SCUS Police Background Check Form.pdf

SUPREME COURT OF THE UNITED STATES POLICE

WASHINGTON, D. C.

CRIMINAL HISTORY REQUEST FORM

Please provide all of the information requested below. Information should either be typed or printed clearly. Failure to provide all of the required information may cause unnecessary delays to include denial of entry from the building if a positive identification can not be determined. All persons must produce valid picture identification, examples: Driver’s License or other government issued photo identification in order to gain access to the building. This information is confidential and will be treated as such.

SIGNATURE AND RELEASE OF INFORMATION:

READ THE FOLLOWING CAREFULLY BEFORE YOU SIGN:

• I understand that the information provided above will be used to check the criminal history records of the Federal Bureau of Investigation (FBI).

• I consent to the use of the information provided above in making a security determination concerning me.

• I certify that to the best of my knowledge and belief, all the information provided above is true, correct, complete, and made in good faith.

Signature

Date Signed (Month, Day, Year)

Company Date Request Needed By Leave Blank For SCUSPD use only

Last Name

First Name Middle Name Other Names Used

Street Address

City State Zip Code

Telephone Date of Birth Place of Birth

Social Security Number

Sex

Race

Height Weight Hair Color Eye Color

Male Female