Form F 8620.42 F 8620.42 Police Check Inquiry

OMB NO: 1140-0068 (xx/xx/xxxx)
U.S. Department of Justice
Bureau of Alcohol, Tobacco, Firearms and Explosives

Police Check Inquiry

This form must be completed by all individuals requiring escorted access to ATF facilities, access to ATF unsensitive information, and/or an ATF
construction site, for the purpose of performing Low Risk-Nonsensitive duties.
1. Mark one of the following:
Contractor
Vendor
Other
3. First Name

2. Last Name
6. Date of Birth

To be Completed by Subject
4. Middle Name

7. Place of Birth (State/Country)

5. Social Security Number

8. Citizenship

9. Sex

10. Other Names Used (Maiden, Nickname, etc)11. If foreign born, provide the type and number for one of the following: alien registration, naturalization certificate,
U.S. passport, or employment authorization card.
Number
Type
12. 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

From:

To:

Address

City

State

13. Employment History (for past 5 years-use additional sheets(s) if necessary)
Address
Employment Name
To:
From:

City

State

From:

To:

Employment Name

Address

City

State

From:

To:

Employment Name

Address

City

State

From:

To:

Employment Name

Address

City

State

From:

To:

Employment Name

Address

City

State

14. Mark one or More of the Following Categories
A person having origin in any of the original peoples of North and South America (including Central
American Indian or Alaska Native
America), and who maintains tribal affiliations or community attachment.
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
Asian
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.
Hispanic or Latino
Native Hawaiian or Other
Pacific Island
White

A person of Cuban, Mexian, Puerto Rican, Cuban, South or Central American, or other Spanish
culture or origin, regardless of race.
A person having origins in any of the original peoples of Hawaii, Guam, Somoa, or other Pacific
Islands.
A peson 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 escorted access to ATF facilities and/or access to ATF unsensitive information, or access to an ATF
construction site. I understand that a felony may automatically disqualify me. Any incident(s) involving firearms or explosives are grounds for disqualification from consideration to perform work in ATF facilities or access to ATF unsensitive data. 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 COTR/ATF POC
16. Subject’s ATF Job Title

15. Subject’s assigned ATF office

17. Assignment Duration Dates
Ending

Beginning
18. Subject’s duties will require the following access:
Escorted Facilities
19. COTR/POC Name

ATF Unsensitive Information

20. COTR/POC Address

Construction Site
21. Phone Number

22. Signature

23. Date

24. See Remarks

To be Completed by the Physical Security Programs Branch/Field Division
25. NCIC Conducted:
/

26. TECS Conducted:

/

N/R

/

/
R

27. State(s):

N/R

R

/

/

/

N/R

R

/

/

/

N/R

R

/

/

/

N/R

R

/

/

/

N/R

R

28. Allied Nations Policy:

N/A

Compliant

None Compliant

29. Residency Requirement:

N/A

Compliant

None Compliant

Access Granted

Authorized Signature

Title

Date

Access Denied
ATF Form 8620. 42 should 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, 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. The Physical Security Programs
Branch or the Field Division is also responsible for ensuring that individuals are in compliance with the Allied Nations and residency policies.
Instructions
Items 1-14. Applicant contractors are responsible for completion of items 1 through 14 in their entirely. No item may be left unanswered.
Items 15-24. To be completed by COTR or ATF POC.
Items 15. Please include both branch or division and physical location. (for example: Phoneix FD, Denver Field Office; or ISD, Software Mgt Branch,
BHQ)
Item 16. Describe the job the contractor is to perform.
Items 25-29. To be completed by the Physical Security Programs Branch or Field Division.
Paper 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 and/or unsensitive information.
The estimate 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,
Document Services Branch, Bureau of Alcohol, Tobacco, Firearms and Explosives, Washington, DC 20226.

ATF Form 8620. 42
Revised (
)

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. Your race, as well as your SSN will be
used as a means to positively identify you in the Federal criminal justice records system.
Your 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 and/or suitability purposes.

ATF Form 8620. 42
Revised (
)