Criminal and Drivers History Consent Form 190-6.pd.pdf

PS Form 190-6, 18 April 2015

CRIMINAL AND DRIVERS HISTORY CONSENT FORM

VERY IMPORTANT! Please Read Privacy Act Statement and *Instruction Sheet Before Completing This Form

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C., 3013; 44 U.S.C. 3101, AR 190-13, Chapter 8, Army Access Control

PRINCIPLE PURPOSE: To obtain information about individuals who seek access to Fort Gordon or Gillem Enclave for employment, recreation or other purposes. By completing and signing this form, individual authorizes Fort Gordon or Gillem Enclave Law Enforcement officials to receive National Crime Information Center (NCIC) criminal and driver history. ROUTINE USE: Department of Defense (DoD) Blanket Law Enforcement Routine Use. Creates record that individual gave consent for Fort Gordon or Gillem Enclave Law Enforcement Officials to obtain criminal and driver history. Social Security Number (SSN), driver’s license number and other documents as requested are used for identification to retrieve information. DISCLOSURE: Disclosure is voluntary. Individuals, who do not disclose requested information, to include SSN, may be denied access to Fort Gordon or Gillem Enclave. Note: Individuals found on or entering Fort Gordon or Gillem Enclave without proper authority are subject to removal, prosecution or other appropriate action.

By completing blocks 1 through 12, the individual in block 1 (BLK1) authorizes Fort Gordon or Gillem Enclave Law Enforcement Officials to receive a report of the individual’s criminal and driver’s history record. If requested, the individual agrees to provide a copy of social security card, a copy of driver’s license and copies of other identification documents as may be required.

Individual in block 1 must put a check mark or X in the box below that designates the purpose for completing this form.

Access to Fort Gordon or Gillem Enclave General Employment with Ft Gordon or Gillem Enclave (Do not check this block if you are a contractor)

Employment with Police / Security / Guards Employment with Children Employment with Elder Care

Type or print neatly in ink, all required information

1. Full Name: (Last, First, Middle) 2. Home Phone No: 3. Cell or Alternate Phone No:

4. Current Address: 5. Sex: 6. Race: 7. SSN:

8. Date of Birth: *(dd/mmm/yyyy) 9. Driver's License No: 10. State of Issue: Upon signing this form in block 11, I declare that the information provided is complete, true, and correct. I understand that a false statement may subject me to prosecution. (18 USC 1001)

11. Signature of Individual in Block 1: 12. Date:

Blocks 13 thru 23 are to be completed by a government employee sponsor (GES) / government representative (GOVREP) or business manager (BM). Blocks 13 thru 23 must be completed when requesting access to Fort Gordon or Gillem Enclave for the person listed in BLK1. A GES or GOVREP must be a Department of Defense (DOD) civilian employee or active duty military.

By completing blocks 13 thru 23, the GES / GOVREP or BM in block 21 verifies the need of individual in BLK1 to access Fort Gordon or Gillem Enclave to: perform work, volunteer, be a transportation provider, provide health care, visit, or other for: (List in block 13) Company, Business, Activity, or MWR Club Member, i.e., Bingo, Golf, Dinner Theatre, Cycling, Bowling, Horse Stables, Sportsman’s Club, etc.

13. Company / Activity / Club:

Individual in BLK1 does not have a current DoD ID card that allows access to Fort Gordon or Gillem Enclave and requests access in order to better serve as a: (List Position or other purpose in block 14)

14. Position or other purpose:

Individual in BLK1 has been or will start working, volunteering, or other : (List date in block 15)

15. I, as the GES / GOVREP or BM, anticipate individual in BLK1 to be employed, volunteer, or other thru:

(List date in block 16)

16. Date:

The GES / GOVREP or BM will be responsible for notifying the DES representative when the individual in BLK1 no longer performs the work, volunteers, is a visitor, etc., for: (List company, business, or activity in block 17), i.e., DPW, MWR, NEC, COE, DES, COMMISSARY, AAFES, EFMP, Health Care Provider, etc.)

17. Activity:

(List email of GES / GOVREP or BM in block 18, phone No. in block 19, and if applicable, contract No. in block 20)

18. Email: 19. Phone No.

21. Printed Name of GES / GOVREP or BM: 22. Signature of GES / GOVREP or BM: 23. Date:

24. Signature of authorized DES representative: 25. Date: 26. For Official Use Only:

Unit Armorers & AA&E Key Custodians

Date:

20. Contract No:

1. CAUTION! When completing the form either type or print neatly in ink all required information. All signature blocks must be signed in ink. Digital signatures are not authorized. If the required information is not complete, true or incorrect, the individual’s request for access to Fort Gordon or Gillem Enclave may be delayed or denied and the form will be returned without processing.

2. By completing blocks 1 through 12, the individual in block 1 authorizes Fort Gordon or Gillem Enclave Law Enforcement Officials to receive a report of the individual’s criminal and driver’s history record. If requested, the individual in block 1 also agrees to provide a copy of their social security card, a copy of their driver’s license and copies of other identification documents as may be required.

3. Individual in block 1 must put a check mark or X in the box that designates the purpose for completing the consent form. For most individuals, the check mark or X would be placed in the box for Access to Fort Gordon or Gillem Enclave. This is especially true for contractors requiring an access pass.

4. Individuals requiring access to Fort Gordon or the Gillem Enclave must complete blocks 1-12. Information required for blocks 1-12 is self explanatory. To reduce any confusion on how to list Date of Birth in block 8, list the month where it shows /mmm/ using the first three letters for the month of your birth date. Example: If the individual listed in block 1 has a Date of Birth of 8 June, 1972, list the Date of Birth as 08/Jun/1972. The individual in block 1 will not complete any blocks from 13 through 26.

5. Blocks 13 through 23 are to be completed by a Government Employee Sponsor (GES) / Government Representative (GOVREP) or Business Manager (BM). The criteria to be a GES or GOVREP, is they must be a Department of Defense (DOD) civilian employee or active duty military. A BM does not have to meet the GES or GOVREP criteria. If there is any question as to who meets the criteria of a GES, GOVREP or BM, please contact the authorized Directorate of Emergency Services (DES) representative to seek clarification.

6. The primary reason GESs, GOVREPs or BMs are required to complete blocks 13-23 is to: a. Verify that the individual listed in block 1 requires access to Fort Gordon or the Gillem Enclave. b. Determine the approximate start and end date the individual in block 1 will need access to Fort Gordon or the Gillem Enclave. c. Be held responsible for notifying the DES representative of terminated contract employees, turn in of expired or revoked identification, or when the individual in block 1 no longer performs the work, volunteers, or other reason that installation access is no longer required.

7. Information required in blocks 13 through 23 for the most part are self-explanatory. For block 13, The GES / GOVREP or BM will list the Company, Business or Activity the individual in block 1 performs work, does volunteering or other reason such as: Visitor, Transportation Provider, Health Care Provider, or MWR Club Member, i.e., Bingo, Golf, Dinner Theatre, Cycling, Bowling, Horse Stables, Sportsman’s Club, etc. For block 17, the GES / GOVREP or BM will list their company, business, activity or the government abbreviation or acronym for their Directorate or Activity in which the individual in block 1 no longer requires access to Fort Gordon or the Gillem Enclave. Examples of government Directorates or Activities are: Directorate of Public Works (DPW), Morale, Welfare, and Recreation (MWR), Network Enterprise Center (NEC), Corps of Engineers (COE), Directorate of Emergency Services (DES), COMMISARY, Army & Air Force Exchange Service (AAFES), Exceptional Family Member Program (EFMP), Health Care Providers, etc. For block 20, the GES / GOVREP shall list the applicable contract number which applies to the individual in block 1. BMs may or may not have a contract in place. When applicable, use the standard 16 character format for contract numbers. Example: XXXXXX-XX-X-XXXX. If clarification is needed for any required information in any of the blocks from 13 through 23, please contact the authorized DES representative.

8. Reminder. The maximum time authorized for a long term pass is one year. If an extended or long term pass is authorized it could be for less than one year depending on the need or justification provided by the GES / GOVREP or BM. National Crime Information Center (NCIC) background checks to obtain access to Fort Gordon or Gillem Enclave are required annually.

INSTRUCTIONS AND GENERAL GUIDANCE FOR COMPLETING THE

CRIMINAL AND DRIVERS HISTORY CONSENT FORM

PS Form 190-6, 18 April 2015