44DOC-S3975 Contractor Background Check Application.docx
DOCX document 36 KB Posted
- Attached to
- Commissary and Supplemental Services
- Solicitation number
- 44DOC-S3975
- Issued by
- Nevada
About this file
This is a Contractor Background Check Application form issued by the Nevada Department of Corrections (NDOC) to support vendor qualification for state contracting opportunities. The form requires applicants to provide comprehensive personal identification information, including full legal names, aliases, maiden names, current and previous addresses, contact information, date of birth, and physical identifiers such as driver's license number, social security number, and distinguishing characteristics. The application also requires disclosure of employment history, particularly any prior work or volunteer experience in correctional settings, and whether the proposed project or duties will involve direct inmate contact, along with specification of which NDOC institutions the contractor will work at.
The application mandates complete disclosure of all criminal history, including arrests regardless of conviction status, across all states and countries, with explicit warnings that omissions or false statements result in automatic denial. Applicants must declare current probation status and any visits to or correspondence with Nevada Department of Corrections inmates. The form includes authorization language permitting NDOC to obtain complete criminal history records under Chapter 179A of the Nevada Revised Statutes for employment determination purposes only, with strict confidentiality protections prohibiting dissemination of obtained information. The application requires applicant signature and authorization before processing and must be mailed to the NDOC Contracts office in Carson City, Nevada.
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Text version
Mail Applications To:
NDOC Contracts P.O. Box 7011 Carson City, NV 89702 Nevada Department of Corrections Attn: Contracts Contractor Background Check Application Please PRINT all information
Phone (775) 977-5592 Fax (775) 977-5683
1. NAMES/ADDRESSES/PROJECT
Applicant Name
Last First MI Please complete this questionnaire in its ENTIRETY and mail it back to the address listed above. BE ADVISED: ANY
OMISSION OR FALSE STATEMENT IS SUFFICIENT REASON FOR DENIAL.
List any other names (alias) you are known by. Include your maiden name and any nicknames, if applicable) (Failure to include all names will result in denial)
Current Physical Address
Full Street City State Current Mailing Address
Zip
Full Street City State Previous Address
Zip
| Full Street | City | State | |
| Home Phone Number ( | ) |
List any other states you have lived in:
Zip
Occupation or Business _Employer
Business Phone ( I Contact Name:
Have you worked/volunteered in a correctional setting? Yes No If Yes, When/Where?
Will your project/duties involve direct inmate contact? Yes No If Yes, in what capacity?
Indicate which institutions you will work at:
| 2. | IDENTIFIERS | |
| Drivers License or ID number | State |
Date of Birth Place of Birth Age
| SSN | Gender: | Male | ❑ | Female |
| ❑ ❑ |
Race Marital Status: Married ❑ Single
Height Weight Hair Color Eye Color
Scars Marks or Tattoos
For NDOC Use Only Application Review Approved ❑ Denied ❑
Signature of Authorized Personnel Date
DOC 560 (3-20)
Please complete the 2' pace
3. Criminal History: ALL arrests must be listed. whether there was a conviction or not. You must also list arrests in other states and countries. Do not exclude anything,: any omission of an arrest is grounds for an automatic denial.
| Have you EVER been | ||
| arrested? Yes | nor No | |
| convicted of a Felony? Yes | or No |
Disposition
| Date of Arrest |
| City/State |
Have you EVER been
Charge
| Charge |
| Disposition |
| Date of Arrest |
| City/State |
| Charge |
| Disposition |
| Date of Arrest |
| City/State |
| Charge |
| Disposition |
| Date of Arrest |
| City/State |
| Charge |
| Disposition |
| Date of Arrest |
| City/State |
Are you currently on Probation? Yes ❑ or No ❑ If yes, in what state?
| 0. | Do you or have you ever visited or corresponded with an inmate incarcerated in a Nevada Department of |
| Corrections Facility? | Yes nor No |
If yes. complete the following section and attach additional sheets if necessary.
| Name and Back Number | |
| Relationship | Indicate whether you visit or |
write this inmate
| 5. | Authorization |
| Chapter 179A of the Nevada Revised Statutes permits an Agency of the Criminal Justice to obtain records of criminal history regarding a prospective employee. Consent is not required in order to obtain information reflecting only convictions. Consent is required in order to obtain a complete record of criminal history. |
The applicant's signature on this consent form will permit the Department of Corrections to obtain complete information regarding arrests, detention, indictments, information or other formal criminal charges and disposition of charges, including dismissals, acquittals, convictions, sentences, correctional supervision and release.
This information will be used only for purposes of determining employability. Chapter 179A of NRS prohibits an employer from dissemination of this information.
| Applicants Signature | Date |
| Agency Authorization for Records Check | Date |
DOC 560 (3-20 )
File details come from the government source that posted it. Updated .