NCIC Rlease Form.pdf

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Canon Printer Ink and Maintenance
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SV0217-26
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This is a background check authorization form issued by the U.S. Department of Justice Federal Bureau of Prisons in March 1999. The form (BP-A660.012) authorizes the Federal Bureau of Prisons to conduct a National Crime Information Center (NCIC) check on an individual's criminal history before granting facility entry or approving volunteer or contract status.

The form requires applicants to provide personal identification information including full name, current address, home telephone number, aliases, citizenship status, Social Security number, date of birth, physical descriptors (sex, race, height, weight, eye color, hair color), and place of birth. Applicants must certify that the provided information is true and correct by signing and dating the form. The Privacy Act Notice indicates that information collected will be used to evaluate fitness for federal employment, clearance to perform contractual services, and security clearance determinations. The notice also specifies that furnishing information is voluntary, but failure to provide complete information may result in denial of facility entry, denial of volunteer or contract status, or termination of employment. The authority for collecting this information is derived from multiple federal statutes including Executive Order 10450 and various USC provisions related to federal employment and security clearances.

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U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

BP-A660.012

MAR 1999 NCIC CHECK

1. Name (Last, First, Middle)

AUTHORIZATION FOR RELEASE OF INFORMATION

NCC (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 a ny Bureau facility. I also understand that refusal to provide all necessary information may result in 1) denial of entry into a Burea u facility and 2) denial of volunteer/contract status.

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):

8a. Sex:

7. Date of Birth (Month, day, year):

6. Social Security Number:

8b. Race:

8d. Weight:8c. Height:

8f. Color of Hair:8e. Color of Eyes:

9. Place of Birth (City, 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

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 Fed eral employment, (2) clearance to perform contractual service for the Federal Government, (3) security clearance or access. The infor mation obtained may be furnished to third parties as necessary in the 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.

name:
phone:
alliases:
citizenship:
ssn:
date:
1:
2:
sex:
race:
height:
weight:
eyes:
hair:
address:
place_of_birth:

File details come from the government source that posted it. Updated .