SEC0010-Temp-Employee-Form-10232013.pdf

CSOSA-SEC-0010 1 Revision: 10/2013

Court Services and Offender Supervision Agency for the District of Columbia

SECURITY FORM FOR TEMPORARY EMPLOYEES

This form is to be used for appointments in the Agency that are for six months or less. It is to be completed as indicated and returned to the Office of Security via the hiring authority and/or the

Office of Procurement. Upon receipt of the completed documentation, the Office of Security will conduct a preliminary background check and will notify the hiring authority once the individual is approved to begin work.

PART I – TO BE COMPLETED BY THE HIRING OFFICIAL

Hiring Office: ______________________ Tel: __________ Date: ________

Hiring Official: __________________________________________

Position Sensitivity: ______________________________________

Desired Performance Start Date: ____________________________

Position Title: __________________________________________

Duration of Assignment: __________________________________

NCIC/WALES Access Required: Yes No

Need Proximity Card: Yes No

If Yes, Temporary Employee must obtain proxy card within 30 days of security approval notification.

PART II – TO BE COMPLETED BY THE INDIVIDUAL

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