Attachment 10_ USCP Request for Criminal History (01.01.2016).pdf
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- Solicitation number
- AOCACB24B0102
- Issued by
-
Architect of the Capitol
About this file
This document is a Request for Check of Criminal History Records from the United States Capitol Police. It requires the applicant to complete sections 1-14 with personal identifying information, and authorizes the agency representative to request a criminal history records check from the Federal Bureau of Investigation. The purpose is to make a security determination concerning the applicant.
The related federal contract opportunity is for the Architect of the Capitol to procure FY24 Sidewalk Replacement services at various locations on the US Capitol Grounds. The work involves removing and replacing sidewalks, curbs, gutters, and ADA ramps to comply with ADA regulations. A site visit is scheduled for August 14, 2024 at 9 AM. Interested vendors must request access to view controlled documents "Attachment 2_Sidewalk Specs" and "Attachment 3_Sidewalk Drawings 05302024".
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Text version
UNITED STATES CAPITOL POLICE
WASHINGTON, D.C 20510-7218
CP-491
(9-09)
REQUEST FOR CHECK OF CRIMINAL HISTORY RECORDS
Applicant: (1) Complete Sections1-14 of this form, have your agency complete Sections 15-20 of this form.
Bring this form along with a Valid (Non-expired), Government Issued, Photo Identification Card to the
Fairchild Building, Room 127, 499 South Capitol Street SW, Washington, D.C. 20003
1. Applicant Name: (Last, First, Middle)
12.
2. Applicant’s Address:
Number and Street City & State, Zip Code Telephone Number
3. Other Names Ever used: (e.g. maiden name, nickname, etc. If you have never used another name write "None"
4. Date of Birth: (Month, Day, Year) 5. Birthplace: (City/State/Country
6. Social Security Number: 7. Gender:
8. Race: 9. Height: 10. Weight: 11. Eye Color: 12. Hair Color:
SIGNATURE AND RELEASE OF INFORMATION:
READ THE FOLLOWING CAREFULLY BEFORE YOU SIGN:
I understand that the information provided by me will be used to check the criminal history records of the Federal Bureau of Investigation (FBI).
I consent to the use of the information provided in making a security determination concerning me.
I certify that, to the best of my knowledge and belief, all of the information provided above is true, correct, and complete, made in good faith.
13. Applicant Signature: 14. Date:
AUTHORIZED REQUESTOR: (Complete 15-20) (Not Applicant; to be filled out by the individual Authorized to Request that the Applicant submit to a Criminal History Records check)
15. Printed Name
15 Tide
16. Position Title/Agency
17. Telephone Number 18. 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 (FBI). This check will be used in making a security determination concerning this applicant/employee.
19. Signature 20. Date Signed (Month/Day/Year)
IDENTIFICATION SECTION ONLY: (Complete 21-23)
21. Individual Conducting Records Check: 22. Date Check Conducted
23. FBI Number, if none, write “None”
| REQUEST FOR CHECK OF CRIMINAL HISTORY RECORDS |
| 15. Printed Name |
| undefined: |
| 3 Other Names Ever used eg maiden name nickname etc If you have never used another name write None: |
| undefined_2: |
| 4 Date of Birth Month Day Year: |
| 5 Birthplace CityStateCountry: |
| 6 Social Security Number: |
| 7 Gender: |
| 8 Race: |
| 9 Height: |
| 10 Weight: |
| 11 Eye Color: |
| 12 Hair Color: |
| undefined_4: |
| undefined_5: |
| undefined_6: |
| 17 Telephone Number: |
| 18 Date of Request: |
| 20 Date Signed MonthDayYear: |
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