Attachment J-1 CSOSA SEC 0010-Temp-Contractor-Form.pdf

CSOSA-SEC-0010 1 Revision: 10/2013

Court Services and Offender Supervision Agency for the District of Columbia

SECURITY FORM FOR TEMPORARY CONTRACTORS

This form is to be used for all contractor personnel performing work under contract with CSOSA. It is to be completed as indicated and returned to the Office of Security by the Contracting Officer. Upon receipt of the completed documentation, the Office of Security will conduct a CSOSA background check and will notify the CO when the individual is approved to begin work.

PART I – TO BE COMPLETED BY THE CONTRACTING OFFICER (CO) OR

CONTRACTING OFFICER REPRESENTATIVE (COR)

COR Program Office: ______________________ Tel: __________ Date: ________

� COR: __________________________________________

� Position Sensitivity: ______________________________________

� Desired Performance Start Date: ____________________________

� Contractor Name:__________________________________

Contract Number:__________________________________

Applicant Name:__________________________________

� Position Title: __________________________________________

� Position Description: __________________________________________

� Duration of Assignment: __________________________________

� NCIC/WALES Access: � Yes � No

� CSOSA Network Access: � Yes � No

Prepared By: ________________________ _______________________________ Print Name Signature & Date

PART II – TO BE COMPLETED BY THE APPLICANT

1. Full Name (Last, First, MI)__________________________________________________

2. Other Names Used (Maiden and Alias) ________________________________________

3. Telephone Number(s) where you can be reached ________________________________

4. Home Address (Street, City, State, and Zip Code)__________________________________

5. E-mail Address ______________________________________________________________

6. Sex Male Female

7. Race: __________________

8. Date of Birth (Mo/Day/Year)________________________________________________

9. Place of Birth (City, State, Country) __________________________________________

10. Social Security Number ____________________________________________________

11. U.S. Citizenship By Birth Naturalized Other

12. In the last seven years, have you been fired from a job, quit after being told you would be fired, or left by mutual agreement following allegations of misconduct or unsatisfactory performance?

Yes No If your answer is “Yes,” explain below:

Date Reason Employer’s Name & Address

13. In the last seven years, have you been arrested for, charged with, or convicted of any offense(s)? (Leave out traffic fines of less than $150).

Yes No If your answer is “Yes,” explain below:

Date Charge Police Agency Disposition

I certify that the statements made by me on this form are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that this information will be used to conduct records checks for the purpose of either paid or unpaid employment with the Court Services and Offender Supervision Agency.

Signature Date

PART II – TO BE COMPLETED BY THE APPLICANT