Dd Form 2981 - Defense Technical Information Center Page 2
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3BASIC CRIMINAL HISTORY AND STATEMENT OF ADMISSION
10. NOTES (Use this space to enter additional comments.)
11. AUTHORIZATION AND RELEASE CERTIFICATION
I hereby authorize the Department of Defense and other authorized federal agencies to obtain any information required from the
Federal government, and/or state agencies, and/or foreign governments, including but not limited to, the Federal Bureau of Investigation
(FBI), the Defense Investigation Service (DIS), the U.S. Office of Personnel Management (OPM), the Department of Homeland Security
(DHS), (if applicable), and from the State Criminal History Repository for each state where I have resided and worked. This authorization is
valid for one year from the date this form was signed or upon termination of my affiliation with the Federal Government, whichever is sooner.
I have been notified of any employer’s or Agency's right to require a criminal history records check as a condition of employment. I
understand that I may request a copy of such records as may be available to me under the law. I understand that I have a right to
challenge the accuracy and competencies of any information contained in the criminal history records check report. I also understand that
pursuant to the Privacy Act, the information collected will be confidential, and disclosure limited to purposes authorized under the Privacy
Act - mainly to conduct the background check.
I release any individual, including records custodians, any component of the United States Government or the individual State Criminal
History Repository supplying information, from all liability for damages that may result on account of compliance, or any attempts to comply
with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and personal representative(s) of
any nature. Copies of this authorization that show my signature are as valid as the original release signed by me.
I declare under penalty of perjury that the statements made by me on this form are true, complete and correct. In addition to the annual
certification, I understand that it is my responsibility to immediately inform my employer/supervisor if I am charged with a crime referenced in
block 9 above.
WARNING: False statements are punishable by law and could result in fines and/or imprisonment for up to five years.
a. SIGNATURE
b. DATE SIGNED
DD FORM 2981 (BACK), MAY 2014
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