Atch_08,_HAFB_Site_Visit_Background_Consent.pdf

BACKGROUND CHECK

CONSENT FORM

Current as of Oct 12

I, __________________________________________________, (Name – typed/printed)

Hereby authorize the U.S. Government (United States Air Force) to conduct background checks confirming my eligibility or ineligibility to gain access to Holloman Air Force Base, New Mexico.

Examples of conditions that may identify ineligibility to access the installation include, but are not limited to, substantiated misconduct, conviction or arrests for violent behavior, dishonesty, sexually aberrant behavior, warrants for arrest, open investigations, or felony charges.

I do so with full knowledge that this information is confidential and as such protected from unauthorized disclosure by the Privacy Act of

1974, as amended.

It is also my understanding that any information provided shall be treated confidentially and be used solely to determine whether I am eligible to access the installation.

***PRIVACY ACT INFORMATION***

PRINT LEGAL NAME:

SSN: BIRTH DATE:

SIGNATURE: COMPANY(if applicable):

DATE:

US CITIZEN? (Circle One): YES / NO

***IFANSWER IS “NO” SEE BELOW***

***NON US CITIZEN MUST PROVIDE***

***PASSPORT# OR VISA#***

PRIVACY ACT STATEMENT

IAW the Privacy Act of 1974, the contents of this document contain privileged or other confidential information.

Unauthorized disclosure may result in civil and criminal sanctions. If you are not the intended recipient, or believe you may have received this communication in error, do not reproduce, retransmit, disseminate, or otherwise use this information.