Background Release Worksheet 2.2.pdf

START DATE: END DATE: Project Name, Building, and/or Location:

Point Of Contact: Phone Numbers: Office: Cell:

Primary Contractor: Sub Contractor:

Escort: Escort Phone Number:

Full Legal Name: Date of Birth:

(Check One)

Driver's License Number: Issuing State: Citizenship: Citizen Non-Citizen (Check One) (Check One)

Gender: MALE FEMALE Race: Asian Black Hispanic Native Other White

Home Address: City: State:

Favorable III Unfavorable III Favorable BMV Unfavorable BMV

Date Checked: Initials:

122d Security Forces Squadron Background Check Release Worksheet

ALL PORTIONS AND SECTIONS ARE MANDATORY

CONTRACT DATES FOR GATE ACCESS

(To be completed by Base Contracting/POC)

CONTRACTOR DETAILS

(To be completed by Primary Contractor)

This worksheet may contain information which must be protected IAW AFI 33-332 and DoD 5400.11; Privacy Act of 1974 as amended 5 U.S.C. 552a applies, and is FOR OFFICIAL USE ONLY(FOUO).

RECIPIENT IS RESPONSIBLE FOR SAFEGUARDING AND MAINTAINING THIS PRODUCT IAW PRIVACY ACT OF 1974 PL 93-579. The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and will not be used for any other purpose.

SECURITY FORCES USE ONLY

I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original or electronic form.

Applicant Wet Signature Only Date

INDIVIDUAL ACCESS INFORMATION

INDIVIDUAL INFORMATION RELEASE

(Must be signed and dated)

In connection with my application to provide contract services, I understand that background investigation checks are to be made on me including, criminal convictions, motor vehicles, and other reports. Further, I understand that the 122d Security

Forces Squadron will be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, criminal, and or civil claims.

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