16._Attachment_15_FTC-OSPR-17Z.pdf

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DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

NAME-BASED CRIMINAL HISTORY RECORD INFORMATION CONSENT/INQUIRY FORM

I hereby give consent for the Federal Law Enforcement Training Centers (FLETC) to receive any State or Interstate Identification Index (III) criminal history record information pertaining to me, as authorized under state and federal law for individuals seeking employment or access with a criminal justice agency. Information provided by those completing this form may be used to conduct background checks on the applicant in accordance with FLETC Directive 71-01, Access Control. Privacy Act Statement: This information is provided in accordance with the Privacy Act of 1974 (5 USC 522a). Authority for this information is 5 USC 301, 5 USC 4101 et seq., Executive Order No. 11348, and Department of Homeland Security Delegation 7050. Disclosure of this information is voluntary. Failure to provide requested information may result in denial of access to the FLETC property.

(Last, First, Middle) (Nicknames, Maiden Names, etc.)

United States Citizen?

Are you a United States Citizen? Check yes or no *If answer is "No" you must contact OSPR/Internal Security for required paperwork* Residential Address:

Race/Ethnicity:

Check all that apply Gender:

check male or female

I certify that the information provided is true and accurate to the best of my knowledge. I acknowledge that knowingly or willfully falsifying information in the document is a violation of 18 U.S. Code Section 1001.

AGENCY USE ONLY

Inquiry resulted in the following:

If results found:

Final Decision:

FTC-OSPR-17Z (5/17)

11.0.0.20130303.1.892433.887364