6-Security Clearance form.pdf
PDF 335 KB Posted
- Attached to
- INSTALLATION OF IMPRESSED CURRENT CP SYSTEM
- Solicitation number
- DOC27GS0003AA
- Issued by
- Hartford County, Connecticut
About this file
This is a background check form issued by the Connecticut Department of Correction (CTDOC) for vendors and contractors seeking entry to state correctional facilities. The form collects personal identification information including name, date of birth, social security number, physical descriptors, and maiden name. Vendors must complete the form and submit it via fax to DOC.Collect1@ct.gov or by email with scanned copies. The form requires applicant signature in the presence of a witness and includes an acknowledgement that CTDOC retains the right to deny any individual entry to CTDOC-administered correctional facilities at any time.
The background verification process includes multiple database checks conducted by CTDOC personnel, including Connecticut driver information inquiries, vehicle and wanted person inquiries, Connecticut master file and suspense file checks, interstate III checks, social security verification, out-of-state checks covering Rhode Island, New York, and Massachusetts, and documentation of any convictions or arrests with associated details including arresting agency, docket number, charge level, and court disposition. The form notes that incomplete or illegible submissions will not be processed and was last revised on March 28, 2023.
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Other files
| File | Type | Posted |
|---|---|---|
| 5-Guide for Contractors in the Correctional Environment.docx | DOCX document | |
| DOC27GS0003AA_Oct_26_26_solicitation_doc.pdf | ||
| EXHIBIT A ICCP Somers.docx | DOCX document | |
| EXHIBIT B PRICE SCHEDULE.xls | XLS spreadsheet |
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Text version
COLLECT BACKGROUND REPORT Fax to DOC.Collect1@ct.gov 860-920-3081 OR- FOR VENDORS/CONTRACTORS Email scanned forms to DOC.Collect1@ct.gov
NAME ________________________________________________________ D.O.B. ______________________
(LAST) (FIRST) (MI) (MM/DD/YYYY)
MAIDEN NAME ____________________________________________ SSN ___________________________
HGT. ________ WGT. __________ RACE ____ SEX ____ EYES ___________HAIR ______________
SCARS TATTOOS ___________________________________ VENDOR:_____________________________
__________________________________________ STATE __________________
CO. CONTACT EMAIL:________________________________________________PHONE: _____________
OFFICIAL USE ONLY DO NOT COMPLETE: POSITIVE NO PRIOR
RESPONSE CONVICTIONS
FL02 DRIVER INFO ____________
FLQW CT VEHICLE/WANTED INQ.
SPRC CT MASTER FILE
SPSC CT SUSPENSE FILE
OBTS OFF. BASED TRACKING CHECK
FLQH INTERSTATE III CHECK
RT45SS DOC SS CHECK
RT45NM DOC NAME CHECK
FLIQ OUT OF STATE CHECKS
RI
NY
MA
CHECK COMPLETED BY _______________________________________________DATE ____________
Comments/Findings: OFFICIAL USE ONLY:
Arrest Date:
Arresting Agency/Docket Number:
Charge: Level:
Misd. or Fel.
Date Disposed:
Court Disposition:
*Please note: this form will not be processed if incomplete or illegible*
*Please read and sign below in the presence of a witness*
ACKNOWLEDGEMENT
I, the undersigned, acknowledge and understand that the Connecticut Department of Correction (CTDOC) can deny any individual entry to any correctional facility administered by the CTDOC at any time.
Signature of Applicant _________________________________________ Date Signed ____________________________________
Signature of Witness __________________________________________ Date Signed _____________________________________
Revised 03/28/2023
File details come from the government source that posted it. Updated .