Form ATF F 8620.42 ATF F 8620.42 Police Check Inquiry

OMB NO: 1140-0068 (
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. 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
Other
To be Completed by Non-ATF Personnel
3. First Name
4. Middle Name

2. Last Name
7. Date of Birth

8. Place of Birth (State/Country)

5. Suffix

6. Social Security Number

9. Citizenship

10. Sex

11. Other Names Used (Maiden, Nickname, etc.) 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.
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

26. NCIC Conducted:

/

To be Completed by the Physical Security Programs Branch/Field Division
(Date) 28. NLETS Conducted:
(Date) 27. TECS Conducted:
/
/
/

/

/

(Date)

States (identify below):
QH

N/R

R

QW

N/R

QPO

N/R

Access Granted

IQ

N/R

R

R

IQ

N/R

R

R

DQ

N/R

R

DQ

N/R

SQ

R

N/R

Signature of Authorized ATF Official

Title

R
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 ( )