Attachment_XI_Form_5000-E_NCIC-III_Request.xlsx
XLSX spreadsheet 12 KB Posted
- Attached to
- UpRange Security Services Federal contract opportunity
- Solicitation number
- W911SG-16-R-0001
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Attachment XI - Form 5000-E NCIC-III Request
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Table 1
| Directorate of Emergency Services Access Control Background Check Request Form | |
| PRIVACY ACT: AUTHORITY: Title 10 United States Code Section 301 Title 5 United States Code Section 2951 Executive Order 9397 dated Nov 22, 1943 (SSN). PRINCIPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately identified. ROUTINE USES: Yur Social Security Number is used as an additional/alternate means of identification to facilitate filing and retrieval. DISCLOSURE: Disclosure of your Social Security Number is voluntary. | |
| Sec 1. | |
| LAST NAME | Sec 2. |
| FIRST NAME | Sec 3. |
| MIDDLE NAME | Sec 4. |
| SSN XXX-XX-XXXX | Sec 5. |
| DATE OF BIRTH MM-DD-YY | Sec 6. |
| DL or ID CARD NUMBER & State of Issue | Sec 7. |
PLACE OF BIRTH (City, State or Country)
Sec 8. Justification for this NCIC-III Criminal records check being submitted and conducted.
| Sec 9. SPONSOR DATA | E-mail your request form encrypted to: USARMY.WSMR.IMCOM-CENTRAL.LIST.PHYSICAL-SECURITY@MAIL.MIL |
| Name of Sponsoring / Vouching Official | |
| Sponsor's Organization: | |
| Sponsor's phone number: | |
| Date submitted: |
| PHYSICAL SECURITY APPROVAL: |
| EWS Form 5000, Current as of 19 March 2015 |
mailto:USARMY.WSMR.IMCOM-CENTRAL.LIST.PHYSICAL-SECURITY@MAIL.MIL
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