Attachment K - Consent for Release of Criminal History Records Form.pdf

Mail Applications To: Nevada Department of Corrections Phone (775) 977-5592

NDOC Contracts Attn: Contracts

P.O. Box 7011 Contractor Background Check Application Fax (775) 977-5683

Carson City, NV 89702 Please PRINT all information

DOC 560 (3-20)

Please complete the 2nd page

For NDOC Use Only

Application Review

Approved Denied

Signature of Authorized Personnel Date

1. NAMES/ADDRESSES/PROJECT

Applicant Name _________________________________________________________________________ Last First MI

Please complete this questionnaire in its ENTIRETY and mail it back to the address listed above. BE ADVISED: ANY

OMISSION OR FALSE STAEMENT IS SUFFICENT REASON FOR DENIAL.

List any other names (alias) you are known by. Include your maiden name and any nicknames, if applicable) (Failure to include all names will result in denial)

Current Physical Address

Current Mailing Address

Full Street City State Zip

Previous Address

Full Street City State Zip

Home Phone Number (

Full Street

City State Zip

List any other states you have lived in: _________________________________________________

Occupation or Business _Employer ________________________

Business Phone ( ) Contact Name: _____________________

Have you worked/volunteered in a correctional setting? Yes No If Yes, When/Where? ____

Will your project/duties involve direct inmate contact? Yes No If Yes, in what capacity?

Indicate which institutions you will work at: ____________________________________________

2. IDENTIFIERS

Drivers License or ID number ________________________________________ State ___________________________

Date of Birth ____________________________ Place of Birth ____________________ Age ____________________

SSN ____________________________________ Gender: Male Female

Race ___________________________________ Marital Status: Married Single

Height ______________ Weight ___________ Hair Color ________________ Eye Color _______________

Scars Marks or Tattoos ______________________________________________________________________________

Agency Authorization for Records Check Date

5. Authorization

Chapter 179A of the Nevada Revised Statutes permits an Agency of the Criminal Justice to obtain records of criminal history regarding a prospective employee. Consent is not required in order to obtain information reflecting only convictions. Consent is required in order to obtain a complete record of criminal history.

The applicant’s signature on this consent form will permit the Department of Corrections to obtain complete information regarding arrests, detention, indictments, information or other formal criminal charges and disposition of charges, including dismissals, acquittals, convictions, sentences, correctional supervision and release.

This information will be used only for purposes of determining employability. Chapter 179A of NRS prohibits an employer from dissemination of this information.

Applicants Signature _______________________________________________ Date ___________________________

3. Criminal History: ALL arrests must be listed, whether there was a conviction or not. You must also list arrests in other states and countries. Do not exclude anything; any omission of an arrest is grounds for an automatic denial.

Have you EVER been arrested? Yes or No

Have you EVER been convicted of a Felony? Yes or No

If yes, complete the following, attach additional sheets if necessary.

Charge Disposition Date of Arrest City/State

Charge Disposition Date of Arrest City/State

Charge Disposition Date of Arrest City/State

Charge Disposition Date of Arrest City/State

Charge __________ Disposition _______ Date of Arrest _______ City/State _________

Are you currently on Probation? Yes or No If yes, in what state?

0. Do you or have you ever visited or corresponded with an inmate incarcerated in a Nevada Department of Corrections Facility? Yes or No

If yes, complete the following section and attach additional sheets if necessary.

Name and Back Number Relationship Indicate whether you visit or write this inmate

DOC 560 (3-20 )