MAR> 99
U.S. Department of Justice Federal Bureau of Prisons
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Authorization For Release of Information
NCIC (National Crime Information Center) Check
I hereby authorize a representative of the feral Bureau of Prisons to obtain any information on my criminal history background. I understand that this check must be done before I am allowed to enter/serve at any Bureau facility. I also understand that refusal to provide all necessary information may reult in 1) denial of entry into a Bureau facility and 2) denial of volunteer/contract status.
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1. Name (Last, First, Middle)
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2. Address (Street address) City, State, County, Zip Code
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3. Home telephone Number (area code):
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4. Aliases/Nickname
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5. Citizenship (list the country you are citizen of)
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6. Social Security Number
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7. Date of Birth (month,day,year)
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8a. sex: 8b. race:
8c. height 8d. weight
8e. Color of eyes: 8f. Color of hair:
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9. Place of birth (city, state, county), (list city, county and country if outside the U.S.A.
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10. The above listed information is true 10a. Date:
and correct. Applicants signature:
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Privacy Act Notice
Authority for collecting information
Purposes and uses
Effects of non-disclosure
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This page is only an example of a document that may be used to allow you entry to a prison facility. It should by no means be copied and used as an official document. Obtain entry documents from the facility you want to ministry in only.
