11-Pre-Bid Form - 2026 Delaware County.pdf

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Institutional Clearance Profile

Complete & Return to: Office Manager, Nicole Miller George W. Hill Correctional Facility / Delaware County

Email: Nicole Miller: millerni@co.delaware.pa.us YOU MUST ALSO SUBMIT A CLEAR PHOTOCOPY OF A CURRENT PHOTO ID w/ ADDRESS

YOU MUST COMPLETE ALL SECTIONS CLEARLY AND LEGIBLY

Personal/Demographic Information

Last Name: First Name: Middle Name: Suffix: (Jr, II, etc.)

Street Address:

City: State: Zip Code:

Phone #: Email Address: (Optional)

Date of Birth: Height: Eye Color: Hair Color: Sex: □M □F □Other

Race (Select One): □White □Black or African American □Hispanic or Latino □Asian or Pacific Islander □American Indian or Alaskan Native

Social Security #: State of ID Issuance: Driver’s License/State #:

A criminal history is NOT an automatic disqualifier for employment, a FAILURE TO DISCLOSE a criminal history may disqualify eligibility for employment

Have you ever been ARRESTED? □ Yes □ No If yes, attach specific details (dates, offenses, dispositions)

Have you ever been CONVICTED of a crime? □ Yes □ No If yes, attach specific details (dates, offenses, dispositions)

Have you ever been incarcerated in any facility? □ Yes □ No If yes, attach specific details (dates, institution)

Have you ever been employed or volunteered at George W. Hill Correctional Facility? □ Yes □ No

Organization Affiliation / George W. Hill Clearance Submission Reason

Name of Org./Program: Director/Supervisor:

Department: Position/Job:

Statement of Integrity

By my signature, I attest that I have been honest, accurate, and forthcoming with the information requested.

Statement of Intent

Notice of Dangerous Conditions and Assumption of Risk By my signature, I attest that I have been advised and clearly understand the following:

• I seek to enter the George W. Hill Correctional facility (GWH) knowing that it is a place of confinement for individuals charged with a crime, individuals awaiting hearings and trials, and individuals convicted and serving sentences.

• I am aware that some confined GWH incarcerated individuals have been charged with and possibly convicted of violent crimes.

• I am aware that some confined GWH incarcerated individuals move freely, unescorted, within their authorized areas and that some of the authorized areas may be where I am assigned to work.

• I am aware that I could be exposed to bodily fluids and bloodborne pathogens.

• I agree to abide by all rules set forth by GWH Administration as well as all applicable laws and understand that any violation of these rules may result in my immediate suspension from the correctional facility and may further be subject to criminal prosecution.

Applicant Signature: Date:

For George W. Hill Official Use ONLY

Clearance Approved: □ Yes □ No If No, Reason for Denial:

Authorized Signature: Date:

Disposition of Original NCIC/CLEAN Responses: □ Destroyed □ Maintained (by OMS) mailto:millerni@co.delaware.pa.us

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Institutional Clearance Profile

List all arrests and convictions with details (brief summary accepted). (Dates, offenses, dispositions)

If you do not have a criminal history, write, “I do not have a criminal history” and sign.

Applicant Signature: Date: