Fillable Ps Form 190-6 (April 2015) Criminal And Drivers History Consent Form (Page 2 of 2) in pdf

INSTRUCTIONS AND GENERAL GUIDANCE FOR COMPLETING THE

CRIMINAL AND DRIVERS HISTORY CONSENT FORM

PS Form 190-6, 18 April 2015

1. CAUTION! When completing the form either type or print neatly in ink all required information. All signature

blocks must be signed in ink. Digital signatures are not authorized. If the required information is not complete,

true or incorrect, the individual’s request for access to Fort Gordon or Gillem Enclave may be delayed or

denied and the form will be returned without processing.

2. By completing blocks 1 through 12, the individual in block 1 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 in block 1 also agrees to provide a copy of their social security card, a copy of their driver’s license and

copies of other identification documents as may be required.

3. Individual in block 1 must put a check mark or X in the box that designates the purpose for completing the consent

form. For most individuals, the check mark or X would be placed in the box for Access to Fort Gordon or Gillem

Enclave. This is especially true for contractors requiring an access pass.

4. Individuals requiring access to Fort Gordon or the Gillem Enclave must complete blocks 1-12. Information

required for blocks 1-12 is self explanatory. To reduce any confusion on how to list Date of Birth in block 8, list the

month where it shows /mmm/ using the first three letters for the month of your birth date. Example: If the individual

listed in block 1 has a Date of Birth of 8 June, 1972, list the Date of Birth as 08/Jun/1972. The individual in block 1

will not complete any blocks from 13 through 26.

5. Blocks 13 through 23 are to be completed by a Government Employee Sponsor (GES) / Government

Representative (GOVREP) or Business Manager (BM). The criteria to be a GES or GOVREP, is they must be a

Department of Defense (DOD) civilian employee or active duty military. A BM does not have to meet the GES or

GOVREP criteria. If there is any question as to who meets the criteria of a GES, GOVREP or BM, please contact the

authorized Directorate of Emergency Services (DES) representative to seek clarification.

6. The primary reason GESs, GOVREPs or BMs are required to complete blocks 13-23 is to: a. Verify that the

individual listed in block 1 requires access to Fort Gordon or the Gillem Enclave. b. Determine the approximate

start and end date the individual in block 1 will need access to Fort Gordon or the Gillem Enclave. c. Be held

responsible for notifying the DES representative of terminated contract employees, turn in of expired or revoked

identification, or when the individual in block 1 no longer performs the work, volunteers, or other reason that

installation access is no longer required.

7. Information required in blocks 13 through 23 for the most part are self-explanatory. For block 13, The GES /

GOVREP or BM will list the Company, Business or Activity the individual in block 1 performs work, does volunteering

or other reason such as: Visitor, Transportation Provider, Health Care Provider, or MWR Club Member, i.e., Bingo,

Golf, Dinner Theatre, Cycling, Bowling, Horse Stables, Sportsman’s Club, etc. For block 17, the GES / GOVREP or

BM will list their company, business, activity or the government abbreviation or acronym for their Directorate or

Activity in which the individual in block 1 no longer requires access to Fort Gordon or the Gillem Enclave. Examples

of government Directorates or Activities are: Directorate of Public Works (DPW), Morale, Welfare, and Recreation

(MWR), Network Enterprise Center (NEC), Corps of Engineers (COE), Directorate of Emergency Services (DES),

COMMISARY, Army & Air Force Exchange Service (AAFES), Exceptional Family Member Program (EFMP), Health

Care Providers, etc. For block 20, the GES / GOVREP shall list the applicable contract number which applies to the

individual in block 1. BMs may or may not have a contract in place. When applicable, use the standard 16 character

format for contract numbers. Example: XXXXXX-XX-X-XXXX. If clarification is needed for any required information

in any of the blocks from 13 through 23, please contact the authorized DES representative.

8. Reminder. The maximum time authorized for a long term pass is one year. If an extended or long term pass is

authorized it could be for less than one year depending on the need or justification provided by the GES / GOVREP

or BM. National Crime Information Center (NCIC) background checks to obtain access to Fort Gordon or Gillem

Enclave are required annually.

Ps Form 190-6 (April 2015) Criminal And Drivers History Consent Form Page 2

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