NCIC FORM.pdf

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)

1a. Name of Company or Organization Represented:

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. 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)

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 the fulfillment of official responsibilities.

Effects of Non-disclosures: Furnishing the requested information is voluntary, but failure to provide all or of part the information may result in lack of further consideration for employment, clearance or access, or in the termination of your employment.

Sensitive - Limited Official Use P.S. 3000.02

November 1, 1993

Attachment 7-16, Page 1

CONTRACTOR PRE-EMPLOYMENT FORM

NAME: ______________________________________________________

ADDRESS: ______________________________________________________

SOCIAL SECURITY NUMBER:_________________________________________

Do you know or are you related to anyone who is currently an inmate in this or any other correctional institution?

______ Yes ______ No

If yes, please provide name, locations, relationships and describe any current or anticipated contact with the inmate(s).

Are there any criminal charges currently pending against you?

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

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

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

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

Sensitive - Limited Official Use