CBKS_228_Access_Form.pdf

Please provide the following information for completion of a National Crime Information Center (NCIC) and Central Police Operations Suite (COPS) installation access check.

NAME:

Last, First Middle Maiden(If applicable)

SSN#:

POB: DOB:

PRIMARY PHONE:

HOME ADDRESS:

SEX: RACE:

PURPOSE OF REQUEST:

(Check Box) ACCESS CONTROL PASS REQUESTED

Signature of Individual

I have been advised that my gaining access to the Carlisle Barracks Installation is contingent upon successful completion of a criminal history background check. I understand that the background check includes accessing information within the NCIC and the COPS. I have been advised that all information received from these checks will be maintained within the Directorate of Emergency Services and properly destroyed at the completion of the purpose of request.

AUTHORITY: 5 USC 552a(b), 10 USC 3013, Title 10 United States Code, Section 3012(g), E.O. 9397 PRINCIPLE PURPOSE: To provide law enforcement officials with means by which information may be accurately identified in order to enforce security provisions.

ROUTINE USE: Your social security number is used as an additional/alternate means of identification to facilitate filing and retrieval.

DISCLOSURE: Disclosure of your social security number is voluntary. Failure to disclose the information requested precludes consideration of an application for access to the Carlisle Barracks Installation through the use of a temporary pass or as part of an event list. Personnel not submitting to a background check will be required to use standard Vehicle Access Control procedures when attempting to gain access to the Carlisle Barracks Installation.

DATA REQUIRED BY THE PRIVACY ACT OF 1974

CARLISLE BARRACKS INSTALLATION

ACCESS CONTROL APPLICATION

CBks (DES) Form 228-R-E Rev Mar 15

Date

DRIVERS LICENSE # / STATE ID #

YYYY/MM/DD

GOVERNMENT SPONSOR POC (NAME /AGENCY/PHONE#):

LAW ENFORCEMENT USE BELOW THIS LINE ONLY

NAME & DATE OF CHECK ONLY

PASS # DLNCICBAR

Print Name / Position / Date

( ) No adverse information found.

( ) Adverse information found Installation Access Control is NOT cleared by this office.

( ) Adverse information found Installation Access Control is cleared by this office.

DATE ACCESS CONTROL PASS REQUESTED TO:

COPS

HEIGHT: WEIGHT:

EYE COLOR: HAIR COLOR:

(UNDER 18) Parent/Guardian Consent (Sign/Print)

(NOT TO EXCEED ONE YEAR)