BGAD_DES_Criminal_Records_Check_Form_FINAL_(2-25-16).pdf

SECTION I. Please Print

1. NAME (Last, First, Middle Name)

3. E-MAIL:

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH

5. OTHER NAMES USED (No nicknames) 6. DRIVER’S LICENSE NUMBER

7. COUNTRY OF BIRTH a. NATURALIZATION NUMBER b.

8. PRINT CURRENT HOME ADDRESS

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

9. NAME OF COMPANY (Full Name):

10. TYPE OF WORK TO BE PERFORMED:

11. PURPOSE OF RECORDS CHECK (Check One):

_____ Federal Employment _____ Contractor (See box 15) _____ Visitor (Reason For Visit) Military Training _____ MOU/MOA Reasearch ____ COA Lease Farmer _____ Other Federal/State Employee

_____Vendor_____ Fishing _____ Pool _____ Golf _____ Gym

_____ Kindling Pass _____ Recreational

_____PRIVATE EVENT

POC AT BGAD: ____________________________________12.

13. POC PHONE NUMBER: ______________________________

14. WHAT AREA’(S) ARE YOU REQUESTING

ACCESS TO

(Check All That Apply):

___ Administrative Area ___ Restricted Area ___ Restricted “A” Area ___ Restricted “G” Area

___ CLA

___ BGCAPP DEMIL

___ Outside Tracts

15.

16. DATE OF LAST BACKGROUND

CHECK BY BGAD: __________________________

MWR MEMBERSHIP ONLY

HUNT ONLY

DATE OF HUNT:________________________________________

3a. PHONE NUMBER*( required):

BLUE GRASS ARMY DEPOT

DIRECTORATE OF EMERGENCY SERVICES

CRIMINAL RECORDS CHECK

Administrative Office of the Courts, Frankfort, KY

National Crime Information Center (NCIC)

FOR OFFICIAL USE ONLY

BGAD CRIMINAL BACKGROUND CHECK FORM, FEB 2016 - 1 PREVIOUS EDITIONS ARE OBSOLETE

STATE

CONTRACTORS: (Must Complete)

COR AT BGAD:_________________________

COR PHONE NUMBER:__________________

CONTRACT NUMBER:___________________

EXPIRATION DATE:_____________________

_______________________ / BECHTEL PARSONS

***EVENT DATE:____________

(required) (required) (required) (If Born Outside of the United States &Must Provide Copy of Certificate)

PASSPORT NUMBER

17. HAVE YOU EVER BEEN CONVICTED OF

A FELONY YES NO

(If Born Outside of the United States & Must Provide Copy Of Passport)

BGAD OFFICIAL USE ONLY (DO NOT WRITE IN THIS BOX)

DATE ENTERED:

janet.thomas Sticky Note Unmarked set by janet.thomas 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

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 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.

a. SIGNATURE OF APPLICANT: b. DATE:

19. RETURN THIS FORM TO:

Directorate of Emergency Services

ATTN: DoD Security Specialist

431 Battlefield Memorial

Highway Richmond, KY

40475-5090

***** APPLICANT DO NOT WRITE BELOW THIS LINE*****

BGAD OFFICIAL USE ONLY SECTION III

REVIEWING AUTHORITY (DES ONLY)

___ APPROVED ___ DISAPPROVED

Print Name Approving Authority

_______________________________________, Directorate of Emergency Services

Reviewing Authority Signature

__________________, Date of Review

REMARKS:

BGCAPP BADGE INFORMATION

TYPE OF BADGE AND EXPIRATION DATE

NCIC & STATE AGENCY CHECK DoD SECURITY CLEARANCE

BGCAPP BADGE OFFICE CONCURRENCE

GOVERNMENT PRIME CONTRACTOR SUBCONTRACTOR

SIGNATURE

SIGNATURE

SIGNATURE

SIGNATURE

DATE

DATE

DATE

DATE

PERSONNEL SECURITY

PH#859-779-6302/6474/6244

FAX# 859-779-6744

EMAIL: usarmy.bluegrass.jmc.list.bgad-pso@mail.mil

HUNT PROGRAM

FAX# 859-779-6465

MWR FAX# 859-779-6438

BGAD CRIMINAL BACKGROUND CHECK FORM, FEB 2016 - 1

PRE-SCREEN

RE-BADGE

NO ESCORT REQUIRED

18.

( Approved By FSO)

PREVIOUS EDITIONS ARE OBSOLETE

GOV'T FIELD OFFICE/BGCAPP SECURITY

CONCURRENCE

Verification for accuracy of all information provided by the applicant has been completed

( Approved By PSO )

BGCAPP FSO CONCURRENCE

Verification for accuracy of all information provided by the applicant has been completed

BGAD PERSONNEL SECURITY CONCURRENCE

( Approved By ACWA )

( Approved By BGCAPP Badging ) brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight brian.purtee Highlight