Attachment 0003 - BGAD NCIC Form.pdf

SECTION I. Please Print

1. NAME (Last, First, Middle Name)

3. PHONE NUMBER * (Required):

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH

5. DRIVER’S LICENSE NUMBER:

6. a. NATURALIZATION NUMBER

7. PRINT CURRENT HOME ADDRESS

a. NUMBER AND STREET b. CITY c. STATE d. ZIP CODE

BLUE GRASS ARMY DEPOT DIRECTORATE

OF EMERGENCY SERVICES NCIC-III Check

Administrative Office of the Courts, Frankfort, KY National Crime Information Center (NCIC)

CUI

BGAD CRIMINAL BACKGROUND CHECK FORM, JAN 2021 - 1

PREVIOUS EDITIONS ARE OBSOLETE

COUNTRY OF BIRTH

(Required) (Only fill out if born outside of the United States. You must provide a copy of the certificate.)

PASSPORT NUMBERb.

(Only fill out if born outside of the United States. You Must Provide Copy of Passport.)

SECTION II I HEREBY CONSENT TO THE RELEASE OF MY CRIMINAL HISTORY RECORDS.

PRIVACY ACT STATEMENT

I Authorize a representative of the Blue Grass Army Depot, Directorate of Emergency Services conducting my background check, to obtain any information relating to my criminal history record. I authorize the Administrative Office of the Courts, Frankfort, KY, and the National Crime Information Center conducting my investigation to disclose the record of my background investigation to the Blue Grass Army Depot, for the purpose of making a determination of suitability or eligibility for security access. I understand that the information released by records custodians and sources of information is for OFFICIAL USE ONLY by the Blue Grass Army Depot for the purposes stated and that it may be redisclosed by the government only as authorized by law. I further understand that with the signing of this form I authorize additional background checks up to 2 years as may be needed by representatives of the Bluegrass Army Depot for continuing access to the installation.

My information on this form is true, complete, and correct to the best of my knowledge. Falsification of information provided will result in being Denied Access to the Blue Grass Army Depot.

8.

SIGNATURE OF APPLICANT:a. DATE:b.

9. RETURN THIS FORM TO:

Directorate of Emergency Services ATTN: Badging Office 431 Battlefield Memorial Highway Richmond, KY 40475

BADGING OFFICE

PHONE NUMBER: (859) 779-6090

FAX NUMBER: (859) 779-6600

MWR

OTHER (AA&E, CEP, ETC.)

BGCAPP

CONTRACTOR

BGAD

BGCA

POC AND PHONE NUMBER

10. The purpose of selecting one of the areas below and providing a POC and phone number will assist the BGAD Badging Office with preperation of BGAD Access Badges or to contact the POC for further information as needed.

STATE OF ISSUEa.

CUI

Controlled By:BGAD Controlled By:DES CUI Category(ies):PRVCY Limited Dissemination:FEDCON POC: Brian Purtee, 859-779-6244 janet.thomas Sticky Note Unmarked set by janet.thomas david.w.shaffer Highlight david.w.shaffer Highlight david.w.shaffer Highlight david.w.shaffer Highlight david.w.shaffer Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight