Attachment 3 - Contracted Provider Offer of Employment Submission Form.pdf

New Jersey State Parole Board – Division of Community Programs Contracted Provider Offer of Employment Submission Form

This original form is to be completed by the contractor applicant and the contracted service provider in its entirety, with all necessary documentation attached as required. The signature of the Director of the contracted provider program is required under Section 1 – Provider Certification prior to submission to the NJSPB. The Contractor will be requested to resubmit incomplete applications. Further, contractor applicants who have served a sentence or are under probation or parole supervision must not be hired until the individual has been released from the service of the aforementioned for a minimum of three (3) years.

Section I. - Provider Certification We, ___________________________________ (name of Contractor), attest that the person listed below has provided full and satisfactory proof of their identity, that s/he has submitted a complete and truthful employment application, and that a full criminal history background investigation has been completed.

NOTE: A full criminal history background investigation shall include a Fed III, NJCCH, NCIC Warrants, Local Warrants, SSN Trace and Address Locator Search, County Criminal Record Search and DMV driver’s license/registration check.

Name of Contracted Provider Program Director (Please Print):

Signature:

Title:

Date:

Complete Section II. on page 3.

Attach legible copies of:

Social Security Card Current Driver’s License Government Issued Photo Identification

NOTE: Copies shall be enlarged by at least 150% to make them more legible.

It is understood that the New Jersey State Parole Board, Office of Professional Standards, will verify that the contractor applicant is not precluded from employment due to one (1) or more of the following reasons:

A. Currently under any form of criminal justice supervision.

B. Has been under any form of criminal justice supervision within the past three (3) years.

C. Has completed a sentence for a felony conviction within the past three (3) years. NJ State Parole

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D. Has been convicted of an ‘index offense’ (murder, rape, robbery, burglary, aggravated assault, larceny over $50, motor vehicle theft and arson), or a sexual offense enumerated below*. Applicants with a documented history of convictions for these offenses will be excluded from employment at and assignment to a SPB contracted program.

* A conviction, adjudication of delinquency, or acquittal by reason of insanity for aggravated sexual assault; sexual assault; aggravated criminal sexual contact; kidnapping pursuant to N.J.SA. 2C:13-1(c)2; endangering the welfare of a child by engaging in sexual conduct which would impair or debauch the morals of the child pursuant to N.J.SA. 2C:24-4(a)1; endangering the welfare of a child pursuant to N.J.S.A. 2C:24-4(b)3, 4, or 5(a); luring or enticing pursuant to N.J.S.A. 2C:13-6; criminal sexual contact pursuant to N.J.S.A. 2C:14-3(b) if the victim is a minor; kidnapping pursuant to N.J.S.A. 2C:13-1, criminal restraint pursuant to N.J.S.A.

2C:13-2, or false imprisonment pursuant to N.J.S.A. 2C:13-3 if the victim is a minor and the offender is not the parent of the victim; knowingly promoting prostitution of a child pursuant to N.J.S.A. 2C:34-1(b)3 or 4; or an attempt to commit any of these enumerated offenses if the conviction, adjudication of delinquency or acquittal by reason of insanity is entered or the offender is serving a sentence of incarceration, probation, parole or other form of community supervision as a result of the offense or is confined following acquittal by reason of insanity or as a result of civil commitment.

New Jersey State Parole Board – Division of Community Programs Contracted Provider Offer of Employment Submission Form

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Section II. - Applicant Information

NAME DOB

LAST FIRST MIDDLE MONTH DAY YEAR

RACE SEX SOCIAL SECURITY #

AKA (IF APPLICABLE) MAIDEN NAME

COLOR EYES COLOR HAIR PLACE OF BIRTH

CITY STATE COUNTRY

PRESENT ADDRESS TOWN/CITY STATE ZIP

DRIVER’S LICENSE # STATE ISSUED

PROGRAM NAME

POSITION ANTICIPATED DATE OF HIRE

HOURS DAYS

(Upon completion of this form, please forward to: New Jersey State Parole Board, Division of Community Programs, P.O. Box 862, Trenton, NJ 08625.

Section III. – Office of Professional Standards Review

The application has been researched and the results are attached to this document.

NAME TITLE DATE

Please provide results to: James Dickinson, Director, Division of Parole and Community Programs.

New Jersey State Parole Board – Division of Community Programs Contracted Provider Offer of Employment Submission Form

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