Fillable Ps Form 190-6 (April 2015) Criminal And Drivers History Consent Form printable pdf download

CRIMINAL AND DRIVERS HISTORY CONSENT FORM

VERY IMPORTANT! Please Read Privacy Act Statement and *Instruction Sheet Before Completing This Form

PRIVACY ACT STATEMENT

AUTHORITY:

10 U.S.C., 3013; 44 U.S.C. 3101, AR 190-13, Chapter 8, Army Access Control

PRINCIPLE PURPOSE: To obtain information about individuals who seek access to Fort Gordon or Gillem Enclave for employment,

recreation or other purposes. By completing and signing this form, individual authorizes Fort Gordon or Gillem Enclave Law Enforcement

officials to receive National Crime Information Center (NCIC) criminal and driver history. ROUTINE USE: Department of Defense (DoD)

Blanket Law Enforcement Routine Use. Creates record that individual gave consent for Fort Gordon or Gillem Enclave Law Enforcement

Officials to obtain criminal and driver history. Social Security Number (SSN), driver’s license number and other documents as requested

are used for identification to retrieve information. DISCLOSURE: Disclosure is voluntary. Individuals, who do not disclose requested

information, to include SSN, may be denied access to Fort Gordon or Gillem Enclave. Note: Individuals found on or entering Fort Gordon

or Gillem Enclave without proper authority are subject to removal, prosecution or other appropriate action.

By completing blocks 1 through 12, the individual in block 1 (BLK1) authorizes Fort Gordon or Gillem Enclave Law Enforcement

Officials to receive a report of the individual’s criminal and driver’s history record. If requested, the individual agrees to provide

a copy of social security card, a copy of driver’s license and copies of other identification documents as may be required.

Individual in block 1 must put a check mark or X in the box below that designates the purpose for completing this form.

Unit Armorers &

General Employment with Ft Gordon or Gillem Enclave

Access to Fort Gordon or Gillem Enclave

AA&E Key Custodians

(Do not check this block if you are a contractor)

Employment with Police / Security / Guards

Employment with Children

Employment with Elder Care

Type or print neatly in ink, all required information

1. Full Name: (Last, First, Middle)

2. Home Phone No:

3. Cell or Alternate Phone No:

4. Current Address:

5. Sex:

6. Race:

7. SSN:

8. Date of Birth: *(dd/mmm/yyyy)

9. Driver's License No:

Upon signing this form in block 11, I declare that

10. State of Issue:

the information provided is complete, true, and

correct. I understand that a false statement may

subject me to prosecution. (18 USC 1001)

11. Signature of Individual in Block 1:

12. Date:

Blocks 13 thru 23 are to be completed by a government employee sponsor (GES) / government representative (GOVREP) or

business manager (BM). Blocks 13 thru 23 must be completed when requesting access to Fort Gordon or Gillem Enclave for the

person listed in BLK1. A GES or GOVREP must be a Department of Defense (DOD) civilian employee or active duty military.

By completing blocks 13 thru 23, the GES / GOVREP or BM in block 21 verifies the need of individual

13. Company / Activity / Club:

in BLK1 to access Fort Gordon or Gillem Enclave to: perform work, volunteer, be a transportation

provider, provide health care, visit, or other for: (List in block 13) Company, Business, Activity, or MWR

Club Member, i.e., Bingo, Golf, Dinner Theatre, Cycling, Bowling, Horse Stables, Sportsman’s Club, etc.

14. Position or other purpose:

Individual in BLK1 does not have a current DoD ID card that allows access to Fort Gordon or Gillem

Enclave and requests access in order to better serve as a: (List Position or other purpose in block 14)

Individual in BLK1 has been or will start

I, as the GES / GOVREP or BM, anticipate individual

16. Date:

15.

Date:

in BLK1 to be employed, volunteer, or other thru:

working, volunteering, or other : (List date in

block 15)

(List date in block 16)

The GES / GOVREP or BM will be responsible for notifying the DES representative when the individual

17. Activity:

in BLK1 no longer performs the work, volunteers, is a visitor, etc., for: (List company, business, or activity in

block 17), i.e., DPW, MWR, NEC, COE, DES, COMMISSARY, AAFES, EFMP, Health Care Provider, etc.)

(List email of GES / GOVREP or BM in

20. Contract No:

19. Phone No.

18. Email:

block 18, phone No. in block 19, and if

applicable, contract No. in block 20)

21. Printed Name of GES / GOVREP or BM:

22. Signature of GES / GOVREP or BM:

23. Date:

24. Signature of authorized DES representative:

25. Date:

26. For Official Use Only:

PS Form 190-6, 18 April 2015

Ps Form 190-6 (April 2015) Criminal And Drivers History Consent Form

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