23-001 Exhibit C - Contractor Blank Form for background check.docx
DOCX document 16 KB Posted
- Attached to
- TECHNICIAN LABOR AND MATERIALS FOR CABLE INSTALLATION AND TERMINATION WITHIN THE ANAMOSA STATE PENNITENTIARY
- Solicitation number
- 23-001
- Issued by
- Jones County, Iowa
About this file
This document is a contractor background information form for a state and local contract opportunity for technician labor and materials for cable installation and termination within the Anamosa State Penitentiary in Iowa. The contract is being solicited by the Iowa Communications Network (ICN) on behalf of the Anamosa State Penitentiary. The contract requires the selected vendor to meet the Chapter 3 Technical Specifications and Requirements. The form collects information about the contractor's background, including any convictions, investigations, and associations with incarcerated individuals, to determine eligibility to work at the penitentiary.
The pricing terms, set asides, funding requirements, and other salient contract details are not provided in this document. However, the contract opportunity is for the state of Iowa, specifically Jones County, and the selected vendor will provide the required technician labor and materials for the duration of the contract term.
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Other files
| File | Type | Posted |
|---|---|---|
| Amendment 1 to ITB 23-001.pdf | ||
| 23-001 Anamosa Wiring ITB FINAL.dat | — | |
| 23-001 Exhibit A- Materials Location and Identification.xlsx | XLSX spreadsheet | |
| 23-001 Exhibit B - ASP Bldg. Numbers.pdf |
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Text version
CONTRACTOR’S BACKGROUND INFORMATION
I affirm that all the information provided here is complete and accurate. I understand that any false or incomplete information or entries may disqualify me from working inside the Anamosa State Penitentiary. I understand that my signature permits the completion of the background check.
| ________________________ | ___________________________ | |
| Signature | Signature of Witness |
Date
1. Have you ever been convicted, civilly adjudicated or administratively adjudicated of engaging or attempting to engage in sexual harassment, or sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or of the victim did not consent or was unable to consent or refuse? (PREA 115.17(a)(2)(3)(b)(f))
□ No □ Yes
Location: ____________________ Date(s) ____________________
2. Have you ever resigned during a pending investigation or an allegation of sexual violence or sexual harassment while employed at a prison, jail, lockup, community confinement facility, juvenile facility or other institution? (PREA 115.17(c)(2))
□ No □ Yes
Location: ____________________ Date(s) ____________________
CONTRACTOR’S INFORMATION
PLEASE PRINT.
Use complete names do not use initials or nicknames. Provide any former names you have used, including maiden or married names. (Please use additional sheets as necessary) First Name: ________________________________________________________ Middle Name: ______________________________________________________ Last Name: ________________________________________________________ Previous Names: ____________________________________________________ Social Security Number: ______________________________________________ Current Address: ____________________________________________________ City: ______________________________________________________________ State: _____________________________________________________________ Zip: _______________________________________________________________ Date of Birth: _______________________________________________________
IDENTIFY ALL CURRENT OR FORMER: FAMILY MEMBERS, FRIENDS, NEIGHBORS, CO-WORKERS, AND CLASSMATES, ANYONE YOU KNOW THAT IS INCARCERATED AND/OR UNDER SUPERVISED/SUPERVISION BY A FEDERAL, STATE OR COUNTY CORRECTIONAL AGENCY.
| NAME |
| RELATIONSHIP |
| AGENCY |
*Please write N/A if this section is not applicable to you* IDENTIFY ALL FELONY AND MISDEMEANOR CONVICTIONS AND ANY PENDING CHARGES THAT MAY BE DISCLOSED BY THE NATION CRIME INFORRMATION CENTER (NCIC) OR OTHER CRIMINAL RECORDS AGENCY.
Location: _______________________________________________________ Charge(s): ______________________________________________________ Date Charges Filed: _______________________________________________ Date of Conviction: _______________________________________________ Correctional Supervision: __________________________________________ Date of Final Release: _____________________________________________ *Please write N/A if this section is not applicable to you*
Please send the completed for to sharon.vratney@iowa.gov or fax it to 319-462-4517.
File details come from the government source that posted it. Updated .