Form Gsa 176 - Basic National Agency Check Criminal History 2009
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2BASIC NATIONAL AGENCY CHECK CRIMINAL HISTORY
OMB Number: 3090-0287
Expires: 9/30/2012
(Child Care Workers)
NOTE: This form is to be used for child care only. Applicants must complete all sections on this form. If more space is needed, continue on back of form and
reference item number continued. Failure to disclose any information may result in an unfavorable adjudication decision.
See Privacy Act and Public Reporting Burden Statements
2. Sex
NAME (Last, First and Middle Name)
1. NAME DATA
Female
Male
(Give your full
name. Initials and
3. Other name(s) Used
5. Date of Birth
6. Social Security Number
4. Place of Birth (City/State, Country)
abridgements are
not acceptable)
7. Center Name
8. Phone Number
9. Fax Number
10. Date Cleared (name check)
11. Race
American Indian or Alaskan Native
Asian or Pacific Islander
Black
White
Hispanic
Other
12. Check One:
By Birth
Naturalized
B - Petition Number
D - Place and Court
A - Certificate
C - Date
Number
(Complete A thru
United States
E)
Citizen
Derived
F - Parent's Certification Number
E - United States Passport Number
(Complete F)
Registration Number
Expiration Date
Date of Entry
Port of Entry
Alien
13. DATES AND PLACES OF RESIDENCES (Physical street address only, no Post Office Boxes. Begin with present and go back (10) years.)
FROM
PHYSICAL STREET ADDRESS
STATE
ZIP CODE
TO
CITY
14. YOUR POLICE RECORD (Do not include anything that happened before your 16 th birthday.)
In the last 5 years, have you been arrested, charged or held by Federal, State or Other Law Enforcement
YES
Authorities for any violation of any Federal law, Military law, State law, County or Municipal law,
NO
Regulation or Ordinance? (Leave out traffic fines of less than $150.)
If you answered “Yes,” explain your answer in the space provided.
Month/Year
State
Zip Code
Offense
Action Taken
Law Enforcement Authority or Court (City and Country if outside the United States)
15. Have you ever been arrested, charged, or held by Federal, State, or other Law enforcement authorities for any crime or offense
involving: Check Yes or No. Failure to provide information may result in an unfavorable adjudication decision. All other charges
must be included in item 14 even if they were dismissed.
Domestic Violence
Child
Sexual Offender/Registry
YES
NO
YES
NO
YES
NO
GENERAL SERVICES ADMINISTRATION
GSA 176 (10/2009)
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