Blank Applicant Release Form - Fillable.pdf

Applicant Release

In connection with my application to enter the installation, I understand that background investigation checks are to be made on me including, criminal convictions, motor vehicle, and other reports. Further, I understand that there will be requests for information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, criminal, and/or civil claims. I authorize without reservation, any party or agency contacted to furnish the above mentioned infonnation and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original or electronic fonn.

Applicant's Signature Date NOTE: The following iliformation is required by law e,iforcement agencies and other elllitiesfor identification p1117Joses when checking record5·. It is confidential and will no/ be used for any other purpose:

APPLICANT FILLS OUT COMPLETELY (Will be returned if not legible.)

Print Full Name: __________ _ Sex: Male D Female D

Dates used: Print other names you have used: _________ _

Date of Birth (rnm/dd/yy): ______ _ City & State of Birth: _______ _

Social Security #: ___________ _ Race:

Current Drivers License#: ________ _ Issuing State: _______ _

Other Drivers License #s: _________ _ Issuing State: _______ _ (List last 7 years only)

HOME ADDRESS:

Street:. _____________ _ City: _______ _ State:

Zip: ________ _ County: _______________ _

From - To Dates: _ _ _ _ _____ _

PRIME CONTRACTOR FILLS OUT FOLLOWING:

Sponsor/Endorsing Office: 434m OPERATIONAL CONTRACTING OFFICE Start Date: ___ End Date: ___ _

Prime Contractor: _________ Employer of Applicant: _ ______________ _ Full address of the applicant's employer

Phone Number of the applicant's employer ________________________ _

SFS FILLS OUT FOLLOWING: DATE/INT's

RECEIVED ____ _ IDACS

SFMIS

This document may contain information which must be protected IA W 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 SAFEGUARDfNG AND MAINTAINING THIS PRODUCT !AW PRIVACY ACT OF 1974 PL 93-579.

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