Detention_Facilities_Site_Requirements_(Forms).pdf

New

Renewal

Agency / Company Name:

Are you an employee of an organization that has an AB109 or other county contract? No Job Title: Supervisor:

MI: Sex:

State:

Zip:

ALAMEDA COUNTY SHERIFF'S OFFICE

DETE

Please print or type all entries. Please complete this form in its entirety. Illegible or incomplete forms will be returned.

Any additional information may be attached to the application

Purpose of obtaining security clearance

Employer: Job Title:

Phone #:Emergency Contact:

Personal Information

Contact Phone #: E-mail:

DOB: SSN:

Address:

Last: First: Race:

CDL/ID:

City:

application. I authorize the Office of the Sheriff to conduct any investigation to confirm the above listed information. I authorize the release of

Have you used any illegal narcotics within the last three years? YES □ NO □ Are you currently on probation or parole? YES □ NO □

If you answered yes to any of the above questions, please explain below:

Policy Acknowledgement I certify that the statements contained herein are true. I understand that any false or inaccurate information may result in the denial of my

FBI: REMARKS:

all confidential documents to the Alameda County Sheriff’s Office to determine my eligibility for a security site clearance. I understand that I am subject to and give my consent to be searched, including my personal affects and vehicle while I am on Sheriff’s Office Property. I acknowledge that I will notify the Sheriff's Office in writing within 24 hours, if anyone I know comes into custody within the Alameda County Jail System.

Applicant Signature: Date:

Office Use Only

DMV: REMARKS:

WARRANTS: REMARKS:

Date: APPROVED □ DENIED □

Reviewed by Lieutenant: Badge #: Date: APPROVED □ DENIED □

Facility Commanding Officer:

Appeal Process

Division Commander: Date: APPROVED □ DENIED □

CII: REMARKS:

Reviewed by Sergeant: Badge #: Date: APPROVED □ DENIED □ Processed By: Badge #: Date:

Have you ever engaged in any type of sexual abuse in any confinement setting? YES □ NO □ Have you been found civily liable for engaging in any form of sexual abuse? YES □ NO □ Have you been civily or administratively adjudicated to have engaged in sexual abuse in any confinement facility? YES □ NO □

*** FAILING TO LIST AN ARREST OR CONVICTION MAY BE BASIS FOR DENIAL ***

Do you have any family members or personal friends in custody in the Alameda County Jail System? YES □ NO □ Have you ever been arrested, charged, or convicted of any criminal offense? YES □ NO □

Yes

Inmate Services Santa Rita Jail

Reason for Visit:

Tour GroupContractor or EmployerVolunteer or Service Provider Santa Rita Jail

Procurement Contract #:

Revised 9/2025

Name of Project:

SANTA RITA JAIL PROJECTS SECURITY CLEARANCE FORM

For SRJ Projects, email completed form to: acsoprojsiteclearance@acgov.org

090420