NCIC_III_Release.pdf

Notification and Authorization to Release Criminal Information for Entry

Notification For the purpose of accessing Picatinny Arsenal I am required to consent to a criminal background check as a condition of being granted access. This check includes the following: Criminal history reference searches for felony and misdemeanour convictions at the county and federal levels of every jurisdiction where I currently reside or where I have resided; and sex offender registry searches at the county and federal levels in every jurisdiction where I currently reside or where I have resided. If I decline to submit to a Criminal background check I understand that I will be denied access to Picatinny Arsenal.

Authorization I hereby authorize Picatinny Arsenal to conduct the criminal background check described above.

I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to entrance to Picatinny Arsenal.

Such information will be used to determine whether the results of the background check reasonably bear on my ability to enter in a manner which is safe for Picatinny Arsenal visitors, employees, and other community members.

Please print LEGIBLY (for identification purposes):

Full Legal Name:

First Middle Last

Date of Birth: Race: Gender: Female Male Month/Day/Year

Place of Birth_________________________ Social Security Number:

Driver’s License # State of Driver’s License

Have you ever been arrested for a criminal *offense or have any pending criminal* charges against you?

Yes (provide detail on the back of page) No

To the best of my knowledge, the information provided in this Notice and Authorization and any attachments thereto is true and complete.

I understand that any falsification or omission of information may disqualify me for entrance and/or may serve as grounds for denial of entry to Picatinny Arsenal. By signing below I hereby provide my authorization to Picatinny Arsenal to conduct a criminal background check. In addition, I understand that I have a right to appeal an adverse decision made by Picatinny Arsenal based on my background check information.

Signature Date

Individual is cleared for entry to Picatinny Arsenal

Yes: ____ No: _____

DEPARTMENT OF THE ARMY

UNITED STATES ARMY INSTALLATION MANAGEMENT AGENCY

PICATINNY ARSENAL, NEW JERSEY 07806-5000