USNA Form 5500/1 Police Record Check

OMB 0703-0036 Exp: Renewal Pending

UNITED STATES NAVAL ACADEMY
Guidance for the Police Record Check Form

Candidates receiving 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 nontraffic 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.

USNA 5500/1 (12-21)

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OMB 0703-0036 Exp: Renewal Pending
POLICE RECORD CHECK
Privacy Act Statement
AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 8454, Midshipmen: number; 10 U.S.C. 8456, Midshipmen: nomination and selection to
fill vacancies; 10 U.S.C. 347, International engagement authorities for service academies; 10 U.S.C. 8458, Midshipmen: qualifications for admission; 10
U.S.C. 8459, Midshipmen: agreement for length of service; 10 U.S.C. 8461, Midshipmen: dismissal for best interests of the service; 10 U.S.C. 8462,
Midshipmen: discharge for unsatisfactory conduct or inaptitude; 10 U.S.C. 8463, Midshipmen: discharge for deficiency; DoDI 1322.22, Service
Academies; OPNAVINST 1531.6D, Nomination and Admission of Citizens of Foreign Countries to the U.S. Naval Academy; E.O. 9397 (SSN), as
amended, and N01531-1.
PRINCIPAL PURPOSE: Candidates receiving 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.
ROUTINE USES: Information will be used by the Naval Academy Office of Admissions for the purposes of admissions and enrollment.
DISCLOSURE: Voluntary; however, failure to provide the required information may preclude appointment to the Naval Academy.
SECTION I. APPLICANT INFORMATION (TO BE COMPLETED BY APPLICANT):
1. LAST NAME:

2. FIRST NAME:

3. MIDDLE NAME:

4. GENDER:
MALE

5. STREET ADDRESS:

6. CITY:

11. DATE OF BIRTH:

12. SOCIAL SECURITY NUMBER:

7. STATE:

8. ZIP CODE:

FEMALE

LIVED HERE 9. FROM DATE: 10. TO DATE:

13. CANDIDATE NUMBER:

By signing in block 14 below, I consent to the release of the information requested in Section II. to the U.S. Naval Academy Admissions Office. I declare
under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person named above
and consenting to and authorizing disclosure of my records [, or records that I am entitled to request as the parent of a minor or the legal guardian of an
incompetent], and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine, imprisonment of
not more than five years, or both, and that requesting or obtaining any record(s) under false pretenses is punishable under the provisions of 5 U.S.C. §
552a(i)(3) by a fine of not more than $5,000.
14. SIGNATURE:

15. DATE:

SECTION II. REQUESTED BACKGROUND INFORMATION (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. Please utilize the enclosed return envelope and return the requested information to: Office of
Admissions, Nominations and Appointments, Halsey Field House, 52 King George Street, Annapolis, MD 21402.
16. DOES THE APPLICANT HAVE A POLICE OR JUVENILE RECORD TO 17. IS THE APPLICANT THE SUBJECT OF CIVIL OR CRIMINAL
INCLUDE MINOR TRAFFIC VIOLATIONS (If yes, please provide details of COURT ACTION OF ANY KIND (If yes, please provide details. Attach any
any charges and their outcomes. Attach any additional necessary
additional necessary documents):
documents):
NO

NO

YES

YES

I declare under perjury or penalty under the laws of the United States that the foregoing is true and correct, and that I am the person named below, and
certify that the above data is true and correct according to the record on file in this office.
18. SIGNATURE:

20. TITLE:

19. DATE:

21. PRINT NAME:

22. PHONE NUMBER:

Agency Disclosure Notice
The public reporting burden for this collection of information, 0703-0036, is estimated to average 15 minute 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 burden reduction suggestions to the Department of Defense, Washington Headquarters
Services, at [email protected]. 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.

USNA 5500/1 (12-21)

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