NCIC Form

CRIMINAL HISTORY CHECK

BP-A0660
MAY 18

U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

AUTHORIZATION FOR RELEASE OF INFORMATION

CRIMINAL HISTORY C H E C K

I hereby authorize a representative of the Federal Bureau of Prisons to obtain information on my criminal history background. I understand that this check must be done before I am allowed to enter/serve at any Bureau facility. I also understand that refusal to provide all necessary information may result in ( 1) denial of entry into a Bureau facility and ( 2) denial of volunteer/contract status.

1. Name (Last, First, Middle)

2. Address (Street address — City, State, County, Zip Code)

3. Home Telephone Number (Area Code, Number):

4. Aliases/Nickname:

5. Citizenship (List the country you are a citizen of):

6. Social Security Number:

7. Date of Birth (Month, day, year):
8a. Sex:

8b. Race:

8c. Height:

8d. W eight:

8e. Color of Eyes:

9f. Color of Hair:

9. Place of Birth (City, State, County) List city, county, and country if outside the U.S.A.

10. The above- listed information is true and correct.
Applicant’s Signature

10a. Date

PRIVACY ACT NOTICE

Authority for Collecting Information : E.O. 10450; 5 USC 1303-1305; 42 USC 2165 and 2455; 22 USC 2585 and 2519; and 5 USC 3301
Purposes and Uses: Information provided on this form will be furnished to individuals in order to obtain information regarding activities in connection with an investigation to determine (1) fitness for Federal employment, (2) clearance to perform contractual service for the Federal Government, (3) security clearance or access. The information obtained may be furnished to third parties as necessary in the fulfillment of official responsibilities. Effects of Non-Disclosures: Furnishing the requested information is voluntary, but failure to provide all or of part the information may result in lack of further consideration for employment, clearance or access, or in the termination of your employment.

PDF

Prescribed by P1280

BP-A0 660

MAIO 18

CHEQUA LA HISTORIA CRIMINAL

DEPARTAMENTO DE JUSTICIA DE EE.UU.

AGENCIA FEDERAL DE PRISIONES

**This template is provided to assist Spanish-speaking persons who are not fluent in English to complete the corresponding Bureau form. It is a template only for instructional purposes, and should not be filled in.** **Este modelo se provee para ayudar a las personas que hablan español y no dominan el inglés para que completen el formulario correspondiente de la Agencia. Es solo un modelo que sirve como ejemplo, y no se debe completar.**