Criminal History Check Forms - Blank.pdf

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BP-A0660 CRIMINAL HISTORY CHECK

MAY 18

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

AUTHORIZATION FOR RELEASE OF INFORMATION

CRIMINAL HISTORY C HECK

I hereby authorize a representative of the Federal Bureau of Prisons to obtain information on my criminal history background. I understand that this check must be done before I am allowed to enter/serve at any Bureau facility. I also understand that refusal to provide all necessary information may result in (1) denial of entry into a Bureau facility and (2) denial of volunteer/contract status.

1. Name (Last, First, Middle)

2. Address (Street address — City, State, County, Zip Code)

3. Home Telephone Number (Area Code, Number):

4. Aliases/Nickname:

5. Citizenship (List the country you are a citizen of):

6. Social Security Number:

7. Date of Birth (Month, day, year):

8a. Sex: 8b. Race:

8c. Height: 8d. Weight:

8e. Color of Eyes: 9f. Color of Hair:

9. Place of Birth (City, State, County) List city, county, and country if outside the U.S.A.

10. The above- listed information is true and correct.

Applicant’s Signature

10a. Date

PRIVACY ACT NOTICE

Authority for Collecting Information: E.O. 10450; 5 USC 1303-1305; 42 USC 2165 and 2455; 22 USC 2585 and 2519;

and 5 USC 3301

Purposes and Uses: Information provided on this form will be furnished to individuals in order to obtain information regarding activities in connection with an investigation to determine (1) fitness for Federal employment, (2) clearance to perform contractual service for the Federal Government, (3) security clearance or access. The information obtained may be furnished to third parties as necessary in the fulfil lment of official responsibilities.

Effects of Non-Disclosures: Furnishing the requested information is voluntary, but failure to provide all or of part the information may result in lack of further consideration for employment, clearance or access, or in the termination of your employment.

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BP-A0 660 CHEQUA LA HISTORIA CRIMINAL

MAIO 18

DEPARTAMENTO DE JUSTICIA DE EE.UU. AGENCIA FEDERAL DE PRISIONES

**This template is provided to assist Spanish-speaking persons who are not fluent in English to complete the corresponding Bureau form. It is a template only for instructional purposes, and should not be filled in.**

**Este modelo se provee para ayudar a las personas que hablan español y no dominan el inglés para que completen el formulario correspondiente de la Agencia. Es solo un modelo que sirve como ejemplo, y no se debe completar.**

AUTORIZACIÓN PARA LA DISTRIBUCIÓN DE INFORMACIÓN

CHEQUA LA HISTORIA CRIMINAL

Por este medio autorizo a un representante de la Agencia Federal de Prisiones a obtener cualquier información sobre los antecedentes de mi historial criminal. Entiendo que este chequeo debe ser hecho antes de recibir permiso para entrar/servir en cualquier instalación de la Agencia Federal de Prisiones. También entiendo que la negación a proveer toda la información necesaria puede resultar en (1) la negación de mi entrada a una instalación de la

Agencia Federal de Prisiones y (2) la negación de mi clasificación como voluntario/contratista.

1. Nombre (Apellido, Nombre, Segundo Nombre)

2. Dirección (Número de Domicilio y Calle) (Ciudad, Estado, Condado, Código Postal)

3. Número de Teléfono de Casa (Código de Área, Número):

4. Alias/Apodos:

5. Ciudadanía (Indique el país de su ciudadanía):

6. Número de Seguridad Social:

7. Fecha de Nacimiento (Mes, día, año):

8a. Sexo: 8b. Raza:

8c. Estatura: 8d. Peso:

8e. Color de Ojos: 9f. Color de Cabello:

9. Lugar de Nacimiento (Ciudad, Estado, Condado), (Indique la ciudad, el condado y el país, si es afuera de EE.UU.)

10. La información anteriormente listada es verdadera y correcta.

Firma de Solicitante

10a. Fecha

AVISO SOBRE LA LEY DE PRIVACIDAD

Autoridad para Obtener Información: E.O. 10450; 5 USC 1303-1305; 42 USC 2165 y 2455; 22 USC 2585 y 2519; y 5

USC 3301

Objetivos y Usos: La información provista en este formulario será entregada a individuos, con el fin de obtener información en cuanto a actividades como parte de una investigación realizada para determinar (1) la aptitud para obtener empleo Federal, (2) la autorización para realizar servicio contratado para el Gobierno Federal, (3) la autorización de seguridad o acceso. La información obtenida puede ser entregada a terceras partes, como lo sea necesario, para realizar las responsabilidades oficiales.

Efectos de Información No Divulgada: El proveer la información solicitada es voluntario, pero la falta de proveer toda o parte de la información puede resultar en la privación de futura consideración para empleo, para autorización o acceso, o puede resultar en la terminación de su empleo.

P.S. 3000.02 November 1, 1993 Attachment 7-16, Page 1

CONTRACTOR PRE-EMPLOYMENT FORM

NAME

ADDRESS

SOCIAL SECURITY NUMBER

Do you know or are you related to anyone who is currently an inmate in this or any other correctional institution? _____Yes _____No

If yes, please provide names, locations, relationships and describe any current or anticipated contact with the inmate(s).

Are there any criminal charges currently pending against you?

_____Yes _____No

If so, please provide charge, date arrested, court dates, docket numbers and any other pertinent details.

Are you now or have you ever been incarcerated or under correctional supervision (including home detention, probation, work release, etc.)? _____Yes _____No

If so, please provide dates of incarceration, sentence, location, charges, current status and any other pertinent details.

CERTIFICATION -- I certify that all of the statements made on these pages are true, complete and correct to the best of my knowledge and belief and are made in good faith.

Signature (sign in ink) Date

Attachment II

Department of Justice

Residency Requirement Certification Form

The residency requirement certification must be completed and returned with the offer/bid/quote for individuals applying for a contract. Companies must submit a completed certification for each of their employees performing work at the Federal Bureau of Prisons, prior to performance.

In order to facilitate the clearance process, companies should submit the certifications as soon as it is apparent which employees will be performing the work but no later than one week prior to performance. Documentation to substantiate residency may be requested at anytime prior to award for contracts with individuals, and prior to performance for awards to other than individuals.

I certify that for three of the five years immediately prior to responding this solicitation, I have:

1) resided in the United States (U.S.); 2) worked for the U.S. overseas in a Federal or military capacity; or 3) have been a dependent of a Federal or military employee serving overseas.

Name of Vendor/Individual Date

Signature of Individual