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

USPP Form 10-2201C (Rev. 04/2018) OMB Control No. 1024-0245

National Park Service Expiration Date 09/30/2018

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

Authority: U.S.C. Title 54, 5 U.S.C. 3301, 3302, 3307, 3309, 3313, and Executive Order 9397.

Purpose: The information collected on this form will be used to review your qualifications for employment in connection with the pre-employment qualification determination phase of the United States Park Police application process.

Routine uses:  In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, all or a portion of the records or information contained in this system may be disclosed outside DOI as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other government agencies, authorized organizations and individuals. The disclosure is only permitted as described under the routine uses for the system of records notice “OPM/GOVT–5 Recruiting, Examining, and Placement Records” when is compatible with the purpose for which the records were compiled.

Disclosure: Voluntary, however, failure to provide the requested information may impede our ability to review your qualifications for 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.

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