**Read before completing packet** ***Include this form when submitting your investigation packet***

CNACI Investigation Packet 1. Complete this packet IN ITS ENTIRETY, signing all locations as required. You are able to sign

the forms digitally or in BLACK ink.2. It is recommended that this packet be completed digitally. To do so, please save a copy to your

desktop or enable features so that fillable fields populate the document

3. If you have any questions, please consult the EXAMPLE packet prior to calling the JROTC

Directorate. The example packet can be found at the JROTC CNACI website labeled as

“EXAMPLE: Investigation Packet”

4. As noted on the notification letter, you have thirty (30) days to complete this packet and send it

via certified mail to the following address:

USACC, JROTC Directorate

ATTN: Background Check Administrator

1307 Third Avenue, Fort Knox, KY 40121

5. Once you have read and understood the above, please complete the information below:

Full Name: ___________________________________________________________________________ (FIRST MIDDLE LAST. If you do not have a middle name, indicate “No Middle Name”. If you have only initials in

your name, indicate “Initial Only”).

Current Address: ______________________________________________________________________

Rank: ______ E-Mail Address: ________________________________________ (Please indicate an e-mail address you have immediate access to)

Place of Birth: ________________________________________________________________________ (City and State or Country if born outside the United States)

Signature: ____________________________________ Date: ___________________________

CONTACT REQUEST

Please complete and return the following requested information listed below so that your investigation can be initiated ..

(Please Print Clearly)

REQUESTED INDIVIDUAL INFORMATION

1. PREFIX/RANK:

2. LAST NAME:

3. FIRST NAME:

4. FULL MIDDLE NAME:

5. DATE OF BIRTH: ( ffi<'<ill,�Lf)�)6. CITY OF BIRTH:

7. STATE OF BIRTH:

8. COUNTRY OF BIRTH:

9 CITIZENSHIP (If born outside of the US or its territories, provide proof):

10. PRIMARY EMAIL ADDRESS (Preferably a MAIL.MIL Account):

11. SECONDARY EMAIL ADDRESS:

12. TELEPHONE NUMBER (work)

13. SECONDARY TELEPHONE NUMBER (Cell/Home) Indicate Which:

14. CURRENT MOS/JOB DESCRIPTION/SPECIAL TY:

15. SUPERVISOR'S PREFIX/RANK NAME AND TITLE:

16. SUPERVISOR'S EMAIL ADDRESS:

17 SUPERVISOR'S PHONE NUMBER:

Privacy act Notice: Disclosure of any information by you is strictly voluntary. All information collected will be used for the initiation of an investigation (initial/PR). Delays in providing the requested may result in a delay in the initiation of your investigation. Complete each numbered section ensuring it is true and accurate.

--

Present

ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION

For use of this form, see AR 600-85; the proponent agency is DCS, G-1.

SECTION A - CONSENT

I, , this day of 20 ,

--

(c/ien1'sf11/l 11a111e)

do hereby voluntarily consent to the release of the following information by Fort Knox, KY or HQDA ASAP (name ofi11stallatio11 ADA PCP)

pertaining to my identity, diagnosis, prognosis, or treatment from any Army record maintained in connection with

alcohol or other drug abuse education, training, treatment, rehabilitatiton, or research toSSG McWilliams/James Skeans

or Child Services Suitability Cell for the purpose of completing a background check requirement in accordance with

Department of Defense Instruction 1402.05 and Anny Directive 2014-23 for individuals who have regular contact with children

namely,

***see above *** (e.tte/11 or nature of i11for111atio11 to be disclosed)

SECTION B- EXPIRATION/REVOCATION

(Check applicable paragraph)

I. D I understand that this consent automatically expires when the above disclosure action has been taken inreliance thereon and that, except to the extent that such action has been taken, I can revoke this consent atany time.

- Or-(For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-/0e(3), AR 600-85)

2. D I understand that this consent automatically expires 60 days from today's date or when my present

criminal justice system status changes to

Further, I understand that if my release from confinement, probation, or parole is conditioned upon my participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective termination or revocation of my release from such confinement, probation, or parole.

SIGNATURE OF CLIENT DATE

NAME OF WITNESS ((l'f'e or />rim) SIGNATURE DATE

SECTION C -APPROVAL AUTHORITY FOR RELEASE OF INFORMATION

NOTE: Other than the MEDCENIMEDDAC Commander. approval authority for release of information may be delegated to the Program Physician or the Clinical Director.

In my judgment, the release of an evaluation of the present or past status of (clie111's name)

in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her. NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE (Type or prim) DATE

SIGNATURE

DA FORM 5018-R, NOV 1981 APD LC v3.00ES

under 18 years of age, namely dates of screening when not enrolled with the primary basis, diagnosis if one is available,

enrollment period if enrolled, with primary basis, diagnosis, success or failure of rehabilitation

SUBJECT: Recruiting Center Live Scan (LS) Support for Army ROTC and Army Civilian Personnel Request Form.

Live Scan Fingerprint Request Form

Subject Name:

SON: 607C

SOI: A662

OPEC/IPEC: DA-EFP

Appointment Date/Time:

Security Manager (James D. Skeans (502-624-5193) james.d.skeans.civ@mail.mil), Dennis A. Ford (502-624-1766)

dennis.a.ford2.civ@mail.mil ):

Subject will not be fingerprinted if they do not arrive with a government issued picture ID (driver’s license,

passport, etc.). Responsibility for the authorization to fingerprint rests solely on the Security Manager. USAREC

personnel will facilitate the capture and transmission of fingerprints, but cannot be required to determine if a

non-applicant subject is authorized to fingerprint.

Recruiter’s Name:________________________________

RSID:____________

Recruiter’s Signature:________________________________Date:___________________

State SF87

FD258

FP

Card

State

FP

Card

State

Request

Form

Requires

Notarized

Signature

OPM

General

Release

Form

Copy

of

Photo

ID

Notes

AL Alabama x x* x x *Form requires notary

signature or two (2)

witness signature

AK Alaska x

AR Arkansas x x x

AZ Arizona

CA California x

CO Colorado x

CT Connecticut

DE Delaware x x

DC DC x

FL Florida

GA Georgia

HI Hawaii

ID Idaho x x

IL Illinois x x

IN Indiana x

IA Iowa x* x *Iowa State REL form is

required for each surname

used throughout a

subject's life

KS Kansas x

KY Kentucky x* x *KY State form must be

witnessed.

LA Louisiana* *Louisiana requirements

may change in the near

future

ME Maine

MD Maryland

MA Massachusetts

MI Michigan x

MN Minnesota x x

MS Mississippi x

MO Missouri x

MT Montana x

NE Nebraska

NV Nevada x x

NH New

Hampshire

x x x

NJ New Jersey x

NM New Mexico x x x

NY New York

NC North Carolina x

ND North Dakota x

OH Ohio x* x* *Both sides of Ohio

fingerprint card must be

completed. Only out-of-

state applicants must

complete the Ohio

Exemption Form

OK Oklahoma

OR Oregon

PA Pennsylvania

RI Rhode Island x x x x

SC South Carolina

SD South Dakota x x* x *Two (2) witnesses

TN Tennessee x

TX Texas x x x

UT Utah 2 cards

VT Vermont

VA Virginia

WA Washington

WV West Virginia 2

cards*

x* *Two (2) FD258, (SF87

not accepted), one (1)

WVSP39 form must be

attached to the back of

one (1) FP card and

signed by Subject, and

West Virginia Card Scan

Services-Information

Form

WI Wisconsin

WY Wyoming x* x *Two (2) FD258