Ps Form 190-6 - Criminal And Drivers History Consent Form Page 2
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2INSTRUCTIONS AND GENERAL GUIDANCE FOR COMPLETING THE
CRIMINAL AND DRIVERS HISTORY CONSENT FORM
PS Form 190-6, 9 FEB 2015
1. Please read the complete Privacy Act Statement before completing the form.
2. 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.
3. 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.
4. Individual in block 1 must put a check mark or X in the box that designates the purpose for
completing the 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.
5. Individual 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 using the three letter abbreviation 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 25.
6. Blocks 13 through 22 are to be completed by a Government (Gov) or Contracting Officer's
Representative (COR) when requesting a Fort Gordon or Gillem Enclave extended pass for the
individual listed in block 1. A Gov or COR must be a Department of Defense (DOD) civilian
employee or active duty military. If there is any question as to who meets the criteria of a Gov
or COR, the Gov or COR shall contact the authorized Directorate of Emergency Services (DES)
representative to seek clarification.
7. Information required in blocks 13 through 22 should be self explanatory. For block 17, the
Gov or COR will list their activity or the government abbreviation or acronym for their
directorate or activity. Examples of government 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), etc. If clarification is needed for any required
information in any of the blocks from 13 through 22, contact the authorized DES
representative.
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