Form DD Form 369 DD Form 369 Police Record Check

1. DATE OF REQUEST

POLICE RECORD CHECK

(YYYYMMDD)

OMB No. 0704-0007
OMB approval expires

The public reporting burden for this collection of information is estimated to average 27 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 aspect of this collection of information, including
suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon,
Washington, DC 20301-1155 (0704-0007). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO ADDRESS SHOWN AT BOTTOM OF FORM.

SECTION I - (To be completed by Recruiting Service)
2. NAME OF APPLICANT (Last, First, Middle Name(s), Alias)

3. SEX
MALE

4. PLACE OF BIRTH
a. CITY

b. COUNTY

c. STATE

FEMALE

5. DATE OF BIRTH 6.a. RACIAL CATEGORY (X one or more)
(YYYYMMDD)

(1) AMERICAN INDIAN/ALASKA NATIVE
(2) ASIAN
(3) BLACK OR AFRICAN AMERICAN

b. ETHNIC CATEGORY
(4) WHITE

(1) HISPANIC OR LATINO

(5) NATIVE HAWAIIAN OR
OTHER PACIFIC ISLANDER

(2) NOT HISPANIC OR LATINO

8. ADDRESS IN ADDRESSEE'S JURISDICTION (See "MAIL TO" block)
a. NUMBER AND STREET (Include apartment no.)

b. CITY

7. SOCIAL SECURITY
NUMBER

9. DATES RESIDED AT THIS ADDRESS
c. STATE

d. ZIP CODE

a. FROM
(YYYYMMDD)

b. TO
(YYYYMMDD)

10. PERSON MAKING THIS REQUEST
a. NAME (Last, First, Middle Name(s))

b. RANK

c. SIGNATURE

d. TITLE

SECTION II - (To be completed by Applicant)
PRIVACY ACT STATEMENT
AUTHORITY: Title 10 United States Code, Sections 504, 505, 508, and 12102; E.O. 9397.
PRINCIPAL PURPOSE: To determine eligibility of a prospective enlistee in the Armed Forces of the United States.
ROUTINE USES: Information collected on this form may be released to law enforcement agencies engaged in the investigation or prosecution of a
criminal act or the enforcement or implementation of a statute, rule, regulation or order; to any component of the Department of Justice for the purpose
of representing the DoD.
DISCLOSURE: Voluntary; however, failure of the applicant to complete Section II may result in refusal of enlistment in the Armed Forces of the
United States.

D R A F T

The data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence in accordance with Federal law and regulations. Making a
knowing and willful false statement on this DD Form 369 may be punishable by fine or imprisonment or both. All information provided by you, which
possibly may reflect adversely on your past conduct and performance, may have an adverse impact on you in your military career in situations such as
consideration for special assignment, security clearances, court martial and administrative proceedings, etc.
SIGNATURE

11. I HEREBY CONSENT TO RELEASE FROM YOUR FILES
THE INFORMATION REQUESTED BELOW.
SECTION III - (To be completed by Police or Juvenile Agency)

The person described above, who claims to have resided at the address shown above, has applied for enlistment in the Armed Forces of the United
States. Please furnish from your files the information relative to Section III below. A return envelope is provided for your convenience.
12. HAS THE APPLICANT A POLICE OR JUVENILE RECORD, TO INCLUDE MINOR TRAFFIC VIOLATIONS?

YES

NO

YES

NO

(If YES, what was the offense or charge, date, disposition and sentence?)

13. IS APPLICANT NOW UNDERGOING COURT ACTION OF ANY KIND? (If YES, give details.)

THIS IS TO CERTIFY THAT THE ABOVE DATA AS CORRECTED ARE TRUE AND CORRECT ACCORDING TO THE RECORD ON FILE IN THIS
OFFICE. THIS INFORMATION IS CONFIDENTIAL AND CANNOT BE USED IN ANY OTHER MANNER EXCEPT FOR OFFICIAL PURPOSES.
14. DATE (YYYYMMDD)

15. TITLE

LAW ENFORCEMENT AGENCY
MAIL TO:

DD FORM 369, 20091214 DRAFT

16. VERIFIED BY (Signature)

RECRUITING AGENCY
MAIL FROM:

PREVIOUS EDITION IS OBSOLETE.

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