USNA 5500 Police Record Check

UNITED STATES NAVAL ACADEMY
Instructions for Police Record Check Form
Candidates rece1vmg an offer of appointment are required to obtain a
routine Police Record Check from their local police department. This background
check is a precursor to the National Agency Check (NAC) that will be initiated
on Induction Day at the Naval Academy. The Police Record Check and the
NAC are utilized to determine credibility and suitability for service and to grant a
security clearance for access to classified material.
To ensure a thorough Police Record Check, you should determine all
jurisdictions under which you might fall. These would include but are not limited
to your city or town police department, sheriff's or constable's office, school law
enforcement office, and other jurisdictions where you have lived or attended
school if they are different from your home of residence. You will need to
provide each agency or office described above with a copy of the Police Record
Check Form, which may be xeroxed, and a stamped envelope addressed to the
Office of Admissions, Nominations and Appointments, Halsey Field House,
52 King George Street, Annapolis, Maryland 21402. A Police Record Check
Form must be filled out by each applicable agency or office.
The local agency or office (not you) must return the completed form to
the Admissions Office. There could be a fee charged by the law enforcement
office to access your police record. You are responsible for any expenses
incurred in connection with this Police Record Check.
The Police Record Check is intended to identify and disclose minor traffic
and non-traffic violations of the law. If civil or criminal charges of a more severe
nature (such as a misdemeanor or a felony) have been filed against you or
adjudicated by a court of law, you will also need to provide the Admissions
Office with these court records. These records are required regardless of the
plea or verdict and should be disclosed even if you were told that the records
were "expunged" or "sealed."
Some law enforcement offices have policies prohibiting the release of
arrest or conviction records, even at your request. In these cases, ask the
law enforcement office to provide a statement of this policy in lieu of the
Police Record Check.

OMB Symbol

POLICE RECORD CHECK

Request Date:

PRIVACY ACT STATEMENT. AUTHORITY: Title 5 USC Cb 301; Title JO USC Cb 403 Sec 4346, Cb 505 Sec 5031, Cb 603 Sec 6958; Title 44 USC 3101: E09397,

Updated Privacy Act Statement

PRINCIPAL PURPOSE; Collection of data on Academy candidate for opening a file. ROUTINE USE: To gather information on a candidate to open a file for
admission to the U.S. Naval Academy. DISCLOSURE IS VOLUNTARY. However, failure to provide infonnation may preclude appointment.

SECTION 1 - (TO BE COMPLETED BY APPLICANT)
1.

2.GENDER

NAME OF APPLICANT (Last, First, Middle)

'

3. ADDRESS (Include City, State, and Zip Code)

5. DATE OF BIRTH

6. SOCIAL SECURITY NUMBER

D

Male

D

Female

4. DATES AT ADDRESS
From:
To:
7. CANDIDATE NUMBER

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
willing false statement on this USNA fonn may be punishable by fine or imprisonment or both. All infonnation provided by you which possibly may reflect adversely on
your past conduct and perfonnance, 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.
I HEREBY CONSENT TO RELEASE FROM YOUR FILES THE INFORMATION REQUESTED BELOW

9. SIGNATURE

10. DATE

SECTION II - (TO BE COMPLETED BY POLICE OR JUVENILE AGENCY)
The person described above, who claims to have resided at the address shown above, has applied to the United States Naval Academy. Please furnish from your files
the information relative to Section II below. A return envelope is provided for your convenience. If the responses to the questions below change between the time of this
initial inquiry and the admission of the applicant to the Academy, please notify the Dean of Admissions, U.S. Naval Academy, Halsey Field House, 52 King George Street,
Annapolis, MD 21402.

11. DOES THE APPLICANT HAVE A POLICE OR JUVENILE RECORD, TO INCLUDE MINOR TRAFFIC VIOLATIONS?
(If yes, please provide details of any charges and their outcomes.)

0

No

D

Yes

12. IS THE APPLICANT THE SUBJECT OF CIVIL OR CRIMINAL COURT ACTION OF ANY KIND?
(If yes, please provide details.)

D

No

0

Yes

MAIL TO:

This is to certify that the above data are true and correct according to the record on file in
OFFICE OF ADMISSIONS

this office. This information is confidential and cannot be used in any other manner except

NOMINATIONS AND APPOINTMENTS

for official purposes.

HALSEY FIELD HOUSE

SIGNATURE:

52 KING GEORGE STREET
ANNAPOLIS, MD 21402

TITLE:
PRINT NAME & PHONE NUMBER:
USNA 550011 (REY. 7/2012)

Agency Disclosure Notice

DATE: