NCIC FORM.doc
DOC document 31 KB Posted
- Attached to
- Space Planning and Design
- Solicitation number
- FN1612-26
About this file
This is an NCIC (National Crime Information Center) Background Check Authorization Form used by the Federal Bureau of Prisons to obtain criminal history information on individuals seeking entry, volunteer status, or contract work at Bureau facilities. The form is a template designed to collect personal identifying information including name, address, Social Security number, date of birth, physical descriptors, citizenship, and driver's license information from applicants. The form explicitly authorizes FBP representatives to access NCIC records and notifies applicants that refusal to provide required information may result in denial of facility access and denial of volunteer or contract status.
The form references authority under Executive Order 10450 and various United States Code sections (5 USC 1303-1305, 42 USC 2165 and 2455, 22 USC 2585 and 2519, and 5 USC 3301) for collecting background information to determine fitness for federal employment, contractual service clearance, and security clearance or access eligibility. Furnishing information is technically voluntary, but failure to provide complete information may result in denial of employment, clearance, contract opportunities, or termination of existing employment. The form is dated March 1999 and serves as a prerequisite screening document for the Unicor Factory and other federal prison facility operations under the Department of Justice Bureau of Prisons.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| FN1612-26 A0001 Space Plan Design.pdf | ||
| Past Performance Survey FN1612 26 REVISED.docx | DOCX document | |
| FN1612-26 A0001 Space Plan Design.pdf | ||
| Spaceplan Pricing Spreadsheet 26-31.xlsx | XLSX spreadsheet | |
| FN1612-26 SPACE PLAN AND INSTALL 2.pdf | ||
| Discount Request.pdf | ||
| SalesTools_ChairSample_Justification.pdf | ||
| Past Performance Survey FN1612 26.docx | DOCX document |
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Text version
BP-S660.012 NCIC CHECK CDFRM
MAR 99
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. Driver=s License Number:
7a. 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)
_______________________________________________________________________________________ 9a. Company Name: _____________________________________________________________________
9b. Department to be Visited: Unicor Factory ________________
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 te fulfilment of official responsibilities.
Effects of Non-disclosures: Furnishing the requested information is voluntary, but failure to provide all or part the information may result in lack of further consideration for employment, clearance or access, or in the termination of your employment.
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