B08 RFP Atch 2 - NCIC CONSENT FORM.pdf

MOTCO NCIC CONSENT FORM

National Crime Information Center (NCIC)

Inquiry Authorization and Waiver

1. All persons requesting admittance to Military Ocean Terminal Concord will be subjected to an NCIC inquiry. This inquiry is a criminal background check utilizing the Federal Bureau of Investigation (FBI) criminal database. The NCIC inquiry is not required for personnel with a valid U.S. Government issued Common Access Card/Personal Identity Verification Card.

2. Individuals who are determined to have been convicted of serious crimes (felonies, as determined by state statutes); or 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, or designated representative) will be denied access IAW Army Directive 2014-05.

3. A NCIC inquiry will produce a complete criminal history background on the individual, which will be maintained on file at the Visitor Control Center, under the control of the Directorate of Emergency Services for one year. After one year, the documents will be destroyed. NCIC inquires will only be conducted and/or viewed by personnel listed on appointment orders approved by the Installation Commander to conduct fitness determinations. The NCIC results of persons denied access to MOTCO will not be maintained. Disclosure of information obtained through an NCIC inquiry is governed by the California State Bureau of Investigation and the FBI.

This form is to be completed by the applicant. All areas below are MANDATORY. Incomplete information will be returned to the applicant without action.

I (print FULL NAME: FIRST, MIDDLE, LAST) ________________________________________________, have read the information presented above and understand the contents. I specifically authorize and voluntarily consent to a National Crime Information Center background check conducted by the Military Ocean Terminal Concord Directorate of Emergency Services for the purpose of obtaining access to the installation.

Signature of Requestor Today’s Date

Date of Birth Race Gender Place of Birth (City and State)

Social Security Number Driver’s License #/State Street Address

Are you currently on probation or parole? YES___ NO___ ________________________ City, State

Do you currently have pending charges? YES___ NO___ ________________________ Zip Code

Are you a US Citizen? YES___ NO___

Company Name Telephone Number (Home or Cell) MOTCO Sponsor/Point of Contact and Telephone Number (CONTRACTORS ONLY)

**NOTE**If your Driver’s License has the “NOT FOR FEDERAL IDENTIFICATION”, you must have another form of Government Photo ID to enter the Military Ocean Terminal Concord. This is in accordance with the Department of Homeland Security REAL ID Act.