Attachment 4-HSPD12.pdf

USSOUTHCOM Personnel Security Local Records Check

For Official Use Only

PART I- SUBJECT INFORMATION

1. Name: (Last, First, M.I.)

Other names: (maiden name, alias, AKA)

2. SSN / Nat’l ID No.:

3. Sex:

Female

Male

4. Date of Birth:

5. Place of Birth:

CITY:

COUNTY:

TOWNSHIP:

STATE: -

COUNTRY:

PROVINCE: -

6. Racial Category

American Indian

Asian

Black or African American

White/Caucasian:

Native Haw aiian or

Other Pacif ic Islander

OTHER

7. Tw o Original Identity Source Documents (one photo ID required)

a. U.S. Passport

b. U.S. Birth Certif icate

c. Report of Birth Abroad

d. U.S. Naturalization

Certif icate

e. DoD or Federal ID

f. Unexpired U.S. Permanent Resident Card

g. Unexpired Employment Authorization

Document

h. Unexpired foreign passport with a valid I-94 or I-94A for a class of admission that permits employment

i. Driver’s License

j. Other ID listed in I-9 Employment Eligibility

Verif ication

8. Country of Citizenship:

9. If not a U.S. Citizen are you a U.S. Permanent Resident:

YES NO

10. Have you been charged and/or convicted of a Felony Offense within the last 10 years?

Yes No

Offense: _____________________________

11. Employer Company or

Agency/Address/Phone:

12. I hereby consent to a Local Records Check w hich will be used for a determination of access to USSOUTHCOM facilities and/or information.

Signature/Date:

PART II – REQUESTING GOVERNMENT SPONSOR

13. Sponsor Printed Name, Position and Phone No.

Sponsor Signature and Date:

PART III – LAW ENFORCEMENT:

14.

FDLE Criminal History Check RECORDS FOUND NO RECORDS FOUND PENDING CHARGES/COURT ACTION

Law Enforcement Agency RECORDS FOUND NO RECORDS FOUND PENDING CHARGES/COURT ACTION

NCIC RECORDS FOUND NO RECORDS FOUND PENDING CHARGES/COURT ACTION

SDN RECORDS FOUND NO RECORDS FOUND PENDING CHARGES/COURT ACTION

E-Verify RECORDS FOUND NO RECORDS FOUND PENDING CHARGES/COURT ACTION

ALERTS (previously COPS) RECORDS FOUND NO RECORDS FOUND PENDING CHARGES/COURT ACTION Results:(List w hether offense was a misdemeanor or felony and year)

At no time dissemination either by writing, verbal, or CJIS hard copy of the criminal history reports obtained through the CJIS System be released to unauthorized persons.

I Certify that a Local Records Check w as conducted and the information is true and correct according to the record on f ile.

NAME: AGENCY: DATE:

PART IV – PERSONNEL SECURITY MANAGER CERTIFICATION:

15. Name/Signature Date: Expires on:

Sponsor Notif ied

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