20-Housing Access Request Form.doc
DOC document 325 KB Posted
- Solicitation number
- 25/0348
- Issued by
- Harris County, Texas
About this file
This is a Housing Access Request Form used by the Harris County Sheriff's Office (HCSO) in Texas to manage and control access to jail facilities. The form is designed for individuals or their employers/organizations who require access to non-public areas of HCSO jail facilities located at three addresses: 1200 Baker Street, 701 North San Jacinto Street, and 1307 Baker Street. Applicants must indicate their desired access type, which includes options for unlimited access, on-call access, business hours access, or off-hours access. The form collects comprehensive personal information including name, physical characteristics, date of birth, identification numbers, contact information, and emergency contact details. Applicants must disclose any criminal arrest history, convictions, current probation or parole status, and whether they have associates or relatives currently in custody at HCSO or other correctional facilities. The form also includes a specialized section for chaplaincy applicants who must specify their classification, religious affiliation, sponsorship, and sponsor contact information.
HCSO emphasizes that providing complete, truthful, and accurate information is mandatory to qualify for access, and any false, misleading, or incomplete information will result in denial of facility access. Applicants must sign and have their application witnessed, acknowledging that the issuance of an HCSO identification card is a privilege that may be revoked at any time and for any reason. The form is processed through HCSO staff who conduct background checks using NCIC, TCIC, LCIC, and SETCIC databases, as well as records from the Houston Police Department. The final section of the form is completed exclusively by HCSO staff and includes approvals or denials of access, determination of identification card type, and spaces for staff signatures and supervisor authorization. Applicants must provide copies of their driver's license and, optionally, Social Security card documentation as part of the clearance process.
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Text version
Housing Access Request Form (1 of 3) You, or your employer/organization, have requested you be given access to the Harris County Sheriff's Office jail facilities. This allows access to certain non-public areas of the jail facilities maintained and secured by the HCSO in its statutory responsibility to safely keep the prisoners of the county.
YOUR ARE UNDER NO RESPONSIBILITY TO GIVE THE REQUESTED INFORMATION. However, to qualify for access you must provide true, complete and accurate answers to the questions contained on this form. Please understand if you do not provide the requested information or any information you provide is found to be false, misleading or incomplete, YOU SHALL NOT BE GRANTED ACCESS TO THE SECURE AREA OF HCSO FACILITIES.
If you are issued a Harris County Sheriff's Office identification card, that card forever remains the property of the HCSO, and must be returned to the designated representative of the HCSO upon demand.
| ACCESS TYPE REQUESTED |
| INDICATE ALL HCSO JAIL FACILITIES YOU ARE REQUESTING ACCESS TO |
| UNLIMITED ON-CALL BUSINESS HOURS OFF-HOURS |
| 1200 BAKER ST 701 N SAN JACINTO ST 1307 BAKER ST |
| Personal Information |
| NAME (LAST, FIRST MIDDLE) |
| RACE |
| HEIGHT |
| WEIGHT |
| GENDER |
| DATE OF BIRTH |
| M F |
| DL/ID NUMBER STATE |
| SOCIAL SECURITY NUMBER |
| CITY , COUNTY, STATE & COUNTRY OF BIRTH |
| CURRENT STREET ADDRESS |
| CITY |
| STATE |
| ZIP CODE |
| HOME TELEPHONE |
| WORK TELEPHONE |
| MOBILE TELEPHONE |
| E-MAIL ADDRESS |
Emergency Contact Information
| NAME (LAST, FIRST, MIDDLE) |
| WORK TELEPHONE |
| MOBILE TELEPHONE |
| HOME TELEPHONE |
| STREET ADDRESS |
| CITY |
| STATE |
| ZIP CODE |
| Arrest Information |
| HAVE YOU EVER BEEN ARRESTED AND/OR CHARGED WITH A CRIMINAL OFFENSE? |
NO YES (If you indicated "Yes," answer the following questions.)
MOST RECENT
ARREST:
| DATE (MM/DD/YYYY) |
| ARRESTING AGENCY |
| CHARGE |
| WERE YOU CONVICTED? |
| COURT |
| COUNTY AND STATE |
| CURRENTLY ON PROBATION OR PAROLE? |
| YES NO |
| YES NO |
| NEXT MOST RECENT ARREST: |
| DATE (MM/DD/YYYY) |
| ARRESTING AGENCY |
| CHARGE |
| WERE YOU CONVICTED? |
| COURT |
| COUNTY AND STATE |
| CURRENTLY ON PROBATION OR PAROLE? |
| YES NO |
| YES NO |
| NEXT MOST RECENT ARREST: |
| DATE (MM/DD/YYYY) |
| ARRESTING AGENCY |
| CHARGE |
| WERE YOU CONVICTED? |
| COURT |
| COUNTY AND STATE |
| CURRENTLY ON PROBATION OR PAROLE? |
| YES NO |
| YES NO |
| Associates/Relatives in Custody |
| DO YOU CURRENTLY HAVE ANY ASSOCIATES AND/OR RELATIVES IN THE CUSTODY OF HARRIS COUNTY SHERIFF'S OFFICE OR ANY OTHER CITY, COUNTY, |
STATE OR FEDERAL CORRECTIONAL FACILITY?
NO YES (If you indicated "Yes," answer the following questions.)
| FULL NAME (LAST, FIRST MIDDLE) |
| RELATIONSHIP |
| SPN/ID NUMBER |
| FACILITY, CITY, STATE |
| FULL NAME (LAST, FIRST MIDDLE) |
| RELATIONSHIP |
| SPN/ID NUMBER |
| FACILITY, CITY, STATE |
| FULL NAME (LAST, FIRST MIDDLE) |
| RELATIONSHIP |
| SPN/ID NUMBER |
| FACILITY, CITY, STATE |
D-820 ~ Housing Access Form
PLEASE CONTINUE TO THE NEXT PAGE
Housing Access Request Form (2 of 3)
COMMENTS (IF APPLICABLE)
THE FOLLOWING SECTION IS TO BE COMPLETED BY CHAPLAINCY APPLICANTS ONLY (IF APPLICABLE)
| CLASSIFICATION OF YOUR TITLE OR POSITION |
| PROFESSIONAL OR RELIGIOUS AFFILIATION OR SPONSORSHIP |
STAFF CHAPLAIN
ASSISTANT CHAPLAIN
RELIGIOUS GROUP REPRESENTATIVE
ALCOHOLICS ANONYMOUS VOLUNTEER
NARCOTICS ANONYMOUS VOLUNTEER
SEXUAL ADDICTS ANONYMOUS VOLUNTEER
| SPONSOR NAME |
| SPONSOR TELEPHONE |
| CONTACT PERSON |
| SPONSOR ADDRESS (STREET ADDRESS) |
| CITY |
| STATE |
| ZIP CODE |
By my signature, I acknowledge my understanding of the terms and conditions under which a Harris County Sheriff's Office Identification Card may be issued to me and I may utilize the card. I also acknowledge my understanding the issuance of this card is a privilege, which may be revoked by the Harris County Sheriff's Office at any time and for any reason. I further certify the information I have provided in this document is true, correct and complete to the best of my knowledge.
| SIGNATURE OF APPLICANT |
| DATE |
| SIGNATURE OF WITNESS |
| DATE |
X
| X |
STOP!
PROCEED NO FURTHER ~ THANK YOU FOR YOUR APPLICATION Requesting Agency's Use Only
STOP!
| AGENCY REQUESTING CLEARANCE |
| SUPERVISOR REQUESTING CLEARANCE |
| SUPERVISOR'S SIGNATURE |
| SUPERVISOR'S TELEPHONE |
| X |
DESCRIBE THE ACCESS REQUESTED TO INCLUDE ALL FACILITIES, FLOORS, SHIFTS AND REGULAR DAYS OFF
-- END OF HOUSING REQUEST FORM --
FINAL PAGE FOR OFFICAL HARRIS COUNTY SHERIFF'S OFFICE USE ONLY
D-820 ~ Housing Access For
Housing Access Request Form (3 of 3) THE FOLLOWING SECTION IS TO BE COMPLETED BY HARRIS COUNTY SHERIFF'S OFFICE STAFF ONLY
| NCIC/ TCIC/LCIC/SETCIC |
| WMIN |
| LOCAL ~ LNAM |
| HOUSTON POLICE DEPARTMENT |
| ACCESS |
| TYPE OF IDENTIFICATION CARD ENTRY |
| APPROVED DENIED ID ONLY |
| STAFF MEMBER'S SIGNATURE |
| DATE |
| APPROVING SUPERVISOR'S SIGNATURE |
| DATE |
X
| X |
| OPERATOR'S LICENSE/OFFICIAL IDENTIFICATION |
| SECONDARY IDENTIFICATION (I.E., SOCIAL SECURITY CARD, ETC.) (OPTIONAL) |
Place Requestor's Driver's License/ Identification Card in this area when photocopying this report.
Place Requestor's Social Security Card in this area when photocopying this report.
COMMENTS
CJC-820 ~ Housing Access Form
File details come from the government source that posted it. Updated .