Fillable Form Gsa 176 - Basic National Agency Check Criminal History 2009 (Page 2 of 2) in pdf

If you answered “Yes,” in Question 15 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)

16. AUTHORIZATION AND RELEASE

I hereby authorize the U.S. General Services Administration and other authorized federal agencies to obtain any information

required from the Federal government and/or state agencies, including but not limited to, the Federal Bureau of Investigation

(FBI), the Defense Investigation Service (DIS), the U.S. Office of Personnel Management (OPM), the Department of Homeland

Security (DHS), (if applicable), and from the State Criminal History Repository for each state where I have resided and worked.

I have been notified of any employer’s right to require a criminal history records check as a condition of employment. I

understand that I may request a copy of such records as may be available to me under the law. I understand that I have a right

to challenge the accuracy and competencies of any information contained in the report. I also understand that pursuant to the

Privacy Act, the information collected will be confidential, and disclosure limited to purposes authorized under the Privacy Act -

mainly to conduct the background check.

I release any individual, including records custodians, any component of the United States Government or the individual State

Criminal History Repository supplying information, from all liability for damages that may result on account of compliance, or any

attempts to comply with this authorization. This release is binding, now and in the future, on my heirs, assigns, associates, and

personal representative(s) of any nature. Copies of this authorization that show my signature are as valid as the original release

signed by me.

17. PRIVACY ACT OF 1974 COMPLIANCE INFORMATION

Privacy Act of 1974 compliance information. Solicitation of information contained herein is authorized by Executive Order

10450 and/or Section 231 of the Crime Control Act of 1990 (42 U.S.C. 13041), and may be used as a basis for suitability

determinations.

Your social security number is being requested pursuant to Executive Order 9397. Disclosure of the information by you is

voluntary. Information may be transferred as a routine use to appropriate federal, state, local, or foreign agencies when relevant to

civil, criminal or regulatory investigation, prosecutions, or pursuant to a request by DHS or such other agency is in connection with

the hiring or retention of an employee, the issuance of a license, grant, or other benefit. Information also may be transferred as a

routine use to a duly authorized official engaged in an investigation or settlement of a grievance, complaint, or appeal filed by an

employee. Failure to provide information requested on this form may result in the government’s inability to determine your

suitability for the position applied for or occupied, and may affect your prospects for employment or continued employment under a

government contract, or at a federal facility, or with a government license.

18. PUBLIC REPORTING BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 30 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 aspects of this collection

of information, including suggestions for reducing this burden, to Personnel Security Requirements Division (CPR), U.S.

General Services Administration, 1800 F Street, NW, Washington, DC 20405.

19. CERTIFICATION

FALSE STATEMENTS ARE PUNISHABLE BY LAW AND COULD

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE

RESULT IN FINES ADN/OR IMPRISONMENT UP TO FIVE YEARS

YOU HAVE ANSWERED ALL QUESTIONS FULLY AND CORRECTLY.

I declare under penalty of perjury that the

Signature

Date

statements made by me on this form are true,

complete and correct.

GENERAL SERVICES ADMINISTRATION

GSA 176 (10/2009) BACK

Form Gsa 176 - Basic National Agency Check Criminal History 2009 Page 2

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