NCIC SECURITY CHECK FORMS.pdf

BP-A0660 CRIMINAL HISTORY CHECK

MAY 1B

U,S DEPARTMENT OF JuST!CE EEQERAL BuREAu QE PRISQNS

AUTHORIZATION FOR RELEASE OF INFORMATION

CRIMINAL HISTORY CHECK

I hereby authorize a representative of the Federal Bureau of Prisons to obtain information on my criminal history background . I understand that this check must be done before I am allowed to enter/serve at any Bureau facil ity . I also understand that refusal to provide all necessary information may resu lt 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. Date of Birth (Month, day , year) :

Ba . Sex: Bb . Race :

Be . Height: Bd . Weight:

Be . Color of Eyes : 9f. Color of Hair:

9. Place of Birth (C ity , State , County) List city , county, and country if outs ide the U.S.A.

10. The above-listed information is true and correct.

Applicant 's Signature

1 Oa. Date

PRIVACY ACT NOTICE

Authority for Collecting Information : E.O. 10450 ; 5 USC 1303-1305; 42 USC 2165 and 2455 ; 22 USC 25B5 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 determ ine (1) fitness for Federal employment , (2) clearance to perform contractua l 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 : Furn ish ing 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 term inat ion of your employment .

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BP-A0660 CHEQUA LA HISTORIA CRIMINAL

MAIO 18

DEPARTAMENTO DE JUSTICIA DE EE.UU . AGENCIA FEDERAL DE PRISIONES

**This template is provided to assist Spanish-speaking persons who are not fluent in English to complete the corresponding Bureau form . It is a template only for instructional purposes , and should not be filled in .**

**Este modelo se provee para ayudar a las personas que hablan espanol y no dom inan el ingles para que completen el formulario correspondiente de la Agencia . Es solo un modelo que sirve coma ejemplo , y nose debe completar .**

AUTORIZACIQN PARA LA DISTRIBUCIQN DE INFORMACIQN

CHEQUA LA HISTORIA CRIMINAL

Por este media autorizo a un representante de la Agencia Federal de Prisiones a obtener cualquier informaci6n sabre los antecedentes de mi historial criminal. Entiendo que este chequeo debe ser hecho antes de recibir perm iso para entrar/servir en cualquier instalaci6n de la Agencia Federal de Prisiones . Tambien entiendo que la negaci6n a proveer toda la informaci6n necesaria puede resultar en ( 1) la negaci6n de mi entrada a una instalaci6n de la Agencia Federal de Prisiones y (2) la negaci6n de mi clas ificaci6n coma voluntario/contratista .

1. Nombre (Apellido , Nombre , Segundo Nombre)

2. Direcci6n (Numero de Domicilio y Calle) (Ciudad , Estado , Condado , C6digo Postal)

3. Numero de Telefono de Casa (C6digo de Area , Numero):

4 . Alias/Apodos :

5. Ciudadanfa (lndique el pafs de su ciudadanfa) :

6. Numero de Seguridad Social :

7. Fecha de Nacim iento (Mes, dfa , ano) :

Ba. Sexo :

Be. Estatu ra :

Be . Color de Ojos :

9. Lugar de Nacimiento (Ciudad, Estado , Condado} , (lndique la ciudad , el condado y el pa fs, si es afuera de EE .UU.)

10 . La informaci6n anteriormente listada es verdadera y correcta.

Firma de Solic itante

Bb. Raza :

Bd. Peso :

9f. Color de Cabello :

1 Oa. Fe cha

AVISO SOBRE LA LEY DE PRIVACIDAD

Autoridad para Obtener lnformaci6n : E.O . 10450; 5 USC 1303-1305; 42 USC 2165 y 2455 ; 22 USC 25B5 y 2519 ; Y 5

USC 3301

Objetivos y Usos: La informaci6n provista en este formulario sera entregada a individuos , con el fin de obtener informaci6n en cuanto a actividades coma parte de una investigaci6n realizada para determinar (1) la aptitud para obtener empleo Federal , (2) la autorizaci6n para realizar serv icio contratado para el Gobierno Federal , (3) la autorizaci6n de seguridad o acceso . La informaci6n obtenida puede ser entregada a terceras partes , coma lo sea necesario , para real izar las responsabilidades oficiales.

Efectos de lnformaci6n No Divulgada : El proveer la informaci6n solicitada es voluntario , pero la falta de proveer toda o parte de la informaci6n puede resultar en la privaci6n de futura cons ideraci6n para empleo , para autorizac i6n o acceso , o puede resultar en la term inaci6n de su empleo .

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HISTORY OF ARREST(S)/CONVICTIONS(S)

NCIC BACKGROUND FOR\-l list all :irrest.5/convictions below-BE VERY THOROUGH. Traffic citations need not be listed; however. any arrest(s) for vehicular law violations need to be listed. If :1 juvenile record e~ists, indic;ire which St:ite(s).

I. DATE & YEAR OF ARR.EST(S) :

2. AGENCY 1\-L\KI.NG ARREST (CITY POLICE, SHERlFF' S OFFICE. ETC.):

3. LOCATION OF ARREST (CITY & STATE):

~- OFFENSE (CHARGE):

5. FINAL DISPOSITION/RESlJL TS (EXPLAIN):

6. ARE YOU CURRENTLY ON PROBATION OR UNDER THE JURISDICTION OF A.'ff

COL""RT? HAVE YOU EVER BEEN IN THE P.-\ST? IF SO PLEASE LIST THE DATES

.6u"ID WHERE.

7. LIST WHETHER OFFENSE WAS MISDEME~'iOR OR FELONY:

8. IF JAIL TER.\'I, HOW MAi."'IY DAYS:

9. fF FINED, HOW Ml:CH:

SIGNATURE DATE

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 i nmate in this or any other correctional institution? ~~-Yes ~~-No

If yes, please provide names , locations, relationship~ and describe any current or anticipated contact with the i nmate(s l.

Are there any criminal charges currently pending against you?

~~-Yes No

If so, please provide charge, date arrested, court dates, docket numbers and any at.hex:

pertinent details .

Are you now or have you ever been incarcerated o r unde:?."

correctional supervision <including home detention, pr o ba t:on , worr. release, etc.)?

-~~Yes ~~-No

It so, please provide dates of incarceration, sentence, location. c harges, current status and any other pertinent details .

CERTIFICATION -- I certify that all of the statemencs made on these pages are true, complete and correct to the best of my knowledge and be l ief and are made in good faith.

Signature {sign in ink) Date