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BP A0660 PDF

This document is an authorization form for a criminal history check. It states that the authorization allows a Bureau of Prisons representative to obtain the applicant's criminal history information. It notes that this check must be completed before entering or serving at any Bureau facility. It also notes that failure to provide all necessary information may result in denial of entry or volunteer/contractor status. The form requests identifying information from the applicant such as name, address, date of birth, physical description, citizenship, and signature.

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Katrina Williams
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225 views2 pages

BP A0660 PDF

This document is an authorization form for a criminal history check. It states that the authorization allows a Bureau of Prisons representative to obtain the applicant's criminal history information. It notes that this check must be completed before entering or serving at any Bureau facility. It also notes that failure to provide all necessary information may result in denial of entry or volunteer/contractor status. The form requests identifying information from the applicant such as name, address, date of birth, physical description, citizenship, and signature.

Uploaded by

Katrina Williams
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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BP-A0660 CRIMINAL HISTORY CHECK

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. 10a. Date
Applicant’s Signature

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 CHEQUA LA HISTORIA CRIMINAL
MAIO 18
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.**

AUTORIZACIÓN PARA LA DISTRIBUCIÓN DE INFORMACIÓN


CHEQUA LA HISTORIA CRIMINAL

Por este medio autorizo a un representante de la Agencia Federal de Prisiones a obtener cualquier información
sobre los antecedentes de mi historial criminal. Entiendo que este chequeo debe ser hecho antes de recibir permiso
para entrar/servir en cualquier instalación de la Agencia Federal de Prisiones. También entiendo que la negación a
proveer toda la información necesaria puede resultar en ( 1) la negación de mi entrada a una instalación de la
Agencia Federal de Prisiones y ( 2) la negación de mi clasificación como voluntario/contratista.

1. Nombre (Apellido, Nombre, Segundo Nombre)

2. Dirección (Número de Domicilio y Calle) (Ciudad, Estado, Condado, Código Postal)

3. Número de Teléfono de Casa (Código de Área, Número):

4. Alias/Apodos:

5. Ciudadanía (Indique el país de su ciudadanía):

6. Número de Seguridad Social:

7. Fecha de Nacimiento (Mes, día, año):

8a. Sexo: 8b. Raza:

8c. Estatura: 8d. Peso:

8e. Color de Ojos: 9f. Color de Cabello:

9. Lugar de Nacimiento (Ciudad, Estado, Condado), (Indique la ciudad,


el condado y el país, si es afuera de EE.UU.)

10. La información anteriormente listada es 10a. Fecha


verdadera y correcta.
Firma de Solicitante

AVISO SOBRE LA LEY DE PRIVACIDAD

Autoridad para Obtener Información : E.O. 10450; 5 USC 1303-1305; 42 USC 2165 y 2455; 22 USC 2585 y 2519; y 5
USC 3301

Objetivos y Usos: La información provista en este formulario será entregada a individuos, con el fin de obtener
información en cuanto a actividades como parte de una investigación realizada para determinar (1) la aptitud para
obtener empleo Federal, (2) la autorización para realizar servicio contratado para el Gobierno Federal, (3) la
autorización de seguridad o acceso. La información obtenida puede ser entregada a terceras partes, como lo sea
necesario, para realizar las responsabilidades oficiales.

Efectos de Información No Divulgada : El proveer la información solicitada es voluntario, pero la falta de proveer toda
o parte de la información puede resultar en la privación de futura consideración para empleo, para autorización o
acceso, o puede resultar en la terminación de su empleo.

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