Police Check Inquiry Form.pdf

OMB NO: 1140-0068 (06/30/2024)

U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives Police Check Inquiry

Instructions: The Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) requires that non-ATF personnel and ATF sponsors (i.e., contracting officer’s technical representative (COTR) and points of contact (POC)) complete ATF Form 8620.42 when requesting that non-ATF personnel be granted escorted access to ATF facilities, non-sensitive information, and/or construction sites in order to perform low risk, non-sensitive duties. Items 1-15 of this form must be completed by all non-ATF personnel requiring escorted access. Items 13-14 may be omitted if access is requested for four or fewer days. Once completed, the non-ATF personnel must sign and date the form and submit it to the ATF sponsor. ATF sponsors will then complete Items 16-25 and forward this form to the Physical Security Programs Branch or appropriate Field Division personnel for processing.

To Be Completed by Non-ATF Personnel

1. Non-ATF Personnel’s Assignment Status (check one): Contractor Vendor Other

2. Last Name 3. First Name 4. Middle Name 5. Suffix 6. Social Security Number

7. Date of Birth 8. Place of Birth (State/Country) 9. Citizenship 10. Sex

11. Other Names Used (Maiden, Nickname, etc.)

12. If foreign born, provide the type and number for one of the following documents: Alien Registration, Naturalization Certificate, U.S. Passport, or Employment Authorization Card.

Type Number

13. Home Address (Provide residential history for past five years. Use additional sheet(s) if necessary.)

From: To: Address City State

From: To: Address City State

From: To: Address City State

From: To: Address City State

14. Employment History (Provide employment information for past five years. Use additional sheets(s) if necessary.)

From: To: Employer Name Address City State

From: To: Employer Name Address City State

From: To: Employer Name Address City State

From: To: Employer Name Address City State

15a. Ethnic Origin

Hispanic or Latino Yes No A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.

15b. Race (Select one or more that apply)

American Indian or Alaska Native A person having origin in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliations or community attachment.

Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Island

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

I, , give my consent and permission for the ATF to conduct a police check inquiry for the purpose of granting me escorted access to ATF facilities, non-sensitive information, and/or construction sites. I understand that a felony conviction will automatically disqualify me. I understand that additional forms may be required by ATF for a more in-depth background investigation. I attest that the information provided is true.

Signature Date

ATF Form 8620.42 Revised June 2021

To Be Completed by ATF Sponsor (e.g., COTR or POC)

16. Subject’s Assigned ATF Office 17. Subject’s Job Title 18. Assignment Duration Dates

Beginning Ending

19. Subject’s Duties Will Require the Following Escorted Access Facilities ATF Non-Sensitive Information Construction Site

20. ATF Sponsor Name 21. ATF Sponsor Address 22. Phone Number

23. Sponsor Signature 24. Date

25. Description of Duties and Other Remarks

To Be Completed by the Physical Security Programs Branch/Field Division

26. NCIC Conducted: (Date)/ /

QH N/R R

QW N/R R

QPO N/R R

27. TECS Conducted: / / (Date)

SQ N/R R

28. NLETS Conducted:

States (identify below):

/ / (Date)

IQ N/R R

IQ N/R R

DQ N/R R

DQ N/R R

Access Granted

Access Denied

Signature of Authorized ATF Official Title Date

Instructions ATF Form 8620.42 must be initiated by the ATF Sponsor (e.g., COTR or POC) prior to granting escorted access to non-ATF personnel to ATF facilities, non-sensitive information, and/or construction sites. Positions that could be escorted are janitorial and/or short-term construction contractors who may be performing electrical or plumbing duties. The Physical Security Programs Branch or Field Division is responsible for conducting the required records and inquiry checks.

Items 1-15. All non-ATF personnel must complete Items 1-15. No item may be left unanswered.

Items 16-25. To be completed by the ATF Sponsor (e.g., COTR or POC).

Items 26-28. To be completed by personel from the Physical Security Programs Branch or Field Division.

Paperwork Reduction Act Notice

This request is in accordance with the Paperwork Reduction Act of 1995. The information collected is used by ATF to screen non-ATF personnel for escorted access to ATF facilities, non-sensitive information, and/or construction sites. The appropriate ATF office (Physical Security Programs Branch or Field Division) will maintain a copy of this form with the results of the indices checks for the duration of the contract employment or for a minimum of one year, whichever is longer.

The estimated average burden associated with this collection of information is 4.98 minutes per respondent, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Report Management Officer, Resource Management Staff, Contract and Forms Office, Bureau of Alcohol, Tobacco, Firearms and Explosives, 99 New York Avenue, NE, Washington, DC. 20226. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Privacy Act Statement

Authority. Solicitation of this information is authorized as part of our investigative authorities under Executive Orders 10450 and 12968. This information will be used by ATF to begin preliminary screening/investigation for security purposes.

Purpose. The information will be used to determine if non-ATF personnel may be granted access to ATF facilities, non-sensitive information, and/or construction sites.

Routine Uses. You are requested to furnish information regarding your race under the authority of 42 USC § 2000e-16, which requires that Federal employment practices be free from discrimination and provide equal employment opportunities for all. Solicitation of this information is in accordance with Department of Commerce Directive 15, “Race and Ethnic Standards for Federal Statistics and Administrative Reporting.”

Disclosure of Social Security Number (SSN). You are further requested to furnish your SSN under authority of Executive Order 9397, published Nov. 22, 1943.

That Order requires agencies to use the SSN for the sake of economy and orderly administration in the maintenance of records. Furnishing your race and SSN is mandatory.

Failure to provide the requested information may negatively impact ATF’s ability to positively identify you in the Federal criminal justice records system.

ATF Form 8620.42 Revised June 2021

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