ATT_5_-_10_ABW_HC_Request_for_IRC.pdf

DEPARTMENT OF THE AIR FORCE

HEADQUARTERS 10TH AIR BASE WING

USAF ACADEMY COLORADO

MEMORANDUM FOR 10 SFS/SFAR

10 MDG/SGOMH (Mental Health) 10 MDG/SGOMH (Family Advocacy) 10 MDG/SGOMH (Drug and Alcohol) 10 ABW/SFS (Security Forces)

FROM: 10 ABW/HC

SUBJECT: Request for Installation Records Check (IRC)

1. Public Law 101-647, Section 231, Crime Control Act, Nov 90, requires all existing and newly hired contractors and volunteers working with children under the age of 18 undergo a criminal history background check. Part of this background check is the IRC, which is a local record check of an individual’s identified residences for the preceding two years before the date of application.

This records check includes Security Forces, Mental Health, Family Advocacy, Drug and Alcohol program, Family Housing and any other agency as appropriate to the extent permitted by law.

Responses by the above agencies are listed on the reverse.

2. If any of your program records indicate any reason why this individual should not perform duties involving children please provide details.

3. Applicants: by signing this form you are giving consent for release of information to the requesting agency.

Signature: (Consent to release information)

PETER N. FISCHER, Ch, Lt Col, USAF Wing Chaplain

This document contains FOR OFFICAL USE ONLY (FOUO) information that must be protected under the Privacy Act of 1974 (AFI 33- 332). Do not release outside of DoD channels without the consent of the originators’ office

APPLICANT’S NAME:

LAST FIRST MIDDLE MAIDEN

SSAN: Date of Birth: Place of Birth

Former Address: Present Address:

Integrity ~ Service ~ Excellence

FA700018Q0007

Attachment 5

BRYAN S. HOCHHALTER, Ch, Lt Col, USAF Wing Chaplain