J.4 CP-491 (05-18) Fillable.pdf
PDF 105 KB Posted
- Solicitation number
- AOCSSB26R0062
- Issued by
-
Architect of the Capitol
About this file
This is a form template for requesting a criminal history records check issued by the United States Capitol Police (CP-491, revised 05/18).
The form is divided into three main sections: applicant information, authorized requestor information, and identification section. Applicants must complete sections 1-17, providing personal details including name, address, date of birth, Social Security number, citizenship, physical descriptors (gender identity, race, height, weight, eye color, hair color), and contact information. The applicant must sign a release of information statement certifying that all provided information is true and complete, acknowledging authorization to work in the United States, and consenting to use of the information for security determination purposes and FBI criminal history record checks. The applicant's agency or authorized requestor must complete sections 18-24, including requestor name, agency, position, title, telephone number, and date of request. The requestor must verify that the applicant is authorized to work in the United States under Immigration Reform and Control Act of 1986 provisions and applicable Form I-9 requirements. The identification section (sections 25-28) is completed by the individual conducting the records check and includes fields for the conducting officer's name, date check was conducted, FBI number if applicable, and document establishing identity. Applicants must bring the completed form and valid government-issued photo identification to the United States Capitol Police Badge & Fingerprinting Office located at Fairchild Building, 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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