Attachment J-11 Security Form for Temporary Contractors.docx
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- Attached to
- Supportive Housing Services (Up to 180 Days)
- Solicitation number
- 9594CS26Q0075
About this file
This is a security form template for temporary contractors performing work under contract with the Court Services and Offender Supervision Agency (CSOSA) for the District of Columbia. The form is designed to collect background information and security clearance documentation necessary before contractor personnel can begin work on CSOSA contracts.
Part I of the form requires completion by the Contracting Officer or Contracting Officer Representative and captures administrative details including the program office, contract number, applicant name, position title, position description, assignment duration, and requirements for NCIC/WALES access and CSOSA network access. Part II requires the applicant to provide personal identifying information including full name, alternate names, contact information, date and place of birth, Social Security number, citizenship status, and race/ethnicity. The form also includes two mandatory disclosure questions requiring applicants to report any employment termination or resignation under misconduct allegations within the past seven years, and any arrests, charges, or convictions (excluding traffic fines under $150) within the same period. Upon completion and submission to the CSOSA Office of Security through the Contracting Officer, the agency will conduct a background check and notify the CO when the individual is approved to commence work.
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Text version
Court Services and Offender Supervision Agency for the District of Columbia
Attachment J-11: 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
CSOSA-SEC-0010 1 Revision: 10/2013
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:Black Not-Hispanic
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
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