Download:
pdf |
pdfOMB NO: 1140-0068 (xx/xx/xxxx)
U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives
Police Check Inquiry
Instructions: ATF Form 8620.42 must be completed by non-ATF personnel and ATF sponsors (COTRs or Points of Contact) when requesting non-ATF
personnel be granted escorted access to ATF facilities, non-sensitive information, and/or construction sites. Items 1-15 of this form must be completed by all
non-ATF personnel requiring escorted access to ATF facilities, ATF non-sensitive information, and/or an ATF construction site for the purpose of performing
low risk, non-sensitive duties for a period of 5 days or longer. Items 13 & 14 may be omitted if access is requested for 4 days or less. Once completed, non-ATF
personnel must sign and date the form and forward it to the ATF sponsor. ATF sponsors will complete items 16-25 and forward this form to the Physical Security
Programs Branch or appropriate Field Division personnel for processing.
1. Non-ATF Personnel’s Assignment Status (check one):
Contractor
Vendor
To be Completed by Non-ATF Personnel
3. First Name
4. Middle Name
2. Last Name
7. Date of Birth
Other
5. Suffix
6. Social Security Number
9. Citizenship
8. Place of Birth (State/Country)
10. Sex
11. Other Names Used (Maiden, Nickname, 12. If foreign born, provide the type and number for one of the following: alien registration, naturalization
certificate, U.S. passport, or employment authorization card.
etc.)
Number
Type
13. Home Address (provide residential history for past 5 years-use additional sheet(s) if necessary)
To:
From:
Address
City
State
From:
To:
Address
City
State
From:
To:
Address
City
State
From:
To:
Address
City
State
14. Employment History (provide employment information for past 5 years-use additional sheets(s) if necessary)
Employer Name
Address
To:
From:
City
State
From:
To:
Employer Name
Address
City
State
From:
To:
Employer Name
Address
City
State
From:
To:
Employer Name
Address
City
State
15a. Ethnicity Origin
Hispanic or Latino
Yes
No
A person of Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish
culture or origin, regardless of race.
15b. Race (mark one or more of the following categories)
American Indian or Alaska Native
A person having origin in any of the original peoples of North and South America (including Central
America), and who maintains tribal affiliations or community attachment.
Asian
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
Subcontinent, including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.
Black or African American
A person having origins in any of the black, Haitian, or Negro racial groups of Africa.
Native Hawaiian or Other
Pacific Island
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.
White
A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
I,
, give my consent and permission for the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF)
to conduct a police check inquiry for the purpose of granting me escorted access to ATF facilities and/or access to ATF non-sensitive information, or
access to an ATF construction site. I understand that a felony conviction will automatically disqualify me. I understand that additional forms may be
required by ATF for a more in-depth background investigation. I attest that the information provided is true.
Signature
Date
ATF Form 8620. 42
Revised ( )
To be Completed by ATF Sponsor (COTR/ POC)
17. Subject’s Job Title
16. Subject’s Assigned ATF Office
18. Assignment Duration Dates
Ending
Beginning
19. Subject’s Duties will Require the Following Escorted Access
Facilities
20. ATF Sponsor Name
ATF Non-Sensitive Information
Construction Site
21. ATF Sponsor Address
22. Phone Number
23. Sponsor Signature
24. Date
25. Description of Duties and Other Remarks
To be Completed by the Physical Security Programs Branch/Field Division
26. NCIC Conducted:
/
QH
N/R
R
QW
N/R
QPO
N/R
Access Granted
/
(Date) 27. TECS Conducted:
SQ
N/R
/
/
(Date) 28. NLETS Conducted:
States (identify below):
R
/
/
IQ
N/R
R
R
IQ
N/R
R
R
DQ
N/R
R
DQ
N/R
R
Signature of Authorized ATF Official
Title
(Date)
Date
Access Denied
Instructions
ATF Form 8620.42 must be initiated by the COTR or ATF Point of Contact (POC) prior to granting escorted access to ATF facilities. Examples of
positions that could be escorted are janitorial or short-term construction contractors who may be performing electrical or plumbing duties. The Physical
Security Programs Branch or Field Division is responsible for conducting the required records and inquiry checks.
Items 1-15.
Non-ATF personnel are responsible for completion of items 1 through 15. No item may be left unanswered.
Items 16-25. To be completed by ATF Sponsor (COTR or ATF POC).
Items 26-28. To be completed by the Physical Security Programs Branch or Field Division.
Paperwork Reduction Act Notice
This request is in accordance with the Paperwork Reduction Act of 1995. The information collected is used by ATF to screen prospective contractors for
escorted access to ATF facilities, non-sensitive information, and /or construction sites. The appropriate ATF office (Physical Security Programs Branch or
Field Division) will maintain a copy of this form with the results of the indices checks for the duration of the contract employment or for a minimum of 1
year, whichever is longer.
The estimated average burden associated with this collection of information is 5 minutes per respondent, depending on individual circumstances.
Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be addressed to the Report Management
Officer, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number.
Privacy Act Statement
You are requested to furnish information regarding your race under the authority of 42 USC § 2000e - 16, which requires that Federal employment practices be free from
discrimination and provide equal employment opportunities for all. Solicitation of this information is in accordance with Department of Commerce Directive 15, “Race and
Ethnic Standards for Federal Statistics and Administrative Reporting.”
You are further requested to furnish your social security number (SSN) under authority of E.O. 9397, published 11/22/1943. That Order requires agencies to use the SSN for
the sake of economy and orderly administration in the maintenance of records. Furnishing your race and SSN is voluntary; however, your failure to provide the requested
information may negatively impact ATF’s ability to positively identify you in the Federal criminal justice records system.
Solicitation of this information is authorized as part of our investigative authorities devolving from E.O. 10450 and E.O. 12968. This information will be used by ATF to
begin preliminary screening/investigation for security purposes.
ATF Form 8620. 42
Revised (
)
| File Type | application/pdf |
| File Modified | 2018-01-19 |
| File Created | 2018-01-19 |