POLICE RECORD CHECK
1. DATE OF REQUEST
(YYYYMMDD)
OMB No. 0704-0007
OMB approval expires
Dec 31, 2017
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)
2. NAME OF APPLICANT (Last, First, Middle Name(s), Alias)
3. SEX
MALE
FEMALE
4. PLACE OF BIRTH
a. CITY b. COUNTY c. STATE
5. DATE OF BIRTH
(YYYYMMDD)
b. RACIAL CATEGORY (X one or more)
(1) AMERICAN INDIAN/ALASKA NATIVE
(2) ASIAN
(3) BLACK OR AFRICAN AMERICAN
(1) HISPANIC OR LATINO
(2) NOT HISPANIC OR LATINO
7. SOCIAL SECURITY
NUMBER
(4) NATIVE HAWAIIAN OR
(5) WHITE
8. ADDRESS IN ADDRESSEE'S JURISDICTION (See "MAIL TO" block)
a. NUMBER AND STREET (Include apartment no.) c. STATE d. ZIP CODEb. CITY
9. DATES RESIDED AT THIS ADDRESS
a. FROM
(YYYYMMDD)
b. TO
(YYYYMMDD)
10. PERSON MAKING THIS REQUEST
a. NAME (Last, First, Middle Name(s)) b. RANK c. SIGNATURE d. TITLE
SECTION II - (To be completed by Applicant)
PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. Sections 136, 504, 505, 12102; 14 U.S.C. Sections 351 and 632; DoDI 1304.2; DoDI 1304.26; AR 601-270; OPNAVINST
1100.4C Ch-1; AFI 36-2003_IP; MCO 1100.75E; COMDTINST M 1100.2E; AR 601-210; and E.O. 9397, as amended (SSN).
PRINCIPAL PURPOSE(S): 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. Completed forms are covered by recruiting and official military personnel
SORNs maintained by each of the Services.
ROUTINE USE(S): DoD "Blanket Routine Use" 2, Disclosure When Requesting Information Routine Use, specifically applies: A record from a system
of records maintained by a DoD Component may be disclosed as a routine use to a Federal, State, or local agency maintaining civil, criminal, or other
relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to a DoD
Component decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance
of a license, grant, or other benefit. The DoD Blanket Routine Uses at https://dpclo.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx apply.
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. An applicant's SSN is used to conduct the police records check and keep all records together during the enlistment process.
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 willful false statement on this DD Form 369 may be punishable by fine or imprisonment or both. All information provided by you, which
possibly may reflect adversely on your past conduct and performance, 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, etc.
11. I HEREBY CONSENT TO RELEASE FROM YOUR FILES
THE INFORMATION REQUESTED BELOW.
SIGNATURE
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?
(If YES, what was the offense or charge, date, disposition and sentence?)
YES
NO
13. IS APPLICANT NOW UNDERGOING COURT ACTION OF ANY KIND? (If YES, give details.)
YES
NO
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 16. VERIFIED BY (Signature)
LAW ENFORCEMENT AGENCY
MAIL TO:
DD FORM 369, DEC 2014
PREVIOUS EDITION IS OBSOLETE.
RECRUITING AGENCY
MAIL FROM:
6.a. ETHNIC CATEGORY
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, Executive Services Directorate, Directives Division, 4800 Mark Center Drive,
Alexandria, VA 22350-3100 (0704-0007). 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.
Adobe Professional X
OTHER PACIFIC ISLANDER
Conroy, Diana, V.
Civ.
Administrative Specialist II
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