Background Check Consent Form printable pdf download

Background Check Consent Form

BACKGROUND CHECK

CONSENT FORM

I, __________________________________________________,

(Name – typed/printed)

Hereby authorize the U.S. Government (United States Air Force) to conduct

background checks confirming my eligibility or ineligibility to gain access to

Holloman Air Force Base, New Mexico.

Examples of conditions that may identify ineligibility to access the installation

include, but are not limited to, substantiated misconduct, conviction or arrests

for violent behavior, dishonesty, sexually aberrant behavior, warrants for arrest,

open investigations, or felony charges.

I do so with full knowledge that this information is confidential and as such

protected from unauthorized disclosure by the Privacy Act of 1974, as

amended.

It is also my understanding that any information provided shall be treated

confidentially and be used solely to determine whether I am eligible to access

the installation.

“ADVISORY”

"I further understand that Holloman Air Force Base is a federal military

installation and that any individual with an active warrant attempting to get

access to this base will be detained and local law enforcement will be notified."

***PRIVACY ACT INFORMATION***

PRINT LEGAL NAME:

SSN:

BIRTH DATE:

SIGNATURE:

COMPANY:

US CITIZEN?

YES

(Circle One):

DATE:

***IFANSWER IS “NO” SEE BELOW***

***NON US CITIZEN MUST PROVIDE***

***RESIDENT ALIEN # OR WORK VISA #***

PRIVACY ACT STATEMENT

IAW the Privacy Act of 1974, the contents of this document contain privileged or other confidential information.

Unauthorized disclosure may result in civil and criminal sanctions. If you are not the intended recipient, or believe

you may have received this communication in error, do not reproduce, retransmit, disseminate, or otherwise use this

information.

Current as of Oct 12

Background Check Consent Form