Attachment_D__Background_Investigation_Documents__Adjunct_Professor_IDIQ_SIPI_2024.pdf

Declaration for Federal Employment* (*This form may also be used to assess fitness for federal contract employment)

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. If you are selected, before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

General Information

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

YES NO (If "NO", provide country of citizenship) ♦

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.)

6. PHONE NUMBERS (Include area codes)

Day ♦ Night ♦

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

Military Service

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If your only active duty was training in the Reserves or National Guard, answer "NO.”

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

YES NO

YES NO

YES NO

YES NO

YES NO

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relative works.

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

Continuation Space / Agency Optional Questions

YES NO

YES NO

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(Sign in ink) (MM / DD / YYYY)

17b. Appointee's Signature: Date:

(Sign in ink) (MM / DD / YYYY)

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? Date:

(MM / DD / YYYY)

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

YES NO DO NOT KNOW

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

Fair Credit Reporting Release

Information provided by you will be furnished to the consumer reporting agency in order to obtain information in connection with personnel security screening to determine (1) Pre-Employment; (2)

Suitability or fitness for employment; and/or (3) Security clearance or access. The information provided may be disclosed to other Federal agencies for the above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law.

PLEASE TAKE NOTICE: One or more consumer credit reports may be obtained for employment purposes pursuant to the Fair Credit Reporting Act, as amended, 15 U.S.C., 1681 ET SEQ. The release is valid for two (2) years from the date signed or upon termination of your affiliation with the Federal Government, whichever is sooner. Should a decision to take any adverse action against you be made, based either in whole or in part in the consumer credit report, the consumer reporting agency that provided the report played no role in the agency’s decision to take such adverse action.

I hereby authorize the Department of the Interior, Bureau of Indian Education to obtain such report(s) from any consumer/credit reporting agency for employment purposes.

Warning: This document may contain Privacy Act Data/Sensitive Data which is intended only for the use of the individual it is addressed or requested. It may contain information that is privileged, confidential or otherwise protected from disclosure under applicable laws.

Version: 02/24/2022

Full Name Signature Date Signed

Noncriminal Justice Applicant’s Privacy Rights

As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.

• You must be provided written notification1 that your fingerprints will be used to check the criminal history records of the FBI.

• You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement when you submit your fingerprints and associated personal information. This Privacy Act Statement should explain the authority for collecting your information and how your information will be used, retained, and shared. 2

• If you have a criminal history record, the officials making a determination of your suitability for the employment, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.

• The officials must advise you that the procedures for obtaining a change, correction, or update of your criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.

• If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on information in the criminal history record.3

You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council.4

If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks.

If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry.

Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.)

1 Written notification includes electronic notification, but excludes oral notification.

2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement 3 See 28 CFR 50.12(b).

4 See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c); 28 CFR 20.21(c), 20.33(d) and 906.2(d).

Version: 02/24/2022 http://www.fbi.gov/services/cjis/identity-history-summary-checks http://www.fbi.gov/services/cjis/identity-history-summary-checks http://www.fbi.gov/services/cjis/identity-history-summary-checks http://www.fbi.gov/services/cjis/compact-council/privacy-act-statement http://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

Privacy Act Statement for Fingerprints

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary;

however, failure to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Full Name Signature Date Signed

Warning: This document may contain Privacy Act Data/Sensitive Data which is intended only for the use of the individual it is addressed or requested. It may contain information that is privileged, confidential or otherwise protected from disclosure under applicable laws.

Have you ever been arrested for or charged with a crime involving a child?

[If “yes,” provide the date, explanation of the violation, disposition of the arrest(s) or charge(s), place of occurrence, and the name and address of the police department or court involved.]

Signature

Version: 04/05/2022

Date Signed

Yes;

Full Name

Applicant Screening Questionnaire Indian Children Protection Requirements

Notification Requirements

1. Section 231(d) of the Crime Control Act of 1990, Public Law 101-647 (codified in 42 United States Code § 13041), requires that employment applications for Federal child care positions ask the following:

No

I certify that my response to the above questions is made under penalty of perjury, which is punishable by fine or imprisonment, and that I have received notice that a criminal history records check will be conducted and is a condition of employment. I understand my right to obtain a copy of any criminal history report made available to the Office of Indian Education Programs and my rights to challenge the accuracy and completeness of any information contained in the report.

2. 25 CFR 63.15(a) requires that employment applications for Federal child care positions ask the following:

Have you been arrested or convicted of a crime involving a child, violence, sexual assault, sexual molestation, sexual exploitation, sexual contact or prostitution, or crimes against persons?

[If “yes,” provide the date, explanation of the violation, disposition of the arrest(s) or charge(s), place of occurrence, and the name and address of the police department or court involved.]

Yes;

No

Places Applicant Lived

Purpose: This document is used to identify each State and Indian Reservations or Pueblos an applicant, employee, contractor, or volunteer has lived during the scope of their background investigation for the purposes of completing state and tribal specific law enforcement inquiries.

Authority: Crime Control Act of 1990, Public Law 101-647, 25 CFR § 63.17.

Scope: This form is to be completed by anyone applying for a position in support of the BIE or going through a periodic reinvestigation.

Directions: Complete Section I, “States Where You Have Lived”, and Section II, “Tribal Residence”, beginning with the most recent and working back 5 or 7 years. Tier-1 positions must provide residence history for the last 5 years and Tier-2 positions provide residence history for the last 7 years. Contact your Human Resources point of contact or Contracting Officer Representative to determine the position sensitivity if you do not know which Tier is required for your position. Once complete, read, sign, and date the certification statement. Dates can be approximate but do not omit any states or locations.

Section I: States Where You Have Lived – List all states for the required time period listed above. Include the month/year that you lived there as ‘From’ and ‘To’

State Lived From (MM/YYYY) To (MM/YYYY or Present)

Section II: Tribal Residence – If you live or have lived on an Indian Reservation or Pueblo, please include the state the reservation is located and the name of the Reservation or Pueblo. Include the month/ year that you lived there as ‘From’ and ‘To’

State Reservation or Pueblo From (MM/YYYY) To (MM/YYYY or Present)

Certification Statement: I understand that the information provided may be used to request law enforcement inquiries. By signing below, I certify that the statements provided on this form, are true, complete, and correct to the best of my knowledge. I understand that a false or fraudulent answer, or intentional omission, may be grounds for not hiring me, or for firing me after I begin work, and may be punishable under penalty of perjury.

Local Law Enforcement Inquiry (Tribal Law Check)

Add Police Department or Court conducting checks information here:

Police Department or Court Name:

Address:

City, State, Zip Code:

Please conduct a search of your records, on the individual listed below, dating back to the individual’s 16th birthday and provide this office with a written confirmation of the results. The person identified below is employed with our organization in a position of public trust with duties and responsibilities that involve regular contact with or control over Indian children. Attached is a Bureau of Indian Education Authorization for Release of Information, which is valid two (2) years from the date signed.

Full Legal Name:

Other Name(s) Used:

Social Security Number:

Date of Birth:

NO RECORD: There is no criminal record for the individual identified in this request.

RECORD: There is a criminal record for the individual identified above. Please provide details of the record below, including the date of occurrence, specific offense(s), whether the offense is a misdemeanor or felony, disposition, and the court that could provide more information. If there are any outstanding warrants, please list the nature of the offense(s) involved. (Please exclude traffic violations for which a fine of $300 or less is imposed or any offense committed as a juvenile.)

Date Offense Misd. or Felony Disposition Court

Person who conducted the records check:

Printed Name:

Title:

Phone Number:

Signature Date

This request is consistent with the requirements derived from one or more of the following regulations: 42 United States Code (U.S.C.) 13041; 25 U.S.C. 3207, as amended; 25 Code of Federal Regulations § 63.19, as amended; and the Privacy Act of 1974.

Version: 09/08/2022

Navajo Nation Authorization for Release of Information

Carefully read this authorization to release information about you, then sign and date.

I, the undersigned, authorize the Navajo Nation Police Department (Information Management Section) to release law enforcement records to the Bureau of Indian Education (BIE). I agree that a copy of this authorization is as valid as the original.

I Understand that the information to be exchanged contains protected information directly related to all criminal records identified with my information within the Navajo Nation Police Department (Information

Management Section) System of Records.

I Understand that the information released to the BIE by the Navajo Nation Police Department

(Information Management Section) is For Official Use ONLY by the Federal Government for the purpose of conducting a pre-employment adjudicative determination, a final adjudicative determination, or when a reinvestigation is required, and that it may be disclosed to other Federal Agencies, only as authorized by law.

I Understand that this authorization expires two (2) years from the date of signature. I agree that I may revoke this authorization at any time prior to the release of criminal records by making the request in writing to the Navajo Nation Police Department (Information Management Section) or to the BIE, but that any such revocation will not apply to the information already released and the agency’s will be held harmless.

Last Name First Name Middle Name (if none, enter “N/A”

Date of Birth (MM-DD-YYYY) Social Security Number

Address City State Zip Code

Signature Date (MM-DD-YYYY)

The above Authorization for Release of Information is consistent with the requirements derived from one or more of the following regulations: 42 United States Code (U.S.C.) 13041; 25 U.S.C. 3207, as amended;

25 Code of Federal Regulations § 63.17, as amended; and the Privacy Act of 1974.

Enclosed: Clear Copy of Unexpired Driver’s License

Authorization for Release of Information

Carefully read this authorization to release information about you, then sign and date.

I Authorize the Department of the Interior (DOI), Bureau of Indian Education (BIE) personnel security representative initiating and/or conducting my background investigation or reinvestigation to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retail business establishments, or other sources of information to include publicly available electronic information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, and criminal history record information.

I understand that, for some sources of information, a separate specific release will be needed, and I may be contacted for such a release at a later date.

I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the BIE personnel security representative authorized above 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 Federal Government in connection with personnel security screening to determine

(1) Pre-Employment; (2) Suitability or fitness for employment; and/or (3) Security clearance or access and that it may be disclosed by the Government only as authorized by law.

Photocopies of this authorization with my signature are valid. This authorization is valid for two

(2) years from the date signed.

DEPARTMENT OF PUBLIC SAFETY / P.O. BOX 1628 / SANTA FE, NM 87504-1628

AUTHORIZATION FOR RELEASE OF INFORMATION

I,___________________________________________________________________________________

NAME (MUST BE PRINTED-LEGIBLY) (SSN#) (DOB)

Alias' Name:___________________________ SSN:____________________DOB:_________________________

Name:___________________________ SSN:____________________ DOB:_________________________

NAME OF AGENCY OR PERSON RECEIVING ARREST RECORD

ADDRESS:__________________________________________________________________________

AS AN AUTHORIZED AGENT FOR ME FOR THE PURPOSE OF INSPECTING (AND /OR

OBTAINING COPIES OF) ANY NEW MEXICO ARREST FINGERPRINT CARD SUPPORTED

ARREST RECORD INFORMATION MAINTAINED BY THE DEPARTMENT OF PUBLIC SAFETY,

INCLUDING INFORMATION CONCERNING FELONY OR MISDEMEANOR ARRESTS AND

INFORMATION OBTAINED FROM RELEVANT FINGERPRINT DATABASES.

TO THE CUSTODIAN OF THE RECORDS IN QUESTION, I HEREBY DIRECT YOU TO RELEASE

SUCH INFORMATION TO THE AUTHORIZED AGENT AS DESCRIBED ABOVE.

I HEREBY RELEASE THE CUSTODIAN OR CUSTODIANS OF SUCH RECORDS AND THE

DEPARTMENT OF PUBLIC SAFETY, INCLUDING ANY OF THEIR AGENTS, EMPLOYEES, OR

REPRESENTATIVES IN ANY CAPACITY, FROM ANY AND ALL CLAIMS OF LIABILITY OR

DAMAGE OF WHATEVER KIND OR NATURE, WHICH AT ANY TIME COULD RESULT TO ME,

MY HEIRS, ASSIGNS, ASSOCIATES, PERSONAL REPRESENTATIVE OR REPRESENTATIVES

OF ANY NATURE BECAUSE OF COMPLIANCE BY SAID CUSTODIAN OR CUSTODIANS WITH

THIS "AUTHORIZATION FOR RELEASE OF INFORMATION" AND MY REQUEST CONTAINED

HEREIN FOR THIS RELEASE OR BECAUSE OF ANY USE OF THESE RECORDS. THIS

RELEASE IS BINDING, NOW AND IN THE FUTURE AND IS VALID FOR A PERIOD OF UP TO

120 DAYS FROM THE DATE SIGNED, ON MY HEIRS, ASSIGNS, ASSOCIATES, PERSONAL

REPRESENTATIVE OR REPRESENTATIVES OF ANY NATURE.

APPLICANT SIGNATURE:_________________________________

DATE:____________________________________

SIGNED AND SWORN TO BEFORE ME ON THIS _______ Day Of________________20______

State of_________________ County of_______________

(SEAL)

(SIGNATURE OF NOTARY PUBLIC)

MY COMMISSION EXPIRES:____________________

For Department of Public Safety Use Only

Bureau of Indian Education - Personnel Security Office - 110

1011 Indian School Road Suite 150 Albuquerque, NM 87104

Accessibility Report

Filename:

02. Fair Credit Reporting Release v. Jul 19 2021.pdf

Report created by:

Jennifer Bauer, Personnel Security Specialist

Organization:

, Department of Interior, Bureau of Indian Education

[Personal and organization information from the Preferences > Identity dialog.]

Summary

The checker found problems which may prevent the document from being fully accessible.

Needs manual check: 2

Passed manually: 0

Failed manually: 0

Skipped: 3

Passed: 24

Failed: 3

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Headings

Rule Name Status Description

Appropriate nesting Failed Appropriate nesting

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Filename:

03. Fingerprint Privacy Act Release v Jul 19 2021.pdf

Report created by:

Jennifer Bauer, Personnel Security Specialist

Organization:

, Department of Interior, Bureau of Indian Education

The checker found no problems in this document.

Needs manual check: 2

Passed manually: 0

Failed manually: 0

Skipped: 3

Passed: 27

Failed: 0

Document

Rule Name Status Description

Accessibility permission flag Passed Accessibility permission flag must be set

Image-only PDF Passed Document is not image-only PDF

Tagged PDF Passed Document is tagged PDF

Logical Reading Order Needs manual check Document structure provides a logical reading order

Primary language Passed Text language is specified

Title Passed Document title is showing in title bar

Bookmarks Passed Bookmarks are present in large documents

Color contrast Needs manual check Document has appropriate color contrast

Page Content

Rule Name Status Description

Tagged content Passed All page content is tagged

Tagged annotations Passed All annotations are tagged

Tab order Passed Tab order is consistent with structure order

Character encoding Passed Reliable character encoding is provided

Tagged multimedia Passed All multimedia objects are tagged

Screen flicker Passed Page will not cause screen flicker

Scripts Passed No inaccessible scripts

Timed responses Passed Page does not require timed responses

Navigation links Passed Navigation links are not repetitive

Forms

Rule Name Status Description

Tagged form fields Skipped All form fields are tagged

Field descriptions Passed All form fields have description

Alternate Text

Rule Name Status Description

Figures alternate text Passed Figures require alternate text

Nested alternate text Passed Alternate text that will never be read

Associated with content Skipped Alternate text must be associated with some content

Hides annotation Passed Alternate text should not hide annotation

Other elements alternate text Passed Other elements that require alternate text

Tables

Rule Name Status Description

Rows Passed TR must be a child of Table, THead, TBody, or TFoot

TH and TD Passed TH and TD must be children of TR

Headers Passed Tables should have headers

Regularity Passed Tables must contain the same number of columns in each row and rows in each column

Summary Skipped Tables must have a summary

Lists

Rule Name Status Description

List items Passed LI must be a child of L

Lbl and LBody Passed Lbl and LBody must be children of LI

Headings

Rule Name Status Description

Appropriate nesting Passed Appropriate nesting

Filename:

Applicant Screening Questionnaire June 2021 .pdf

Report created by:

Jennifer Bauer, Personnel Security Specialist

Organization:

, Department of Interior, Bureau of Indian Education

The checker found problems which may prevent the document from being fully accessible.

Needs manual check: 2

Passed manually: 0

Failed manually: 0

Skipped: 3

Passed: 24

Failed: 3

Document

Rule Name Status Description

Accessibility permission flag Passed Accessibility permission flag must be set

Image-only PDF Passed Document is not image-only PDF

Tagged PDF Passed Document is tagged PDF

Logical Reading Order Needs manual check Document structure provides a logical reading order

Primary language Passed Text language is specified

Title Passed Document title is showing in title bar

Bookmarks Passed Bookmarks are present in large documents

Color contrast Needs manual check Document has appropriate color contrast

Page Content

Rule Name Status Description

Tagged content Passed All page content is tagged

Tagged annotations Failed All annotations are tagged

Tab order Passed Tab order is consistent with structure order

Character encoding Passed Reliable character encoding is provided

Tagged multimedia Passed All multimedia objects are tagged

Screen flicker Passed Page will not cause screen flicker

Scripts Passed No inaccessible scripts

Timed responses Passed Page does not require timed responses

Navigation links Passed Navigation links are not repetitive

Forms

Rule Name Status Description

Tagged form fields Skipped All form fields are tagged

Field descriptions Passed All form fields have description

Alternate Text

Rule Name Status Description

Figures alternate text Passed Figures require alternate text

Nested alternate text Passed Alternate text that will never be read

Associated with content Skipped Alternate text must be associated with some content

Hides annotation Passed Alternate text should not hide annotation

Other elements alternate text Passed Other elements that require alternate text

Tables

Rule Name Status Description

Rows Passed TR must be a child of Table, THead, TBody, or TFoot

TH and TD Passed TH and TD must be children of TR

Headers Failed Tables should have headers

Regularity Passed Tables must contain the same number of columns in each row and rows in each column

Summary Skipped Tables must have a summary

Lists

Rule Name Status Description

List items Passed LI must be a child of L

Lbl and LBody Passed Lbl and LBody must be children of LI

Headings

Rule Name Status Description

Appropriate nesting Failed Appropriate nesting

Filename:

BIE Authorization for Release of Information July 6, 2021.pdf

Report created by:

Jennifer Bauer, Personnel Security Specialist

Organization:

, Department of Interior, Bureau of Indian Education

The checker found no problems in this document.

Needs manual check: 2

Passed manually: 0

Failed manually: 0

Skipped: 3

Passed: 27

Failed: 0

Document

Rule Name Status Description

Accessibility permission flag Passed Accessibility permission flag must be set

Image-only PDF Passed Document is not image-only PDF

Tagged PDF Passed Document is tagged PDF

Logical Reading Order Needs manual check Document structure provides a logical reading order

Primary language Passed Text language is specified

Title Passed Document title is showing in title bar

Bookmarks Passed Bookmarks are present in large documents

Color contrast Needs manual check Document has appropriate color contrast

Page Content

Rule Name Status Description

Tagged content Passed All page content is tagged

Tagged annotations Passed All annotations are tagged

Tab order Passed Tab order is consistent with structure order

Character encoding Passed Reliable character encoding is provided

Tagged multimedia Passed All multimedia objects are tagged

Screen flicker Passed Page will not cause screen flicker

Scripts Passed No inaccessible scripts

Timed responses Passed Page does not require timed responses

Navigation links Passed Navigation links are not repetitive

Forms

Rule Name Status Description

Tagged form fields Skipped All form fields are tagged

Field descriptions Passed All form fields have description

Alternate Text

Rule Name Status Description

Figures alternate text Passed Figures require alternate text

Nested alternate text Passed Alternate text that will never be read

Associated with content Skipped Alternate text must be associated with some content

Hides annotation Passed Alternate text should not hide annotation

Other elements alternate text Passed Other elements that require alternate text

Tables

Rule Name Status Description

Rows Passed TR must be a child of Table, THead, TBody, or TFoot

TH and TD Passed TH and TD must be children of TR

Headers Passed Tables should have headers

Regularity Passed Tables must contain the same number of columns in each row and rows in each column

Summary Skipped Tables must have a summary

Lists

Rule Name Status Description

List items Passed LI must be a child of L

Lbl and LBody Passed Lbl and LBody must be children of LI

Headings

Rule Name Status Description

Appropriate nesting Passed Appropriate nesting