J.11 USCP Request for Check of Criminal History.pdf
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- Blanket Purchase Agreements (BPAs) for Uniforms
- Solicitation number
- AOCSSB26Q0038
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Architect of the Capitol
About this file
This is a form template issued by the United States Capitol Police for requesting criminal history record checks. The form (CP-491, dated 01/21) is designed to be completed by applicants seeking security clearance or badging and credentialing with the Capitol Police.
The applicant section (Sections 1-17) requires comprehensive personal information including full name, address, employer, alternate names used, contact information, date of birth, birthplace, Social Security number, citizenship, and physical descriptors (gender identity, race, height, weight, eye color, and hair color). The applicant must sign a release authorization certifying that all information is truthful and complete, acknowledging consent to FBI criminal history record checks for security determination purposes, and confirming authorization to work legally in the United States. The authorized requestor section (Sections 18-24) is completed by the individual's agency representative and includes the requestor's name, agency, position, and telephone number, along with certification that the applicant is legally authorized to work under Immigration Reform and Control Act requirements and any applicable Memoranda of Understanding with the Capitol Police. The Badging and Credentialing Division completes the final section (Sections 25-28) documenting the individual conducting the records check, the date of the check, FBI identification number if applicable, and the document used to establish identity. Applicants must bring the completed form and valid government-issued photo identification to the Capitol Police Badging and Credentialing Division located at the Fairchild Building, 499 South Capitol Street, SW, Room 127, Washington, DC 20003.
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Text version
CP-491
(01/21) 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 Badging and Credentialing Division 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)
BADGING AND CREDENTIALING DIVISION
25. INDIVIDUAL CONDUCTING
RECORDS CHECK
26. DATE CHECK
CONDUCTED
27. FBI # (If none, write none”)
28. DOCUMENT
ESTABLISHING IDENTITY
File details come from the government source that posted it. Updated .