ATTACHMENT_IV_BP-S660.012_NCICCheck.pdf

Company Name:~-S660.012 NCIC CHECK CDFRM R 99

US. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS

AUTHORIZATION FOR RELEASE OF INFORMATION

NCIC (National Crime Information Center) CHECK

I therebY authorize a representative of the Federal Bureau of Prisons to obtain any i formation on my criminal history background. I understand that this check must be done b fore I am allowed to enter/serve at any Bureau facility.. I also understand that refusal t provide all necessary information may result in 1) denial of entry into a Bureau f cility and 2) denial of volunteer/contract status.

Name (Last, First, Middle)t

Address (Street address) (City, State, County, Zip Code)~

~. Home Teleph~ne Number (Area Code, Number):

Aliases/Nickname:

~. Citizenship (List the country you are a citizen of):

~. Social Security Number:

~. Place of Birth (City, State, County), (List city, county and country if outside the ~.S.A)

110. The above listed information is true and correct. Applicant's Signature lOa.

Date

PRIVACY ACT NOTICE

Authoritvfor Collectinq Information: E.O. 10450; 5 USC 1303-1305; 42 USC 2165 and 2455;

22 USC 2585 and 2519; and 5 USC 3301

~rposes 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 t etermine (1) fitness for Federal employment, (2) clearance to perform contractual service or the Federal Government, (3) security clearance or access. The information obtained ay be furnished to third parties as necessary in te fulfilment of official esponsibilities.

~ffects 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 $mployment, clearance or access, or in the termination of your employment.