B_NCIC_SECURITY_CHECK_FORMS.pdf

BP-A0660

JUN 10

U.S. DEPARTMENT OF JUSTICE

NCIC CHECK CDFRM

FEDERAL BUREAU OF PRISONS

AUTHORIZATION FOR RELEASE OF INFORMATI ON

NCIC (Nat i onal Crime Information Center) CHECK

I hereby a uthorize a rep resenta tive of the Federal Bureau of Prisons to obtain any information on my crimina l his t ory background . I understand that this check must b e done be fore I a m allowed to e nter/se rve at any Bureau facility. I also understand that refusal to provide all neces s a ry information ma y result in 1) denial of entry into a Bureau facility and 2) d enial of volunteer/contra ct status.

1. Name (Last, First, Middle)

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

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

4. Aliases/Nickna me:

5. Citizenship (List the country you are a citi z.e n of):

6. Social Se curity Number:

7. Date of Birth (Mo n th, day, year):

Sa. Sex: Sb. Ra ce:

Be. Height: Sd. Weight:

Be . Color of Eyes: 9f. Color of Ha i r:

9. Place of Birth {City, State , Count y), {Lis t city, county and country if outsid e the U.S.A)

10. The above listed information is true lOa. Date and correct . Applicant' s Signature

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 b e furnished to individuals in order to obtain information regard ing activities in connection with an inve stigation to determine (1) fitness for Fe dera l employment, (2) cle arance to p erform contra ctual servi ce for t h e Federal Governmen t, (3) s e c urity clea rance or ac c ess. The information obta ine d may be furnishe d to third p art i e s a s ne ces sary in the f ulfillment of official resp onsibilities.

Effects of Non-disclosures : Furni s hing t he reque s ted informa tion is voluntary, but failure to p r ov i de a ll or of part t he inf ormat ion ma y result in lack of furthe r consid eration for e mployment, clearance or a cces s, or in the termination of your e mployment.

NCIC Additional Information

Complete the following questions and return with the NCIC Release:

1. Your name:

2. Your Social Security Number: _______ _

3. YourcurrentZipCode: ___________ _

4. Your Date of Birth:

5. List the other States where you have lived in the last seven (7) years: ________ _

HISTORY OF ARR.EST(S)/CONVICTIONS(S)

NCIC BACKGROUND FOR\-[

list all :irrests/convictions below-BE VERY THOROUGH. Traffic citations need not be listed: however, any arrest(s) for vehicular law violations need to be listed. If :i juvenile record exists, indic:ite "'hich State(s).

1. DATE & YEAR OF ARR.EST(S):

2. AGE~CY ~l.\..KDIG ARREST (CITY POLICE, SHERJFF' S OFFICE. ETC.):

3. LOCATION OF ARREST (CITY & STATE):

-'· OFFENSE (CHARGE):

5. FINAL DISPOSITION/RESlJL TS (EXPLAIN):

6. ARE YOU CURRENTLY ON PROBATION OR UNDER THE JURISDICTION OF ANY

COURT? HA VE YOU EVER BEEN IN THE PAST? IF SO PLEASE LIST THE DATES

• .\.."ID WHERE.

7. LIST WHETHER OFFENSE WAS MISDEMEA.t'fOR OR FELONY:

8. IF JAIL TER'\tl, HOW MA1'fY DAYS:

9. IF FINED, HOW l\fUCH:

SIGNATURE DATE

I

P.S. 3000.02 November 1, 1993

Attachment 7-16, Page 1

CONTRACTOR PRE-EMPLOYMENT FORM

NAME

ADDRESS

SOCIAL SECURITY NUMBER

Do you kn.ow 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 inrnate(sl.

Are there any criminal charges currently pending against you?

~~-Yes ~~-No

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

Are you now or have you ever been incarcerated or under correctional supervision <including home detention, probat ion, work release, etc.)?

~~-Yes No

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

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