J.10 CP-491 (05-18) Fillable.pdf
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- Solicitation number
- AOCSSB26R0023
- Issued by
-
Architect of the Capitol
About this file
This is a form template used by the United States Capitol Police to request criminal history record checks for applicants and employees. The CP-491 form (dated 05/18) serves as the official document for initiating background investigations through the Federal Bureau of Investigation.
The form is divided into three primary sections. The applicant section (fields 1-17) requires submission of personal identifying information including name, address, date of birth, Social Security number, citizenship status, and physical descriptors. Applicants must provide a valid government-issued photo identification and sign a release acknowledging their understanding that the information will be used for security determinations and that falsification of information is subject to prosecution. The authorized requestor section (fields 18-24) must be completed by an individual with authority to request the background check, typically representing the applicant's agency or employing office. This section includes verification that the applicant is legally authorized to work in the United States under the Immigration Reform and Control Act of 1986. The identification section (fields 25-28) documents the completion of the records check and is completed by the Capitol Police official conducting the verification, including the date of the check and any FBI number assigned. The form must be brought in person to the United States Capitol Police Badge & Fingerprinting Office located at 499 South Capitol Street, SW, Room 127, Washington, DC 20003.
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Text version
CP-491
(05/18) UNITED STATES CAPITOL POLICE
REQUEST FOR CHECK OF CRIMINAL HISTORY RECORDS
(Please Type or Print Legibly)
INSTRUCTIONS
• APPLICANT – Complete Sections 1- 17 of this form.
• APPLICANT’S AGENCY – Complete sections 18-24 of this form.
• Bring this form along with a valid (non-expired) government-issued photo identification that officially establishes your identity to the
United States Capitol Police Badge & Fingerprinting Office located in the Fairchild Building, 499 South Capitol Street, SW, Room 127, Washington, DC 20003.
1. NAME (Last, First, Middle)
2. ADDRESS (Complete Address)
3. EMPLOYER
4. OTHER NAMES EVER USED (e.g. maiden name, nickname, etc.). If you have never used another name write “None”
5. TELEPHONE
NUMBER
6. DATE OF
BIRTH (mm/dd/yyyy)
7. BIRTHPLACE
(City /State/ Country)
8. SOCIAL
SECURITY #
9. COUNTRY OR
CITIZENSHIP
10. GENDER IDENTITY 11. RACE 12. HEIGHT 13. WEIGHT 14. EYE COLOR 15. HAIR COLOR
SIGNATURE AND RELEASE OF INFORMATION: READ THE FOLLOWING CAREFULLY BEFORE SIGNING
• I understand that the information provided above will be used to check the criminal history records of the Federal Bureau of
Investigation.
• I consent to the use of the information provided above in making a security determination concerning me.
• I certify that I am authorized to work in the United States and if requested can provide legal documents supporting my certifications.
• I acknowledge by my signature below that any falsification of the information provided and or the use, possession, or representation of any false identification by me is subject to prosecution and penalties.
• I certify that to the best of my knowledge and belief, all the information provided above is true, correct, complete, and made in good faith.
16. APPLICANT SIGNATURE 17. DATE (mm/dd/yyyy)
AUTHORIZED REQUESTOR
To be filled out by the individual Authorized to Request that the Applicant submit to a Criminal History Records check.
18. NAME (Last, First, Middle) please print 19. AGENCY
20. POSITION/TITLE 21. TELEPHONE NUMBER 22. DATE OF REQUEST
I request that the applicant/employee indicated above be fingerprinted by the United States Capitol Police and that these fingerprints be submitted for a check of the criminal history records of the Federal Bureau of Investigation. This check will be used in making a security determination concerning this applicant/employee. I have verified that the applicant is authorized to legally work within the United States in accordance with the federal government hiring provisions of the Immigration Reform and Control Act of 1986 (Pub. L. 603), as amended, applicable Form I-9 requirements, and any executed Memorandum of Understanding with the United States Capitol Police regarding Requests for Criminal History Record Information by Congressional Employing Offices.
23. SIGNATURE 24. DATE (mm/dd/yyyy)
IDENTIFICATION SECTION
25. INDIVIDUAL CONDUCTING
RECORDS CHECK
26. DATE CHECK
CONDUCTED
27. FBI # (If one, write none”)
28. DOCUMENT
ESTABLISHING IDENTITY
| 1 NAME Last First Middle: |
| 2 ADDRESS Complete Address: |
| 3 EMPLOYERRow1: |
| 4 OTHER NAMES EVER USED eg maiden name nickname etc If you have never used another name write NoneRow1: |
| 5 TELEPHONE NUMBERRow1: |
| 6 DATE OF BIRTH mmddyyyyRow1: |
| 7 BIRTHPLACE City State CountryRow1: |
| 8 SOCIAL SECURITY Row1: |
| 9 COUNTRY OR CITIZENSHIPRow1: |
| 10 GENDER IDENTITYRow1: |
| 11 RACERow1: |
| 12 HEIGHTRow1: |
| 13 WEIGHTRow1: |
| 14 EYE COLORRow1: |
| 15 HAIR COLORRow1: |
| 17 DATE mmddyyyyRow1: |
| 18 NAME Last First Middle please printRow1: |
| 19 AGENCYRow1: |
| 20 POSITIONTITLERow1: |
| 21 TELEPHONE NUMBERRow1: |
| 22 DATE OF REQUESTRow1: |
| 24 DATE mmddyyyyRow1: |
| 25 INDIVIDUAL CONDUCTING RECORDS CHECKRow1: |
| 26 DATE CHECK CONDUCTEDRow1: |
| 27 FBI If one write noneRow1: |
| 28 DOCUMENT ESTABLISHING IDENTITYRow1: |
| RESET: |
| PRINT: |
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