7-Addendum Security Clearance.pdf

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:

NEXT MOST

RECENT ARREST:

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

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