity
- Solicitation number
- W15QKN-23-R-0073
About this file
This document contains a criminal background check authorization form for access to Picatinny Arsenal. The form notifies individuals that a criminal background check including criminal history, felony, misdemeanor, and sex offender registry searches will be conducted for all jurisdictions where the individual currently or previously resided. The individual must provide identifying information including full legal name, date of birth, race, gender, place of birth, social security number, driver's license number and state. The individual will also disclose any previous arrests or pending charges. By signing, the individual authorizes Picatinny Arsenal to conduct the criminal background check and understands they have a right to appeal any adverse decisions based on the results. The related federal contract opportunity is a solicitation from the Department of the Army Materiel Command Contracting Command Picatinny Arsenal for digital X-ray computed tomography equipment.
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Text version
Notification and Authorization to Release Criminal Information for Entry
Notification For the purpose of accessing Picatinny Arsenal I am required to consent to a criminal background check as a condition of being granted access. This check includes the following: Criminal history reference searches for felony and misdemeanour convictions at the county and federal levels of every jurisdiction where I currently reside or where I have resided; and sex offender registry searches at the county and federal levels in every jurisdiction where I currently reside or where I have resided. If I decline to submit to a Criminal background check I understand that I will be denied access to Picatinny Arsenal.
Authorization I hereby authorize Picatinny Arsenal to conduct the criminal background check described above.
I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to entrance to Picatinny Arsenal.
Such information will be used to determine whether the results of the background check reasonably bear on my ability to enter in a manner which is safe for Picatinny Arsenal visitors, employees, and other community members.
Please print LEGIBLY (for identification purposes):
Full Legal Name:
First Middle Last
Date of Birth: Race: Gender: Female Male Month/Day/Year
Place of Birth_________________________ Social Security Number:
Driver’s License # State of Driver’s License
Have you ever been arrested for a criminal *offense or have any pending criminal* charges against you?
Yes (provide detail on the back of page) No
To the best of my knowledge, the information provided in this Notice and Authorization and any attachments thereto is true and complete.
I understand that any falsification or omission of information may disqualify me for entrance and/or may serve as grounds for denial of entry to Picatinny Arsenal. By signing below I hereby provide my authorization to Picatinny Arsenal to conduct a criminal background check. In addition, I understand that I have a right to appeal an adverse decision made by Picatinny Arsenal based on my background check information.
Signature Date
Individual is cleared for entry to Picatinny Arsenal
Yes: ____ No: _____
DEPARTMENT OF THE ARMY
UNITED STATES ARMY INSTALLATION MANAGEMENT AGENCY
PICATINNY ARSENAL, NEW JERSEY 07806-5000
| DEPARTMENT OF THE ARMY |
| UNITED STATES ARMY INSTALLATION MANAGEMENT AGENCY |
| PICATINNY ARSENAL, NEW JERSEY 07806-5000 |
| Full Legal Name: |
| Date of Birth: |
| Race: |
| Gender Female: |
| Male: |
| Place of Birth: |
| Social Security Number: |
| Drivers License: |
| State of Drivers License: |
| Yes: |
| provide detail on the back of page No: |
| Date: |
| Yes_2: |
| No: |
File details come from the government source that posted it. Updated .