Fprm Fd 816 Form – Fill Out and Use This PDF

FD-Slo (1-22-93)

ACCESS OF NON-FBI PERSONNEL TO FBI FACILITIES

BACKGROUND DATA INFORMATION FORM

(COMPLETE ALL ITEMS)

Name (Type or Print Legibly)				Other Names Used (Maiden name and alias)
Residence (Include City and State)				Social Security Number
Date of Birth Month/Day/Year		Place of Birth			Sex	Male
						Female
Company Name & Address				Supervisor & Telephone Number
U. S. Citizenship:	By Birth	By Naturalization	By Other
Location Naturalized				Date Naturalized
Alien Registration Number		Location Registered		Date Registered
Have you ever been chamed with or convicted of any felony offense					Yes	No
Have you ever been chamed with or convicted of a firearms or explosives offense?					Yes	No
Are there currently any charges pending against you for any criminal offense?					Yes	No
Have you ever been charged with or convicted of any offense(s) related to alcohol or drugs?					Yes	No
In the last 10 years, have you been arrested for, charged with, or convicted for any offense(s)
not listed above?	(Leave out traffic fines less than $100)				Yes	No

If yes, or if you have doubts (e.g-expungement, pardon, etc.) furnish details on back of form.

Attach additional sheet if necessary.

Have you ever lived in or visited a foreign country	Yes	No
If yes, thrnish details. Attach additional sheet, if necessary

CERTIFICATION THAT MY ANSWERS ARE TRUE

I have read and understand each of the above questions. My statements on this form, and any attachments to this form, are true, complete, and correct to the best of my knowledge and belief and axe made in good faith. I understand that a knowing and willfi.il false statement on this form can be punished by fine or imprisonment or both and will be reason to deny access to all FBI fficilities.

Signature __________________________________________________________ Date _______________________________

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FD-484

FEDERAL BUREAU OF INVESTIGATION

06-03-1982PRIVACY ACT NOTICE FOR MAINTENANCE EMPLOYEES

PRIVACY ACT NOTICE

This is to advise you, in conformance with the Privacy Act of 1974, that the information solicited from you by personnel of the FBI is needed to complete background inquiries by the authority granted in Title 28, Part 0, Subpart P, Paragraph 0.85, Subparagraph C, Code of Federal Regulations. The furnishing of this information is voluntary on your part and will be used to determine your eligibility for access to FBI space or certain FBI material. You should also be aware that willfully making a false statement or concealing a material fact could be a basis for refusing you access to FBI space or certain FBI material, and may constitute a violation of Section 1001, Title 18, united States Code.

You are not required to execute this form; however, if you do not, this refusal may result in the inability of the FBI to obtain information necessary to complete background inquiries and thus lead to a denial of your request for access to FBI space or certain FBI material.

	CONSENT
Signature of Applicant:	Date:

FD-484 (Revised 06-03-1982)

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FEDERAL BUREAU OF INVESTIGATION