TE_3_-_Attch_3._DA_Release_Consent_Form_v._1_Feb_18.pdf

Department of the Army

RELEASE/CONSENT STATEMENT

PRIVACY ACT STATEMENT

AUTHORITY: 42 USC 13041 AND 10 USC 3013.

PRINCIPAL PURPOSE: TO COMPLY WITH REQUIREMENTS OF PUBLIC LAW 101-647, SECTION 231 (CRIME CONTROL ACT OF 1990), DoDI 1402.05 AND FOR NONAPPROPRIATED FUND, ARMY REGULATION (AR) 215-3.

ROUTINE USES: TO INITIATE THE BACKGROUND CHECK REQUIREMENTS OF THE STATUTE AND GOVERNING REGULATION.

Type or Print Name (Last, First MI):

Section I: Statement of Previous Arrest or Charge:

1. Have you ever been arrested for or charged with a crime involving a child? _____Yes _____No

2. Have you ever been asked to resign because of, or been decertified for, a sexual offense? _____Yes _____No

3. Have you ever been convicted of any offense against the law or forfeited collateral or are you now under charges for any offense against the law? (You may omit: (1) Traffic violations for which you paid a fine of $300.00 or less unless the violation was alcohol or drug related, and (2) any offense committed before your 21st birthday which was finally adjudicated in a juvenile court or under a youth offender law.) _____Yes _____No If you answer "yes" to any question above, describe the case disposition below. Include the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved; or if a military action (to include Article 15), the military authority or court involved, and the final disposition of the case; to include fine(s)/amount paid, found guilty or not, loss of rank etc. Be sure to disclose any covered charges or incidents, even if they were expunged, and/or even if you have been advised by your attorney that you do not need to disclose them on employment forms, as they will be identified in the background check process. You must also disclose all covered incidents even if you did so on a previous consent and release form, Optional Form 306, Department of Army Form 3433, or other such document and/or if the incident was previously considered by a Program Review Board or otherwise adjudicated IAW Army guidance. If additional space is needed, please attach a separate sheet of paper as a continuation page and include your printed name at the top and signature and date at the bottom.

Date of

Violation/Incident Explanation of

Violation/Incident or Charge

Place of Occurrence

Name and Address of Police

Department or Court Involved

If Military, Military Authority or Court

Involved

Final Disposition of the Case

RELEASE/CONSENT STATEMENT (Cont)

Type or Print Name (Last, First MI)

Section II: Statement of Understanding and Release:

1. I have been advised that my being hired or selected for, and continuing employment or service in a position having regular contact with children under the age of 18 will be based upon favorable completion of all required background checks. I understand that these may include:

a. Army Law Enforcement Reporting & Tracking System (ALERTS) // Defense Central Index of Investigations (DCII)

b. Army Substance Abuse Program (ASAP) to include records from the Substance Use Disorder Clinical Care (SUDCC) which may include that pertaining to my identity, diagnosis, or treatment from any Army record maintained in connection with alcohol or other drug abuse education, training, treatment, rehabilitation or research.

c. Medical Treatment Facilities (MTF) – Army Central Registry (ACR)

d. Federal Bureau of Investigation Fingerprint Special Agreement Check (FBI-FP-SAC)

e. State Criminal History Repository (SCHR) Checks for each state where I have resided for the last five years.

f. Any other records as appropriate and to the extent permitted by law.

2. I have been advised and understand that the above listed checks will be completed annually, or every three or five years (depending on the position) while I am employed/contracted/volunteering in a position that requires regular contact with children under the age of 18, and that these checks may also be completed to authenticate issues that surface during my employment or service. I understand that this consent does not expire and will be utilized to conduct these periodic reverification checks. I also understand that except to the extent such action has been taken, I can revoke my consent at any time but this will preclude my continued service in a child services position. I also understand that if the report of these checks contains adverse information, I have a right to challenge the accuracy or completeness of the information contained therein.

3. I understand that failure to disclose this information or provide consent precludes me from employment or continued service in a child services position, and may form the basis for withdrawal of a tentative (conditional) job offer, or removal from my position and/or the federal service.

Section III: Signature:

A false statement may result in adverse action up to and including removal. Under U.S. Code 1001, the federal punishment for perjury is fine or imprisonment for up to 5 years or both.

I declare under penalty of perjury that the information contained in this application form and any attachments or documents submitted in connection with my application for this position are true and correct to the best of my knowledge, information, and belief.

I hereby confirm my understanding of the information in this statement; and authorize the release of my name and Social Security Number for the purpose of conducting the required checks in Section II.

Signature Date

If the applicant is a minor, a Parent or Legal Guardian must grant permission below for the background checks. The Parent/Legal Guardian is certifying they understand the purposes of these checks and hereby provide consent for the background checks.

Signature Date

IRCR 1 FEB 18