Form GSA Form 176 GSA Form 176 Basic National Agency Check Criminal History

BASIC NATIONAL AGENCY CHECK CRIMINAL HISTORY
(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
4. Place of Birth (City/State, Country) 5. Date of Birth 6. Social Security Number
abridgements are
not acceptable)
7. Center Name
11. Race

8. Phone Number

American Indian or Alaskan Native

12. Check One:

9. Fax Number
Asian or Pacific Islander

Black

White

Hispanic

Other

By Birth
Naturalized
(Complete A thru
E)
Derived
(Complete F)

United States
Citizen

A - Certificate
Number

B - Petition Number C - Date

E - United States Passport Number

Registration Number Expiration Date

Alien

10. Date Cleared (name check)

Date of Entry

D - Place and Court

F - Parent's Certification Number
Port of Entry

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

TO

CITY

STATE

ZIP CODE

14. YOUR POLICE RECORD (Do not include anything that happened before your 16th birthday.)
In the last 5 years, have you been arrested, charged or held by Federal, State or Other Law Enforcement
Authorities for any violation of any Federal law, Military law, State law, County or Municipal law,
Regulation or Ordinance? (Leave out traffic fines of less than $150.)

YES

NO

If you answered “Yes,” explain your answer in the space provided.
Month/Year

Offense

Action Taken

Law Enforcement Authority or Court (City and Country if outside the United States) State

Zip Code

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.

Child

YES

NO

Sexual Offender/Registry

GENERAL SERVICES ADMINISTRATION

YES

NO

Domestic Violence

YES

NO

GSA 176 (9/2009)

If you answered “Yes,” in Question 15 explain your answer in the space provided.

Month/Year

Offense

Action Taken

Law Enforcement Authority or Court (City and Country if outside the United States) State

Zip Code

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
RESULT IN FINES ADN/OR IMPRISONMENT UP TO FIVE YEARS

I declare under penalty of perjury that the
Signature
statements made by me on this form are true,
complete and correct.
GENERAL SERVICES ADMINISTRATION

BEFORE SIGNING THIS FORM, REVIEW IT CAREFULLY TO MAKE SURE
YOU HAVE ANSWERED ALL QUESTIONS FULLY AND CORRECTLY.

Date

GSA 176 (9/2009) BACK