Contractor Background Check Application Form ~2.docx
DOCX document 36 KB Posted
- Attached to
- Staffing Analysis Services
- Solicitation number
- 44DOC-S2838
- Issued by
- Churchill County, Nevada
About this file
This document is a Contractor Background Check Application Form provided by the Nevada Department of Corrections (NDOC). The form requires applicants to provide detailed personal information, including name, address, employment history, and criminal history, in order to obtain approval to work or volunteer in a correctional setting. The application indicates that any omission or false statement is grounds for denial.
The related State and Local Contract Opportunity is for Staffing Analysis Services for NDOC correctional facilities under RFP 44DOC-S2838. The selected contractor will be responsible for reviewing existing staffing levels, recommending optimal staffing, developing standardized staffing patterns, and conducting a security post prioritization study. The contract term is one year, with a publicly available budgeted amount of $395,000.00. Proposals must be submitted by July 25, 2024, and the State intends to award one contract based on factors such as competence, experience, and cost. The State will apply a 5% preference for Nevada-based businesses and an inverse preference for vendors from states that apply an in-state preference.
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Text version
Mail Applications To:
NDOC Contracts P.O. Box 7011 Carson City, NV 89702 Nevada Department of Corrections Attn: Contracts Contractor Background Check Application Please PRINT all information
Phone (775) 977-5592 Fax (775) 977-5683
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 STATEMENT IS SUFFICIENT 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
Full Street City State Current Mailing Address
Zip
Full Street City State Previous Address
Zip
| Full Street | City | State | |
| Home Phone Number ( | ) |
List any other states you have lived in:
Zip
Occupation or Business _Employer
Business Phone ( I 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
For NDOC Use Only Application Review Approved ❑ Denied ❑
Signature of Authorized Personnel Date
DOC 560 (3-20)
Please complete the 2' pace
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 | nor No | |
| convicted of a Felony? Yes | or No |
Disposition
| Date of Arrest |
| City/State |
Have you EVER been
Charge
| 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 nor 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
| 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 |
| Agency Authorization for Records Check | Date |
DOC 560 (3-20 )
File details come from the government source that posted it. Updated .