Background_Clearance_Form.doc
DOC document 38 KB Posted
- Solicitation number
- USM-HQ-17-0007
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Background Clearance Form
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Text version
US MINT, PHILADELPHIA, PA
BACKGROUND CLEARANCE FORM
| NAME: |
| STREET ADDRESS: |
| (LAST, FIRST, MIDDLE) |
| CITY, STATE, ZIP: |
| SSN: |
| DOB: FORMTEXT |
POB:
(Place of Birth, City/State)
| SEX: |
| HEIGHT: |
| US CITIZEN: |
REPRESENTING (COMPANY):
| DATE(S) OF ENTRY REQUIRED |
| FROM: |
| TO: |
(NOTE: CLEARANCES ARE ONLY VALID FOR ONE YEAR AFTER SUBMISSION; HOWEVERE EACH REQUEST FOR ENTRANCE MUST BE AUTHORIZED AND CLEARED BY DEPT HEAD.)
| REQUESTING OFFICIAL: |
| // |
| ____________________________ |
(PRINT) (SIGNATURE)
| PURPOSE: (PLEASE CHECK) |
| MEETING |
| VISIT |
| WORK x |
| INTERVIEW |
(FOR CONTRACTORS WORKING AT THE MINT, A PRE-APPOINTMENT INVESTIGATION MAY BE REQUIRED)
PARKING REQUIRED: YES ___ NO ___ PARKING IS NOT NORMALLY PROVIDED, HOW-EVER, IS VEHICLE IS REQUIRED TO ACCOMPLISH TASK, CHECK YES UNDER PARKING.
HAVE YOU EVER BEEN ARRESTED?
DECISIONS FOR PRELIMINARY CLEARANCE WILL BE BASED ON THE INFORMATION YOU PROVIDE. ARREST CHARGES ARE CONSIDERED WHEN MAKING THE DECISION, NOT NECESSARILY CONVICTIONS ONLY. FAILURE TO PROVIDE ABOVE REQUESTED INFORMATION WILL RESULT IN NON-ADMITTANCE TO THE FACILITY.
DO NOT WRITE BELOW THIS LINE, POLICE DIVISION ONLY
DATE INFORMATION RECD: ______________ DATE NCIC CONDUCTED: _________
CLEARANCE: YES: ______ NCIC BY: ______________
SUBMIT NACI: ______
NOTE: NEGATIVE INFORMATION SHOULD BE DISSEMINATED TO POLICE OFFICIALS
ONLY.
PRIOR TO ENTRY, MUST BE AUTHORIZED BY CHIEF, INSPECTOR, OR INVESTIGATIVE BRANCH.
ENTRY AUTHORIZED: ____________________ TITLE: _____________ DATE: ________
Rev. 3/05
File details come from the government source that posted it. Updated .