Form 10-2201C Form 10-2201C Lautenberg Certification

USPP Form 10-2201C (Rev. 07/2017) OMB Control No. 1024-0245

National Park Service Expiration Date ##/##/####

L AUTENBERG CERTIFICATION

(FOR OFFICIAL USE ONLY)

United States Park Police

Headquarters

1100 Ohio Drive, S.W.

Washington, D.C. 20002

The Lautenberg Amendment to the Gun Control Act of 1968 (18 U.S.C. § 922) makes it unlawful for any person who has been convicted of a misdemeanor crime of domestic violence to ship, transport, possess, or receive firearms or ammunition. This prohibition applies to persons convicted of such misdemeanors at any time.

A misdemeanor crime of domestic violence is defined as one that includes the use or attempted use of physical force, or the threatened use of a deadly weapon, committed by a current or former spouse, parent or guardian of the victim, by a person with whom the victim shares a child in common, by a person who is cohabiting with or has cohabited with the victim as a spouse, parent, or guardian, or by a person similarly situated to a spouse, parent or guardian of the victim.

Failure to provide the requested information will result in automatic disqualification as an applicant with the United States Park Police. If you have any questions pertaining to this legislation, please contact [Insert Recruiter Name] at [Insert telephone number].

To resolve any question of whether you are affected by the statute, that is, whether you have ever been convicted of a misdemeanor crime of domestic violence within the meaning of the statute, you should contact a United States Park Police Personnel representative or a private attorney.

CERTIFICATION

Please answer the following questions:

1. Have you ever been convicted of a misdemeanor crime of domestic violence? Yes No Not Sure

Full Signature and Date

2. If you answered “YES” to question 1 above, please provide the following information with respect to the conviction:

Court/Jurisdiction:	Docket/Case Number:
     	     
Statute/Charge:	Date Sentenced:
     	     

 

3. If you answered “YES” to the first question, was that conviction expunged or set aside or have you been pardoned for the offense?

Yes No

__________________________________________________________________________

Full Signature and Date

4. Applicant and witness names, signatures and dates:

Applicant’s Full Name (Print)	Applicant’s Full Signature/Date
     
Witness’ Full Name (Print)	Witness’ Signature/Date
     

NOTICES

PRIVACY ACT NOTICE

General: This information is provided pursuant to Public Law 93-579 (Privacy Act of 1974), December 21, 1984, for individuals completing Federal Investigative forms.

Authority: The authority to collect information on the attached form is derived from one or more of the following:

Title 5, Code of Federal Regulations, section 5.2; Title 5, United States Code, sections 1303, 1304, and 3301; sections 8(b), 8(c), and 9(c) of Executive Order 10450; Title 42, United States Code, section 2455; and Title 22, United States Code, sections 1434 and 2585.

Purposes and Uses: The information you supply will be used principally as a basis for review of your qualifications for employment purposes. As part of such a review, the Standard Form 87 (Fingerprint Chart) will be sent to the Federal Bureau of Investigation and may be retained there. This information and information developed through investigation may be furnished to designated officers and employees of agencies and departments of the Federal Government for employment purposes.

Effects of Nondisclosure: The Personal Qualification Statement requests specific information. It is in your best interest to answer all of the questions. The U.S. Criminal Code, Title 18 U.S.C. 1001, provides that knowingly falsifying or concealing a material fact is a felony that may result in fines of up to $10,000 or 5 years in prison, or both. Under 5 U.S.C. 8315, a false answer to questions relating to membership in the Communist Party, U.S.A., or other communist or fascist organizations could deprive you of your right to an annuity when you reach retirement age. Deliberately and materially making false or fraudulent statements on this form will be grounds for not hiring you or for firing you after you begin work. In addition, these violations will become part of your permanent record for future employment.

PAPERWORK REDUCTION ACT STATEMENT

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) as part of the Pre-employment Suitability Phase of the application process to help us determine your suitability for the position of a United States Park Police Officer. Your response is required to obtain or retain a benefit; however, failure to provide the requested information may prevent or delay the processing of your pre-employment suitability determination, adversely affecting your consideration for appointment as a United States Park Police Officer. The OMB Control Number, 1024-0245, is currently valid. We may not collect this information and you are not required to respond unless this number is displayed.

ESTIMATED BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 5 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 the burden estimate or any other aspect of this collection of information to the Information Collection Clearance Officer, National Park Service, 12201 Sunrise Valley Dr. (MS-242), Reston, VA 20192. Do not send your completed form to this address.

RECORDS RETENTION - TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule Management and Accountability) (Item 10D) (N1-79-08-4))