190-5 Access Control Background Check Form (01 Jun 22).pdf

CUI

ACCESS CONTROL BACKGROUND CHECK FORM

PRIVACY ACT STATEMENT:

AUTHORITY: 10 U.S.C. 3013, Secretary of the Army; Army Regulation 190-13, The Army Physical Security Program; E.O. 9397 (SSN); 5 U.S.C. 6311;

Homeland Security Presidential Directive (HSPD) 12; Army Directive-Type Memorandum 09-012; and Army Directive (AD) 2014-05.

PRINCIPAL PURPOSE(S): To provide PBA with the information and consent to perform a background check to determine applicant's eligibility for access to the Pine Bluff Arsenal (PBA). Additional purposes may include: to support Department of the Army physical security and access control programs;

Information Assurance program; to record personal data registered with the Department of the Army; to provide a record of security/access badges issued;

to restrict entry to installations and activities; to ensure positive identification of personnel authorized access to restricted areas; to maintain accountability for issuance and disposition of security/access badges and for producing installation management reports.

ROUTINE USES: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) as follows: The DoD 'Blanket Routine Uses' also apply to this system of records.

DISCLOSURE: Disclosure is voluntary. Non-disclosure of the requested information will result in denial of access to Pine Bluff Arsenal for any purpose.

For additional information regarding privacy practices see System Of Record Notice (SORN) A0191-13 OPMG at http://dpcld.defense.gov/Privacy/ SORNsIndex/DOD-wide-SORN-Article-View/Article/569989/a0190-13-opmg/

-------------------------------------------------------- PERSONAL INFORMATION -----------------------------------------------------

Middle: ___________________Last: ____________________________ First: __________________________ Suffix (Sr, Jr)_______

SSN: Sex: Male Female DOB: ______________________________ ______________________________________

U.S. Hair Eye Citizen: Yes No Height: _______________ Weight: __________ Color: ___________ Color: _____________

(Ft & In)

DRIVER’S LICENCE (DL) / STATE IDENTIFICATION (ID)

DL / ID Expiration Date: _______________ DL / ID Number: _______ DL / ID State: _________ _________________________

-------------------------------------------------------------- AUTHORIZATION -------------------------------------------------------------

Date: __________________________

In accordance with Army Regulation (AR) 190-13, access will only be granted to individuals whose National Crime Information Center Interstate Index inquiry (NCIC-III) check does not contain any of the following: Senior Commander Determines a Potential Threat to the Installation; Fraudulent Identity Information; Arrest Warrant; Barred from a Federal installation; Sex Offenses/Registered Sex Offender; Armed/Aggravated Robbery; Drug Possession with Intent/Purpose to Sell/Deliver; Drug Distribution; Espionage;

Sabotage; Treason; Terrorism; Murder; Felony within 10 years; Felony Firearms or Explosives Violation; Acts or Activities Designed to Overthrow the U.S. Government by force, Identified in Terrorist Screening Database. In addition, the following criteria will prevent hunting on PBA: Felony or Domestic Violence; Possession, Use or Sale of Marijuana, Dangerous or Narcotic Drugs; Declared Mentally Incompetent; DUI/DWI within 5 years; Order of Protection.

My signature indicates that the information provided is true, complete and correct to the best of my knowledge and gives PBA consent to run an NCIC-III check.

Signature: ___________________________________________________________________

*************************************************** FOR DES USE ONLY **************************************************

General Admission: Approved Denied Hunting: Approved Denied

Certified ACIC / NCIC Operator Signature: _________________________________________________________ Date Conducted: ___________________

General Admission: Approved Denied Hunting: Approved Denied

Certified ACIC / NCIC Operator Signature: _________________________________________________________ Date Conducted: ___________________

General Admission: Approved Denied Hunting: Approved Denied

Certified ACIC / NCIC Operator Signature: _________________________________________________________ Date Conducted: ___________________

Controlled By: DES CUI Category: PRVCY

LDC: FED ONLY

POC: Shannon Stowell; 870-540-4080

PBA Form 190-5 CUI 01 Jun 2022 http://dpcld.defense.gov/Privacy/