W912MM19Q5005-Consent_for_Background_Check.docx

CONSENT FOR BACKGROUND CHECK

PHOTO COPY OF STATE IDENTIFICATION, DRIVERS LICENSE, OR PASSPORT IS REQUIRED WITH THIS FORM

SUBMIT THIS COMPLETED FORM AND PHOTO COPY OF IDENTIFICATION TO:

(usaf.sd.114-msg.mbx.contractors@mail.mil) SEVEN DAYS PRIOR TO VISIT.

BASE ACCESS WILL BE DENIED IF THIS FORM IS INCOMPLETE.

PRIME CONTRACTOR or COMPANY:

SUB CONTRACTOR:

PRIVACY ACT STATEMENT

AUTHORITY: Section 3101, Title 44-10 United States Code (U.S.C) 8013 Executive Order 9397, USC 552A.

PRINCIPLE PURPOSE: Criminal History Background Checks on individuals working on Federal Installations DISCLOSURE: Voluntary. However, refusal to provide required information or sign this form will prevent the individual from gaining access to Federal Installations NOTICE: The information on this form is being collected in accordance with federal law permitting the installation commander to limit access to the installation for security reasons (50 U.S.C. Section 797 and DoD Directive 5200.8) This data will be used to screen individuals who have, or are seeking access to, the 114th FW, Sioux Falls, South Dakota. Failure to provide truthful, complete and accurate responses may be used as a basis to deny entry to the installation and is also punishable as a criminal offense.

SECTION 1.

I have been advised and I understand the United States Air Force has an obligation to require a criminal history background check as a condition prior to allowing unescorted access to the installation in order to provide security for personnel and property under it’s' control. I also understand that random criminal history background checks will be conducted on me while I am working on Federal Installations. I have been further advised that I have a right to obtain a copy of any report and to challenge the accuracy and completeness of any information included in the criminal history report.

SECTION 2.

I understand that the record checks may include the following:

A State Criminal History Repository Check in the state where I currently reside and in states where I have formerly resided.

A National Agency Check with inquires which includes a Federal Bureau of Investigation, fingerprint check as required.

SECTION 3.

I hereby authorize any Federal, State, or Local agency or office to release any record relation to me, which is necessary to complete the record checks, described above.

SECTION 4. PERSONAL INFORMATION

HOME ADDRESS

STREET ADDRESS:

Phone #:

Supervisor:

*Employees operation their personal vehicles on base must have current proof of insurance, driver’s license and vehicle registration.

SECTION 5. EMPLOYEE CERTIFICATION

THIS CERTIFICATION CONCERNS A MATTER WITHIN THE JURISDICTION OF AN AGENCY OF THE UNITED STATES AND MAKING OF A FALSE, FICTITIOUS, OR FRAUDULENT CERTIFICATION MAY RENDER THE MAKER SUBJECT TO PROSECUTION UNTER TITLE 18, UNITED STATES CODE, SECTION 1001 OR OTHER APPLICABLE LAWS AND REGULATIONS.

SIGNATURE:

DATE:

In the case you are denied access to the installation due to results of the criminal background check, a rebuttal may be made to further review circumstances of denial. It is the responsibility of the individual to submit a written rebuttal explaining the nature of their offenses. Justification is also needed to be granted access to the installation to complete the contracted work.

SECTION 6. TO BE COMPLETED BY SECURITY FORCES

Contractor

Other:

114 SFS FORM 48

PREVIOUS VERSIONS

114 FW FM 48 OBSOLETE SDANG CONTRACTOR’S CONSENT FORM Page 1 of 1 image1.png