NCIC III BACKGROUND CONSENT WAIVER.pdf

United States Army Garrison FT Hamilton A check of records through the National Crime Information Center (NCIC) Interstate Identification Index (III), background check is the minimum baseline for entrance onto Ft. Hamilton for non-CAC holders to include entrance of visitors as per AR 190-13 chapter 8.

NCIC III -BACKGROUND CONSENT/WAIVER

IAW AR 190-13, Physical Security Program, 25 February 2011 Army Directive 2014- 05

1. I hereby give my permission to the Directorate of Emergency Services to obtain information relating to my criminal history record. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct. I understand this information will be used, in part, to determine my eligibility access to US Army Garrison Fort Hamilton.

2. I, ______________________________ the undersigned, do, for myself, my heirs, executors and administrators hereby remise, release and forever discharge and agree to indemnify the Directorate of Emergency Services and each of their officers, directors, employees and agents and hold them harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever (including claims for negligence, gross negligence, and/or strict liability) and any and all related attorneys’ fees, court costs and other expenses resulting from the investigation of my background in connection with my application to access US Army Garrison Fort Hamilton.

Printed Name: LAST, FIRST, MI________________________________ Date of Birth:____________

List other names, maiden used:____________________________ Gender:___Male___Female

Address________________________________City_______________State_______ZIP________

Signature:__________________________ RACE: __Wh__Blk __PI/Asian__ Amer In ___Other

State ID # __________________________ State /Country of Issuance____________________

SSN___________________________ Phone number #____________________

Reason for access to Fort Hamilton_______________________________

The following are reasons for denied access to include, but not limited to:

OMITTING OR REFUSING TO PROVIDE ANY OF THE ABOVE INFORMATION.

Have ever been convicted of crimes encompassing sexual assault, armed robbery, rape, child molestation, production or possession of child pornography, trafficking in humans, drug possession with intent to sell or drug distribution.

Have a U.S. conviction of espionage, sabotage, treason, terrorism or murder.

Registered sex offender

Convicted of a felony within the past 10 years, regardless of the offense or violation or convicted of a felony firearms or explosives violation.

Have engaged in acts or activities designed to overthrow the U.S. Government by force.

Are identified in the TSDB as known to be or suspected of being a terrorist or belonging to an organization with known links to terrorism or support of terrorist activity. When this capability becomes available to DoD, security personnel performing installation access control personnel will strictly follow the Federal Bureaus on Investigation’s published engagement protocols.

Convicted of 3 or more misdemeanors within the last 5 years.

Visitor Control Center 718 630 4848

DES Signature:

BACKGROUND SEARCH COMPLETED BY: ___________________ DATE: ______________________