Fillable Dd Form 369 - Police Record Check printable pdf download

1. DATE OF REQUEST

OMB No. 0704-0007

POLICE RECORD CHECK

(YYYYMMDD)

NCIC

OMB approval expires

Oct 31, 2014

The public reporting burden for this collection of information is estimated to average 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering

and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,

including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, Suite 02G09, Alexandria, VA

22350-3100 (0704-0007). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information

if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO ADDRESS SHOWN AT BOTTOM OF FORM.

SECTION I - (To be completed by Recruiting Service)

2. NAME OF APPLICANT

3. SEX

4. PLACE OF BIRTH

(Last, First, Middle Name(s), Alias)

a. CITY

b. COUNTY

c. STATE

MALE

FEMALE

5. DATE OF BIRTH

7. SOCIAL SECURITY

6.a. RACIAL CATEGORY

(X one or more)

b. ETHNIC CATEGORY

NUMBER

(YYYYMMDD)

(1) AMERICAN INDIAN/ALASKA NATIVE

(4) WHITE

(1) HISPANIC OR LATINO

(2) ASIAN

(5) NATIVE HAWAIIAN OR

(2) NOT HISPANIC OR LATINO

(3) BLACK OR AFRICAN AMERICAN

OTHER PACIFIC ISLANDER

8. ADDRESS IN ADDRESSEE'S JURISDICTION

(See "MAIL TO" block)

9. DATES RESIDED AT THIS ADDRESS

a. FROM

b. TO

a. NUMBER AND STREET (Include apartment no.)

b. CITY

c. STATE

d. ZIP CODE

(YYYYMMDD)

PRESENT

10. PERSON MAKING THIS REQUEST

a. NAME (Last, First, Middle Name(s))

b. RANK

c. SIGNATURE

d. TITLE

SECTION II - (To be completed by Applicant)

PRIVACY ACT STATEMENT

AUTHORITY: 10 U.S.C. Sections 136, 504, 505, 12102; 14 U.S.C. Sections 351 and 632; DoDI 1304.2; DoDI 1304.26; AR 601-270; OPNAVINST

1100.4C Ch-1; AFI 36-2003_IP; MCO 1100.75E; COMDTINST M 1100.2E; AR 601-210; and E.O. 9397, as amended (SSN).

PRINCIPAL PURPOSE(S): The information collected on this form is used to screen and identify applicants to the Armed Forces who may have

discreditable involvement with the police or other law enforcement agencies. Completed forms are used to conduct background records checks used

to determine eligibility of applicants for accession into the Armed Forces. Completed forms are covered by recruiting and official military personnel

SORNs maintained by each of the Services.

ROUTINE USE(S): DoD "Blanket Routine Use" 2, Disclosure When Requesting Information Routine Use, specifically applies: A record from a system

of records maintained by a DoD Component may be disclosed as a routine use to a Federal, State, or local agency maintaining civil, criminal, or other

relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to a DoD

Component decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance

of a license, grant, or other benefit. The DoD Blanket Routine Uses found at l apply to this collection.

DISCLOSURE: Voluntary. However, failure of the applicant to complete Section II may result in refusal of enlistment in the Armed Forces of the

United States. An applicant's SSN is used to conduct the police records check and keep all records together during the enlistment process.

The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with Federal law and regulations. Making a

knowing and willful false statement on this DD Form 369 may be punishable by fine or imprisonment or both. All information provided by you, which

possibly may reflect adversely on your past conduct and performance, may have an adverse impact on you in your military career in situations such as

consideration for special assignment, security clearances, court martial and administrative proceedings, etc.

SIGNATURE

11. I HEREBY CONSENT TO RELEASE FROM YOUR FILES

THE INFORMATION REQUESTED BELOW.

SECTION III - (To be completed by Police or Juvenile Agency)

The person described above, who claims to have resided at the address shown above, has applied for enlistment in the Armed Forces of the United

States. Please furnish from your files the information relative to Section III below. A return envelope is provided for your convenience.

12. DOES THE APPLICANT HAVE A POLICE OR JUVENILE RECORD, TO INCLUDE MINOR TRAFFIC VIOLATIONS?

YES

(If YES, what was the offense or charge, date, disposition and sentence?)

13. IS APPLICANT NOW UNDERGOING COURT ACTION OF ANY KIND?

(If YES, give details.)

YES

DRIVER'S LICENSE INFO

THIS IS TO CERTIFY THAT THE ABOVE DATA, AS CORRECTED, ARE TRUE AND CORRECT ACCORDING TO THE RECORD ON FILE IN THIS

OFFICE. THIS INFORMATION IS CONFIDENTIAL AND CANNOT BE USED IN ANY OTHER MANNER EXCEPT FOR OFFICIAL PURPOSES.

14. DATE

15. TITLE

16. VERIFIED BY

(YYYYMMDD)

(Signature)

LAW ENFORCEMENT AGENCY

RECRUITING AGENCY

MAIL TO:

MAIL FROM:

Commanding Officer

Director (Police Record Checks)

Coast Guard Recruiting Command

Coast Guard Investigative Service

US Coast Guard Stop 7419

4200 Wilson Blvd., #110-358

2703 Martin Luther King Jr. Ave SE

Arlington, VA 22203

Washington DC 20593-7419

Fax - 202-493-6619

DD FORM 369, OCT 2011

PREVIOUS EDITION IS OBSOLETE.

Dd Form 369 - Police Record Check

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