USMA Form 13-16 Personnel Background Check.pdf

Page

Yes / No

CONTRACTING OFFICER REPRESENTATIVE (COR)/CONTRACT #:

Typed Name and Signature (Contractor Project Manager/COR/Sponsor of Volunteer, Family Caregiver or Spouse)

PERSONNEL BACKGROUND CHECK

of

TODAY'S DATE:

CONTRACTOR'S/SPONSOR NAME:

EXPIRATION END DATE (not to exceed 1 year):

LAST NAME FIRST NAME MI Suffix SSN Birth Date

(mm/dd/yyyy) City, State, Country of Birth

Status

(Perm/Temp)

NTE Date for Temps

(mm/dd/yyyy)

Perm/Temp

Perm/Temp

Perm/Temp

Perm/Temp

Perm/Temp

Perm/Temp

Perm/Temp

Perm/Temp

Perm/Temp

Perm/Temp

USMA Form 1 Apr 06 13-16

By signing this form, I certify that the above subject’s information is accurate and that I have informed the individuals of its use in conducting a background investigation for the purpose of determining suitability for issuance of identification. Identification issuance requires that all employees pass a background check. Furthermore, I certify that proper installation clearance procedures are established and implemented to address the termination of personnel to include, but not limited to, collecting and turning in ID Badge to the Adjutant General and vehicle decals to the Provost Marshal Office.

PMO

Criminal

History

PERSONNEL BACKGROUND CHECK

USMA Form Mar 04 13-16

These instructions explain how to fill out the "Personnel Background Check''. Each column heading's data is explained below:

LAST NAME These 4 items must be the legal name of the individual. Nick names and unofficial aliases are not acceptable. "Ml' stands for FIRST NAME Middle Initial. Suffixes are things like "Jr., Sr., III, etc." These are required if they are part of the legal name of the individual.

MI

SUFFIX

SSN This is the Social Security Number of the employee.

BIRTH DATE This is the employee's date of birth. Format as mm/dd/yyyy.

CITY, STATE All three of these items must be provided.

COUNTRY OF BIRTH

STATUS (PERM/TEMP) This is the employee's hired status within the company.

NTE DATE FOR TEMPS This is the date that the employee must not exceed as a temporary hire. Format as mm/dd/yyyy.

AUTHORITY: Title 10, United States Code, Section 3013

PRINCIPAL PURPOSES(S): To obtain information for background investigation on personnel for the purpose of issuing government identification cards.

ROUTINE USES: The Installation Security Office will use information.

DISCLOSURE: Voluntary. However, failure to provide all the requested information may result in individual not being issued identification card.

DATA REQUIRED BY THE PRIVACY ACT OF 1974