NCIC FORMS CONTRACTOR UPDATED.pdf

SENSITIVE LOU

NCIC CHECKLIST

for Contractors

The following forms must be submitted for all NCIC checks (Contractors)

Required Forms for all Contractor NCIC’s.

NCIC Check form - BP-S660.-12, Dated March 1999

Contractor Pre-Employment Form

*Department of Justice Residency Requirement Certification Form

Copy of Current Driver’s Licence

COPY OF SOCIAL SECURITY CARD

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)

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 te fulfilment of official responsibilities.

Effects 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 employment, clearance or access, or in the termination of your employment.

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 names, locations, relationships and describe any current or anticipated contact with the inmate(s).

Are there any criminal charges currently pending against you?

_____Yes _____No

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.)?

_____Yes _____No

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

DEPARTMENT OF JUSTICE

RESIDENCY REQUIREMENT CERTIFICATION FORM (JUNE 2004)

This certification is required to be completed for all purchase card transactions for services that are subject to the DOJ Residency Requirement.

If the service is to be provided by an individual, that individual must sign the certification and return it to the cardholder for filing with the purchase card acquisition form. If the service is to be provided by a company, one certification may be submitted by an authorized company representative. By submitting this certification, the company is agreeing to provide the BOP with contract employees that meet the DOJ Residency Requirement.

Individuals

By signing this certification I certify that for three of the five years immediately prior to responding to this solicitation, I have: 1) legally resided in the United States (U.S.); 2) worked for the U.S. overseas in a Federal or military capacity; or 3) have been a dependent of a Federal or military employee serving overseas.

Companies

By signing this certification I certify that for three of the five years immediately prior to responding to this solicitation, the contract employees providing services to the BOP have:

1) legally resided in the United States (U.S.); 2) worked for the U.S.

overseas in a Federal or military capacity; or 3) have been a dependent of a Federal or military employee serving overseas.

Name of Individual/Vendor Date

Signature of Individual or Vendor Representative

COPY OF VALID DRIVERS LICENSE

or

Valid Picture ID Here

(To be completed by all contractors)

Updated 12/10/2003