122d_Background_Check_Release.docx

122d Security Forces Squadron Background Check Release Worksheet

This worksheet may contain information which must be protected IAW AFI 33-332 and DoD 5400.11; Privacy Act of 1974 as amended 5 U.S.C. 552a applies, and is FOR 0FFICIAL USE ONLY (FOUO).

RECIPIENT IS RESPONSIBLE FOR SAFEGUARDING AND MAINTAINING THIS PRODUCT IAW PRIVACY ACT OF 1974 PL 93-579.

The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential and will not be used for any other purpose.

Name (As it appears on your driver’s license):

Date of Birth:

Race:

Current Drivers License Number:

Issuing State:

Citizenship or Immigration Status:

Home Address:

City:

State:

Zip:

Company Name:

Project Name or Work Sight:

Primary Contractor (If sub-contracting)

Dates of Contract (If known) :

Start Date:

End Date:

In connection with my application to provide contract services, I understand that background investigation checks are to be made on me including, criminal convictions, motor vehicle, and other reports. Further, I understand that the 122d Security Forces Squadron will be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, criminal, and/or civil claims.

I authorize without reservation, any party or agency contacted to furnish the above mentioned information and release all parties involved from liability and responsibility for doing so. This authorization and consent shall be valid in original or electronic form.

Applicant’s Signature

Date

FOR OFFICE USE

IDACS Check results:

BMV Check Date:

Checked By:

III Check Date:

Checked By:

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