Microsoft Word - EPD-21 (02-20).docx

EDP-21 (Rev 03/20) Page 1 of 11

Security Background Document

Date:

Consultant/A

licant Instructions

Complete all forms in their entirety. The Standard Clauses for Consultant/Contractor/Vendor Services and Authorization for Release of

Information must be complete and the signature witnessed. These forms can be witnessed by anyone who will verify your identity.

Only original copies will be accepted.

You or your agency should mail all documents in the same envelope to the CJIS Security and Compliance Unit at the address below. (You may

place several transactions in the same envelope; however, it is recommended that you keep a record of the fingerprint transactions you mail for your

reference.)

Attn: CJIS Security and Compliance Unit

New York State Police

1220 Washington Ave, Bldg. 22

Albany, NY 12226

Checklist

Submit the following items to the CJIS Security and Compliance Unit:

Privacy Statements

Completed Security Background Document

Copy of current Driver’s License or State Identification

Pre-enrollment IdentoGo form

Fingerprint Card **For NYS Non-Residents ONLY ** (Applicant must be printed on the FBI non-criminal card.)

Copy of Birth Certificate or Passport

Privac

Act Statement

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28

U.S.C. § 534. Depending on the nature of your application, supplemental authorities include: Federal statutes, State statutes pursuant to Pub.

L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary;

however, failure to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint

-based

background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigation, or otherwise

responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation

Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of

the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in

NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints

submitted to or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information/

biometrics

are retained in NGI, your information may be disclosed pursuant to your consent and may be disclosed without your consent as permitted by

the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses

for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental

or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability

determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national

security or public safety.

(03/30/2018)

Certification

* I acknowledge receipt of this Privacy Act Statement.

Signature (If handwriting, print and sign your name.) Date (mm/dd/yyyy)

EDP-21 (Rev 03/20) Page 2 of 11

Security Background Document

Date:

Non-Criminal Justice A

licant’s Privac

hts

As an applicant or person requesting access to Criminal Justice Information who is the subject of a national fingerprint-based criminal history

record check for a non-criminal justice purpose (such as an application for employment), you have certain rights which are discussed below.

All notices must be provided to you in writing. ¹ These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code (U.S.C.)

§ 552a, an

d Title 28 Code of Federal Regulations (CFR), 50.12, among other authorities.

 Included in your background packet you received a written FBI Privacy Act Statement (dated 2013 or later). This Privacy Ac

State

ment explains the authority for collecting your fingerprints and associated information and whether your fingerprints an

associated information will be searched, shared, or retained.²

 You have the right to request a change, correction, or update of your FBI criminal history record as set forth at 28 CFR 16.34.

Information regarding this process may be found at https://www.fbi.gov/services/cjis/identity-history-summary-checks

and

https://www.edo.cjis.gov. You also have the opportunity to complete or challenge the accuracy of the information in your FBI criminal

history record (if you have such a record).

 You ha

ve the right to request a change, correction, or update of your New York State criminal history record. Information can b

fou

nd at https://www.criminaljustice.ny.gov/ojis/recordreview.htm

 If you have a criminal history record and have been denied access to Criminal Justice Information, you have the right to request a

meeti

ng with the appropriate suitability agency regarding the negative review. After that time, you will be afforded a reasonab

amo

unt of time to correct or complete the record (or decline to do so) before you are permanently denied access based on

information in the criminal history record. If you wish to request a meeting, contact:

New York State Police

CJIS Security and Compliance Unit

1220 Washington Avenue, Bldg. 22

Albany, NY 12226

(518) 485-0538

[email protected]

 If agency policy permits, the officials may provide you with a copy of your FBI and/or New York state criminal history record for

view and possible challenge.

 If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the

agency that contributed the questioned information to the FBI, for example the police department. Alternatively, you may send you

challen

ge directly to the FBI by submitting a request via https://www.edo.cjis.gov. The FBI will then forward your challenge to

the

agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of

an official c

ommunication from that agency, the FBI will make any necessary changes/corrections to your record in accordance wi

the i

nformation supplied by that agency. (See 28 CFR 16.30 through 16.34.

)

 You ha

ve the right to expect that officials receiving the results of the criminal history record check will use it only for authorized

purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedu

re, or

stan

dard established by the National Crime Prevention and Privacy Compact Council.³ The agency responsible for your suitability

determination will not divulge any information to your hiring authority that they are not entitled to receive.

____________________________

¹ Written notification includes electronic notification, but excludes oral notification.

² https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

³ See 5 U.S.C. § 552a(b); 28 U.S.C. § 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c); 28 CFR 20.21(c), 20.33(d) and

906.2(d).

(11/06/2019)

Certification

* I acknowledge receipt of this Non-Criminal Justice Applicant’s Privacy Act document.

Signature (If handwriting, print and sign your name.) Date (mm/dd/yyyy)

EDP-21 (Rev 03/20) Page 3 of 11

Security Background Document

Date:

Personal Information

Name (Last, First, MI) Alias/Maiden Name Sex Social Security #

XXX-XX-

DOB (mm/dd/yyyy) Place of Birth (City or County) State or Province Country (If other than US)

Physical Address (Number & Street) City State Zip

Mailing Address (If different from above) City State Zip

Home Phone # Business Phone # Father’s Full Name Mother’s Name (Maiden)

Previous Ph

sical Addresses - Past 5 Years

(

Include colle

e housin

. Use “Remarks” if more s

ace needed.

)

Physical Address (Number & Street) City State Zip

ment Histor

- Past 5 Years

Instructions: List current employer. Consultants, list the consultant company information, not the agency worked for. (Use “Remarks” if

more space needed.)

Title & Dates (From/To) Employer’s Name, Address, and Phone #

Title _______________________________________

____________________ To ____________________

Current

Employer:

Address:

Phone #:

SUPERVISOR:

Title _______________________________________

____________________ To ____________________

Current

Employer:

Address:

Phone #:

SUPERVISOR:

Education & Trainin

(

Use “Remarks” if more s

ace needed.

)

Name of Institution Location Dates Attended Major/Course Diploma/Degree Earned

Do you have a High School Equivalency Diploma (GED)? Yes No If yes, specify certificate number

EDP-21 (Rev 03/20) Page 4 of 11

Security Background Document

Date:

Additional Information

(

Answer all

uestions.

)

1. Do you possess a current Driver’s License? If yes, Issuing State ______ License # ________________________ Yes No

2. Except for minor traffic violations, have you ever been convicted of a crime (misdemeanor or felony), including

DWI?

(

Explain in “Remarks” below.)

Yes No

3. Are there current pending charges against you for any crime (misdemeanor or felony), including DWI? (Explain

in “

Rem

arks” below.)

Yes No

4a. Are you a citizen of the United States?

b. Do

you have the legal right to accept employment in the United States?

c. If

you are not a US citizen, specify INS # ___________________________

Yes No

5. Were you ever discharged from any employment due to something other than a lack of work or funds? (Explain

in “

Rem

arks” below.)

Yes No

6. Have you ever resigned from any employment in lieu of disciplinary action or termination? (Explain in

“

marks” below.)

Yes No

7. Have you ever had any professional license suspended, modified, or revoked? (Explain in “Remarks” below.) Yes No

Remarks

(

Attach additional sheets if necessar

)

Affirmation

FALSE STATEMENTS MADE ON THIS FORM ARE PUNISHABLE AS A CLASS A MISDEMEANOR AS DEFINED IN SECTION 210.45 OF THE NEW

YORK STATE PENAL LAW. In accordance with the Federal Privacy Act of 1974, you are hereby notified that your Social Security Number is

not mandated by law. It is required by the agency as part of the standard application process for the New York State Police. Failure to disclose

your Social Security Number will prohibit your application from being processed. The State Police will release your Social Security Number

only for reasons required by law or with your written consent.

By my signature, I agree to be fingerprinted and have my prints processed by the Division of Criminal Justice Services (DCJS) and the

National Crime Information Center (NCIC). Furthermore, I understand that local law enforcement agencies will be contacted, and if there are

any open questions, I will be contacted.

I hereby certify that all questions answered and all information provided by me on this form are true and correct. Knowingly providing false

information could result in the disqualification of this application and may exclude me from the position. I agree to and authorize investigation

and verification of all information provided.

Signature (If handwriting, print and sign your name.) Date (mm/dd/yyyy)

EDP-21 (Rev 03/20) Page 5 of 11

Security

Background Document

Date:

Authorization for Release of Information -

licant for Em

ment with New York State

To: The US Armed Forces, Maritime Service, Veteran’s Administration, Selective Service Administration;

Any Academic Dean, Registrar, Principal, Guidance Counselor, or authorized person at any School, College, University, Business

Sch

ool, Trade School, Elementary, or High School;

Any Local, State, or Federal Law Enforcement Agency;

Any past or present Employer;

Any Credit Bureau or Retail Merchants Association;

Any Bank or Financial Institution;

Any Insurance Company;

Any State, County, or Municipal Bureau of Vital Statistics Office;

Any State or Local Civil Service Agencies;

Any Grievance Committee or Disciplinary Committee;

Other:

________________________________________________

I, _________________________________________________________,

(First Name, Full Middle, Last Name)

have applied for employment with the State of New York or other public employer. I am aware that my entire background will be thoroughly

investigated. I hereby authorize and request the release to an authorized representative of the New York State, any and all information you

have that concerns me, including academic transcripts, disciplinary matters, and if the position for which I am applying is that of a peace

office or police officer, sealed records pursuant to Section 160.50(1)(d) of the NYS Criminal Procedure Law. This authorization, or a

reproduction thereof, shall remain in effect for a period of one year from the date of execution of this document.

__________ The position for which I am applying is that of a peace office or police officer.

(Initials)

Pre

vious Names Used: ____________________________________________________________

(First Name, Full Middle, Last Name)

____________________________________________________________

(First Name, Full Middle, Last Name)

Date o

f Birth: ____________________ Place of Birth: ___________________________________

In accordance with the Federal Privacy Act of 1974, you are hereby notified that your Social Security Number is not mandated by law. It is required by the

New York State Police for this application process. Failure to disclose your Social Security Number will prohibit your application from being processed.

The State Police will release your Social Security Number only for reasons required by law or with your written consent.

Social Security #: XXX-XX-_______

Militar

y Branch: _______________________________ Dates of Service: _____________________________________________________________

_________

________________________________________________

(Signature of Witness)

_________

_______________________

(Date)

_________

__________________________________________________

(Applicant Signature)

_________

__________________________________________________

(Street Address)

_________

__________________________________________________

(City, State, Zip)

_____

__________________________

(Date)

EDP-21 (Rev 03/20) Page 6 of 11

Security Background Document

Date:

Standard Clauses for Consultant/Contractor/Vendor Services

Security, Non-Disclosure, Confidentiality, and Press Releases

The consultant/contractor/vendor shall maintain the security, non-disclosure, and confidentiality of all information in accordance with the

following clauses in performance of its activities under this Agreement:

Security Procedures

Consultant/contractor/vendor agrees to comply fully with all security procedures of the State in relation to providing services and agrees that

its officers, agents, employees, and subcontractors shall be required to undergo the same security clearances as are required of the

employees of NYSP. Specifically, each prospective and current employee of Contractor designated to work under this Agreement with NYSP

shall submit identifying information and may be fingerprinted.

Non-Disclosure and Confidentiality

Except as may be required by applicable law or a court of competent jurisdiction, the Contractor, its officers, agents, employees, and

subcontractors shall maintain strict confidence with respect to any Confidential Information to which the Contractor, its officers, agents,

employees, and subcontractors have access. This representation shall survive termination of this Agreement. For purposes of this

Agreement, Contractor, its officers, agents, employees, and subcontractors agree to treat all information (oral, visual, or written) gathered in

the course of their employment for NYSP as Confidential Information, unless provided written release from this designation for specified

information by authorized NYSP staff.

Press Releases

Contractor agrees that no brochure, news/media/press release, public announcement, memorandum, or other information of any kind

regarding this Agreement shall be disseminated in any way to the public, nor shall any presentation be given regarding this Agreement

without the prior written approval by the undersigned or the undersigned’s designee from NYSP, which written approval shall not be

unreasonably withheld or delayed provided, however, that Contractor shall be authorized to provide copies of this Agreement and answer any

questions relating thereto to any State or Federal regulators or, in connection with its financial activities, to financial institutions for any

private or public offering.

Public Information

Disclosure of items related to this Agreement shall be permitted consistent with the laws of the State of New York and specifically the

Freedom of Information Law (FOIL) contained in Section 87 of the Public Officers Law. The State shall take reasonable steps to protect from

public disclosure any of the records relating to this procurement that are otherwise exempt from disclosure under that statute. Information

constituting trade secrets, for purposes of FOIL, must be clearly marked and identified as such upon submission. If the Contractor intends to

seek an exemption from disclosure of these materials under FOIL, the Contractor shall, at the time of submission, request the exemption in

writing and provide an explanation of why the disclosure of the identified information would cause substantial injury to the competitive

position of the Contractor. Acceptance of the identified information by the State does not constitute a determination that the information is

exempt from disclosure under FOIL. Determinations as to the availability of the identified information will be made in accordance with FOIL at

the time a request for such information is received by the State.

Administrative Obligation

Consultant/contractor/vendor agrees not to use NYSP or State provided equipment to engage in non NYSP related activities while on NYSP

time.

Consultant/contractor/vendor will be held accountable for reporting work hours and/or work activity consistent with the terms of the

consultant/contractor/vendor engagement. In the case of consultants/contractors/vendors working in a staff augmentation capacity, daily time

records showing actual hours worked will be maintained by the consultant/contractor/vendor and provided to the direct NYSP supervisor in a

format specified by the NYSP supervisor.

Sexual Harassment

1. Civil Rights Act Violation

Title VII of the Civil Rights Act of 1964 as amended prohibits discrimination on the basis of race, color, religion, sex, and national origin. The

Equal Employment Opportunity Commission has amended its Guidelines on Discrimination Because of Sex to include Sexual Harassment as

an unlawful employment practice and thereby a violation of Section 703 of Title VII of the Civil Rights Act.

2. Policy

NYSP, as an Agency of the Executive Department of the State of New York, is committed to a philosophy which prohibits sexual harassment

in the workplace.

Unwelcome sexual advances, requests for sexual favors, or other verbal or physical conduct of a sexual nature will constitute sexual

harassment when:

 Submission to the conduct is either explicitly or implicitly a term or condition of an individual’s employment,

 Submi

ssion to or rejection of such conduct by an individual is used as the basis for the employment decisions affecting such

individuals, or

 The conduct has the purpose or effect of unreasonably interfering with an affected person’s work performance, or creating an

intimidating, hostile, or offensive work environment.

EDP-21 (Rev 03/20) Page 7 of 11

Security Background Document

Date:

Standard Clauses for Consultant/Contractor/Vendor Services Cont’d

3. Procedure

The Equal Employment Opportunity Section of the Office of Human Resources will process such complaints. Complaints may be referred in

writing or by direct contact with staff assigned to the Equal Opportunity Employment Section of the Office of Human Resources or reported to

an appropriate supervisor as circumstances warrant.

All allegations of sexual harassment shall be promptly, thoroughly, and confidentially investigated as set forth in the New York State Police

Administrative Manual, Article 9: Complaints Against Personnel, and shall be resolved without reprisal or threat of reprisal to the employee

making such allegation.

In each case, when an allegation of sexual harassment is substantiated, it may result in disciplinary action against the

consultant/contractor/vendor engaging in such misconduct, as well as against supervisory personnel who knowingly allow such behavior to

continue.

4. Right of Redress

 All consultants/contractors/vendors have the right of redress.

 Complaint resolution channels have been established to investigate incidents of sexual harassment.

 The Division Affirmative Action Officer under the Office of Employee Relations will process such complaints.

 Complaints may be referred in writing or by direct contact with the Division Affirmative Action Officer or reported to the appropriate

supervisor as circumstances warrant.

Consultant/contractor/vendor agrees to follow generally accepted business standards for selecting a wardrobe suitable for the workplace.

In circumstance where the signer of this document represents a consultant/contractor/vendor with more than one employee assigned to

NYSP, consultant/contractor/vendor agrees that all consultant/contractor/vendor staff now working for NYSP and all future staff who may be

assigned to NYSP have been and will be instructed in the requirements of this agreement.

Certification

* I have read and understand the contents of this document.

Consultant/Contractor/Vendor Signature (If handwriting, print and sign your name.) Date (mm/dd/yyyy)

Witness Signature (If handwriting, print and sign your name.) Date (mm/dd/yyyy)

EDP-21 (Rev 03/20) Page 8 of 11

Security Background Document

Date:

Federal Bureau of Investigation

Criminal Justice Information Services

Security Addendum

Certification

I hereby certify that I am familiar with the contents of (1) the Security Addendum, including its legal authority and purpose; (2) the NCIC

Operating Manual; (3) the CJIS Security Policy; and (4) Title 28, Code of Federal Regulations, Part 20, and agree to be bound by their

provisions.

I recognize that criminal history record information and related data, by its very nature, is sensitive and has potential for great harm if

misused. I acknowledge that access to criminal history record information and related data is therefore limited to the purpose(s) for which a

government agency has entered into the contract incorporating this Security Addendum. I understand that misuse of the system by, among

other things: accessing it without authorization; accessing it by exceeding authorization; accessing it for an improper purpose; using,

disseminating or re-disseminating information received as a result of this contract for a purpose other than that envisioned by the contract,

may subject me to administrative and criminal penalties. I understand that accessing the system for an appropriate purpose and then using,

disseminating or re-disseminating the information received for another purpose other than execution of the contract also constitutes misuse. I

further understand that the occurrence of misuse does not depend upon whether or not I receive additional compensation for such authorized

activity. Such exposure for misuse includes, but is not limited to, suspension or loss of employment and prosecution for state and federal

crimes.

_______________________________________________________________ ____________________________

Printed Name/Signature of Contractor Employee

ate

_______________________________________________________________ ____________________________

Printed Name/Signature of Contractor Representative (Superviso

Date

_______________________________________________________________

Organization and Title of Contractor Representative

08/16/2018

CJISD-I

TS-DOC-08140-5.7

EDP-21 (Rev 03/20) Page 9 of 11

Security Background Document

Date:

Com

leted Militar

Service

(

DD-214

)

If you need to request your DD-214, follow the instructions below. If you already have a copy, please forward with your background packet.

The consultant/applicant will request his/her records by using the following website: https://vetrecs.archives.gov/VeteranRequest/home.html.

Once you have entered the above website, the following sections will need to be completed in the following manner:

• “Records Locator Information” tab: Ensure you enter the branch of service they last completed. (If applicant has served in other branches,

this information can be entered in the next section.)

• “Documents Requested” tab: Ensure you select “an undeleted report of separation” as this will have the reason of separation dele

ted.

Withi

n this section, is a “comments box” where you can request further documents from other service. Do NOT create a separate reque

as this may delay a response.

• “Return Address” tab: List your name and address.

After submission, print a “signature verification” page which must be signed and faxed to (314) 801-9049. Keep the original “signat

ure

verification” page for proof of transaction.

Once the DD-214 is received, a copy must be submitted with your paperwork as part of the background packet.

Fin

rint Cardscan

Fingerprints are required for ALL consultants/applicants to confirm identify and determine employment suitability. Consultants/applicants will

need to pre-enroll with IdentiGo and provide basic demographic and payment information.

NY Residents

Schedule an appointment for fingerprinting at an IdentoGo location. Follow the “Directions for Pre-Enrollment and Payment Process” below.

Non-Residents of NY

Cardscan processing is available for those consultants/applicants residing outside of New York or physically unable to visit an IdentoGo

location. In order to complete the process, applicants must complete the following steps:

1. Ob

tain fingerprints on a FBI (FD-258) fingerprint card and complete personal information fields on the fingerprint card.

2. Pre-enr

oll for cardscan submission at http://uenroll.identogo.com all processing fees will be collected during the pre-enrollment process. A

pre-enrollment confirmation page will be provided once registration is complete.

3. Print a

nd sign the completed pre-enrollment confirmation page, which includes the barcode printed on the top right of the page. Mail

the

signe

d pre-enrollment confirmation page and the completed fingerprint card to the mailing address provided by your agency. For mailin

addres

s or further instructions, each applicant should contact their employer or agency contacts for those detail

Directions for Pre-Enrollment and Pa

ment Process

–

uired for ALL Fin

rint Cards

1. Visit http://uenroll.identogo.com and enter your 6-character Service Code. For IT hires, use code 15427V. For Non-IT hires, contact the State

Police section who is responsible for releasing their service code. Click the “GO” button.

EDP-21 (Rev 03/20) Page 10 of 11

Security Background Document

Date:

2. The next screen is where NY residents are going to select “Schedule or Manage Appointment” or NY Non-Resident will select “Submit a

Fingerprint Card by Mail.”

3. You

will need to confirm that you would like to proceed with submitting a fingerprint card for processing. Select “Continue” to proceed to

the

EDP-21 (Rev 03/20) Page 11 of 11

Security Background Document

Date:

4. The next few screens will collect essential information such as name, date of birth, address, etc. You will need to complete all required

information.

5. Pay for your service using an Authorization Code or Credit Card. If the Service is Auto-Billed to your Agency, payment will not be required.

6. Once you have submitted your payment, you will be directed to the final registration page. You will need to complete sections 2 and 3 and

submit this page along with your fingerprint card for processing.

If your agency needs to contact IdentoGo to check on the processing status of a particular fingerprint transaction, the IdentoGo call center

staff may be reached toll free at (877) 472-6915.

Should the fingerprint submission be rejected due to image quality reasons, IdentoGo will contact the applicant via US Mail and advise that

he/she must be reprinted. There is no additional cost for resubmission. There will be a small percentage of the population (3-5%) that have

difficulties in providing a good set of prints due to the quality of their skin/fingerprint ridges. In the event that you have an applicant who has

been rejected multiple times by NYS Department of Criminal Justice Services (DCJS), please contact DCJS for assistance at (800) 262-3257,

and ask to speak to someone in the Civil Identification Bureau. DCJS is willing to review the most recent transmission and determine if we can

accept the transaction for processing, taking into consideration any additional information you may be able to provide to indicate that a better

set of prints may not be obtainable.