NCIC_CONSENT_FORM_-_May_2019_Fillable.pdf

DOCUMENTS ENCLOSED ARE SUBJECT

TO THE PRIVACY ACT OF 1974

Contents shall not be disclosed, discussed, or shared with individuals unless they have a direct need-to-know in the performance of their official duties. Deliver this/these document(s) directly to the intended recipient. DO NOT drop off with a third-party.

To be used on all documents containing personal information

The enclosed document(s) may contain personal or privileged information and should be treated as “For Official Use Only.” Unauthorized disclosure of this information may result in CIVIL and CRIMINAL penalties. If you are not the intended recipient or believe that you have received this document(s) in error, do not copy, disseminate or otherwise use the information and contact the owner/creator or your Privacy Act officer regarding the document(s).

DD FORM 2923, SEP 2010

Privacy Act Data Cover Sheet

Privacy Act Data Cover Sheet

THIS SPACE IS TO BE USED FOR ADMINISTRATIVE DATA

National Crime Information Center (NCIC) Consent Form

Inquiry Authorization and Waiver

1. In accordance with Army Regulation 190-13, Army Directive 2014-05, and Military Ocean Terminal Concord (MOTCO) policy, all individuals requesting admittance to MOTCO will be subjected to NCIC vetting. This inquiry is a criminal history check utilizing the Federal Bureau of Investigation (FBI) criminal database.

2. Individuals who are determined to have been convicted of serious crimes (felonies, as determined by state statutes); or a pattern of criminal activity, which is determined to be prejudicial to good order and discipline on a military installation (as determined by the Installation Commander) will be denied access.

3. An NCIC inquiry will produce a complete criminal history background on each individual, which will be maintained on file at the MOTCO Visitor Control Center (VCC), under the control of the Installation Security Assistant for one year. After one year, the criminal history background will be destroyed. NCIC results will only be viewed by authorized MOTCO security personnel. Disclosure of information obtained through an NCIC inquiry is governed by the California Department of Justice and the FBI.

I (print) FIRST, MIDDLE, LAST_____________________________________________, have read the information presented above and understand the contents. I specifically authorize and voluntarily consent to a NCIC background check conducted by the MOTCO/834th VCC for the purpose of obtaining access to MOTCO. I give consent to the VCC conducting my criminal history check:

One year only: (NCIC Consent Form and results will be destroyed after one year)

Annual for ADDITIONAL 1 2 3 years (NCIC Consent form and results will be destroyed one year after the term chosen) *****OPTING OUT OF RECURRING

VETTING MUST BE DONE IN WRITING TO MOTCO SPONSOR*****

Signature of Requestor Race Date

Date of Birth Place of Birth Gender (City & State)

Social Security Number Address:

DL#/State

Company Name Telephone