NCIC_and_amendment_2.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. CONTRACT ID CODE PAGE OF PAGES

2. AMENDMENT/MODIFICATION NO. 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQ. NO. 5. PROJECT NO. (If applicable)

6. ISSUED BY CODE 7. ADMINISTERED BY (If other than Item 6) CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code) 9A. AMENDMENT OF SOLICITATION NO.

9B. DATED (SEE ITEM 11)

10A. MODIFICATION OF CONTRACT/ORDER NO.

10B. DATED (SEE ITEM 13)

CODE FACILITY CODE

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

The above numbered solicitation is amended as set forth in Item 14. The hour a nd date specified for receipt of Offers is extended, is not extended.

Offers must acknowledge receipt of this amendment prior to the hour and date sp ecified in the solicitation or as amended, by one of the following methods:

(a) By completing Items 8 and 15, and returning copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or

(c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

D. OTHER (Specify type of modification and authority)

E. IMPORTANT:

Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force a nd effect.

15A. NAME AND TITLE OF SIGNER (Type or print) 16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA

BY

(Signature of Contracting Officer)

16C. DATE SIGNED

PREVIOUS EDITION UNUSABLE

STANDARD FORM 30 (Rev. 10-83) Prescribed by GSA

FAR (48 CFR) 53.243

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

This form was electronically produced by Elite Federal Forms, Inc.

( ) A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER

NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.)

SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

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BP-A 660 NCIC CHECK CDFRM

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

AUTHORIZATION FOR RELEASE OF INFORMATION

NCIC (National Crime Information Center) CHECK

I hereby authorize a representative of the Federal Bureau of Prisons to obtain any 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 fulfillment 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.

BP- 660 CHEQUEO DE NCIC CDFRM

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

CHEQUEO DE NCIC (Centro Nacional de Información sobre el Crimen)

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.

3 NCIC

Mid-Atlantic Regional Office/FAO 302 Sentinel Drive, Suite 200 Annapolis Junction, MD 20701

A. Remove original broken link from solicitation containing the blank NCIC form, and include this NCIC form for site visit requirement.

NO OTHER CHANGES ARE MADE AT THIS TIME.