Form DD Form 369 DD Form 369 Police Record Check

CUI when filled

Prescribed By: DoDI 1304.02

1. DATE OF REQUEST (YYYYMMDD)

POLICE RECORD CHECK

OMB No. 0704-0007
OMB approval expires
YYYYMMDD

The public reporting burden for this collection of information is estimated to average 27 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 this burden estimate or any other aspect of
this collection of information, including suggestions for reducing the burden, 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.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO ADDRESS SHOWN AT BOTTOM OF FORM.

SECTION I - (To be completed by Recruiting Service)
3. SEX

2. NAME OF APPLICANT (Last, First, Middle Name(s), Alias)

MALE
FEMALE
4. PLACE OF BIRTH

5. DATE OF BIRTH (YYYYMMDD)

A. CITY

C. STATE

B. COUNTY

6. RACE AND ETHNICITY (Select all that apply and enter additional details in the spaces below)
AMERICAN INDIAN/ALASKA NATIVE - Enter, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village
of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

ASIAN - Provide details below.
Chinese
Vietnamese

Asian Indian

Filipino

NEEDS DD67
Korean

Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

BLACK OR AFRICAN AMERICAN - Provide details below.
African American

Jamaican

Haitian

Nigerian

Ethiopian

Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

HISPANIC OR LATINO - Provide details below.
Mexican

Puerto Rican

Salvadoran

Cuban

Dominican

Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

MIDDLE EASTERN OR NORTH AFRICAN - Provide details below.
Lebanese

Iranian

Egyptian

Syrian

Iraqi

Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER - Provide details below.
Native Hawaiian

Samoan

Chamorro

Tongan

Fijian

Marshallese

English

German

Irish

Italian

Polish

Scottish

Enter, for example, Chuukese, Palauan, Tahitian, etc.

WHITE - Provide details below.

Enter, for example, French, Swedish, Norwegian, etc.

DD FORM 369, DRAFT 20250409
PREVIOUS EDITION IS OBSOLETE.

CUI when filled

Controlled by: OUSD(P&R)
Page 1 of 2
CUI Category: PRVCY
LDC: FEDCON
POC: [email protected]

CUI when filled
7. SOCIAL SECURITY NUMBER

8. ADDRESS IN ADDRESSEE'S JURISDICTION (See "MAIL TO" block)
A. NUMBER AND STREET (include apartment no.)

B. CITY

9. DATES RESIDED AT THIS ADDRESS

10. PERSON MAKING THIS REQUEST

A. FROM (YYYYMMDD)

A. NAME (Last, First, Middle Name(s))

B. RANK

B. TO (YYYYMMDD)

C. SIGNATURE

D. TITLE

C. STATE

D. ZIP CODE

SECTION II - (To be completed by Applicant)
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 10 U.S.C. Subtitle A, General Military Law, Part II, Personnel (Chapter
31, Enlistments); DoD Instruction (DoDI) 1304.02, Accessions Processing Data Collection Forms; DoDI 1304.26, Qualification Standards for Enlistment,
Appointment, and Induction; and E.O. 9397 (SSN), as amended.
PURPOSE: The information collected on this form is used to screen and identify applicants to the Armed Forces who may have discreditable involvement with the
police or other law enforcement agencies. Completed forms are used to conduct background records checks used to determine eligibility of applicants for
accession into the armed forces.
ROUTINE USE(S): Disclosure of records are generally permitted under 5 U.S.C. 522a(b) of the Privacy Act of 1974, as amended. Pursuant to 5 U.S.C. 522a(b)
(3), records may be disclosed as a routine use to other Federal, state, local, territorial or tribal, international, or foreign agencies, and to financial institutions, in
order to obtain information relevant and necessary to USMEPCOM's qualification determinations for the individuals covered by this system of records. A complete
list of routine uses may be found in the applicable System of Records Notice, United States Military Entrance Processing Command (USMEPCOM) Integrated
Resource System (USMIRS), A0601-270 at: https://www.federalregister.gov/documents/2021/04/21/2021-08286/privacy-act-of-1974-system-of-records
DISCLOSURE: Voluntary. However, failure of the applicant to complete Section II may result in refusal of enlistment in the Armed forces of the United States.

NEEDS DD67

Additional system of records notices:
Military Human Resource Records: https://www.federalregister.gov/documents/2024/05/15/2024-09967/privacy-act-of-1974-system-of-records
United States Coast Guard Military Pay and Personnel System: https://www.federalregister.gov/documents/2008/12/19/E8-29793/privacy-act-of-1974united-states-coast-guard-014-military-pay-and-personnel-system-of-records
SIGNATURE

11. I HEREBY CONSENT TO RELEASE YOUR FILES FROM THE
INFORMATION REQUESTED BELOW.
SECTION III - (To be completed by Police or Juvenile Agency)

The person described above, who claims to have resided at the address shown above, has applied for enlistment in the Armed Forces of the United
States. Please furnish from your files the information relative to Section III below. A return envelope is provided for your convenience.
12. DOES THE APPLICANT HAVE A POLICE OR JUVENILE RECORD, TO INCLUDE MINOR TRAFFIC VIOLATIONS?

YES

NO

YES

NO

(If YES, what was the offense or charge, date, disposition and sentence?)

13. IS APPLICANT NOW UNDERGOING COURT ACTION OF ANY KIND?
(If YES, give details.)

THIS IS TO CERTIFY THAT THE ABOVE DATA, AS CORRECTED, ARE TRUE AND CORRECT ACCORDING TO THE RECORD ON FILE IN THIS OFFICE.
THIS INFORMATION IS CONFIDENTIAL AND CANNOT BE USED IN ANY OTHER MANNER EXCEPT FOR OFFICIAL PURPOSES.
14. DATE (YYYYMMDD)

15. TITLE

LAW ENFORCEMENT AGENCY
MAIL TO:

16. VERIFIED BY (Signature)

RECRUITING AGENCY
MAIL FROM:

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DD FORM 369, DRAFT 20250409
PREVIOUS EDITION IS OBSOLETE.

CUI when filled