BGAD_DES_Criminal_Records_Check_(Access_Requirements).pdf

SECTION I. Please Print

1. NAME (Last, First, Middle Name)

3. E-MAIL:

2. SOCIAL SECURITY NUMBER

4. DATE OF BIRTH

5. OTHER NAMES USED (No nicknames) 6. DRIVER’S LICENSE NUMBER & STATE

7. CITIZENSHIP (Country) a. NATURALIZATION NUMBER b. PASSPORT NUMBER

8. PRINT CURRENT HOME ADDRESS

a. NUMBER AND STREET b. CITY c. STATE d. ZIP CODE

9. NAME OF COMPANY (Full Name):

10. TYPE OF WORK TO BE PERFORMED:

11. PURPOSE OF RECORDS CHECK (Check One):

_____ Federal Employment _____ Contractor _____ Visitor _____ Military Training _____ MOU/MOA Reasearch ____ COA Lease Farmer _____ Other Federal/State Employee

_____ Vendor_____ Fishing _____ Pool _____ Golf _____ Gym

_____ Kindling Pass _____ Recreational

_____PRIVATE EVENT

DATE OF PRIVATE EVENT: _____________________________

POC AT BGAD: _____________________________________12.

13. POC PHONE NUMBER: ______________________________

14. WHAT AREA’(S) ARE YOU

REQUESTING ACCESS TO

(Check All That Apply):

___ Administrative Area ___ Restricted Area ___ Restricted “A” Area ___ Restricted “G” Area

___ CLA

___ BGCAPP DEMIL

___ Outside Tracts

15. HAVE YOU SUBMITTED (1)FINGER

PRINT CARD FOR A BACKGROUND

CHECK AT BGAD?

___ YES (Date of submission_________________

___NO

16. DATE OF LAST BACKGROUND

CHECK BY BGAD: __________________________

BGAD OFFICIAL USE ONLY

DO NOT WRITE HERE

DATE ENTERED:

MWR MEMBERSHIP ONLY

HUNT ONLY

DATE OF HUNT:________________________________________

3a. PHONE NUMBER*( required):

BLUE GRASS ARMY DEPOT

DIRECTORATE OF EMERGENCY SERVICES

CRIMINAL RECORDS CHECK

Administrative Office of the Courts, Frankfort, KY

National Crime Information Center (NCIC)

FOR OFFICIAL USE ONLY

BGAD CRIMINAL BACKGROUND CHECK FORM, SEP 2015 PREVIOUS EDITIONS ARE OBSOLETE

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SECTION II

I HEREBY CONSENT TO THE RELEASE OF MY CRIMINAL HISTORY RECORDS.

PRIVACY ACT STATEMENT

I Authorize a representative of the Blue Grass Army Depot, Directorate of Emergency Services conducting my background check, to obtain any information relating to my criminal history record. I authorize the Administrative Office of the Courts, Frankfort, KY, conducting my investigation to disclose the record of my background investigation to the Blue Grass Army Depot, for the purpose of making a determination of suitability or eligibility for security access. I understand that the information released by records custodians and sources of information is for OFFICIAL USE ONLY by the Blue Grass Army Depot for the purposes stated and that it may be redisclosed by the government only as authorized by law. I further understand that with the signing of this form I authorize additional background checks as may be needed by representatives of the Bluegrass Army Depot for continuing access to the installation.

17. My information on this form is true, complete, and correct to the best of my knowledge.

a. SIGNATURE OF APPLICANT: b. DATE:

18. RETURN THIS FORM TO:

Directorate of Emergency Services

ATTN: DoD Security Specialist

431 Battlefield Memorial

Highway Richmond, KY

40475-5090

***** APPLICANT DO NOT WRITE BELOW THIS LINE*****

BGAD OFFICIAL USE ONLY SECTION III

REVIEWING AUTHORITY (DES ONLY)

___ APPROVED ___ DISAPPROVED

Print Name Approving Authority

_______________________________________, Directorate of Emergency Services

Reviewing Authority Signature

__________________, Date of Review

REMARKS:

BGCAPP BADGE INFORMATION

TYPE OF BADGE AND

EXPIRATION DATE

BGAD PERSONNEL SECURITY

CONCURRENCE

GOV'T FIELD OFFICE/BGCAPP

SECURITY CONCURRENCE

BGCAPP BADGE OFFICE

GOVERNMENT PRIME CONTRACTOR SUBCONTRACTOR

SIGNATURE

SIGNATURE

SIGNATURE

DATE

DATE

DATE

PERSONNEL SECURITY

PH#859-779-6302/6244

FAX# 859-779-6744

EMAIL: usarmy.bluegrass.jmc.list.bgad-pso@mail.mil

HUNT PROGRAM

MWR FAX# 859-779-6438

BGAD CRIMINAL BACKGROUND CHECK FORM, SEP 2015 PREVIOUS EDITIONS ARE OBSOLETE

MAIL TO: ATTN NATHAN WHITE

431 Battlefield Memorial Highway

Richmond, KY 40475

FAX: 859-779-6465