Attachment 2(C) - CSO Form 005.pdf

Page 1 of 3 CSO FORM 005 (REV. 05/06) Section J - Attachment 2(C)

COURT SECURITY OFFICER CONTRACTOR’S

PRELIMINARY BACKGROUND CHECK FORM

ATTENTION CONTRACTOR: This form must be used to conduct preliminary background checks on those individuals proposed to perform on your company’s behalf under the United States Marshals Service’s contract for court security services. Incomplete forms will be considered unacceptable and will be returned for completeness. Type or legibly print all requested information. If the information is not legible, the form will be considered unacceptable and returned for correction. This form must be submitted in accordance with the time requirements stated in the applicable United State Marshals Service’s contract.

CONTRACTOR COMPANY’S NAME TELEPHONE NO.

CONTRACTOR COMPANY’S ADDRESS

Street Address

City State Zip Code

NAME OF THE PERSON CONDUCTING STATE THE DISTRICT, BUILDING,

THE PRELIMINARY BACKGROUND CHECK AND FACILITY WHERE THE

APPLICANT WILL WORK.

Title

1. APPLICANT’S NAME

Last First Middle

2. PREFERRED TITLE Mr. Mrs. Miss Ms.

3. OTHER NAMES USED (Include nicknames, aliases, maiden name, etc.)

4. SOCIAL SECURITY NUMBER - -

5. DATE OF BIRTH (MM/DD/YYYY) - -

6. PLACE OF BIRTH (City/State/County or Foreign Country)

7. ARE YOU A CITIZEN OF THE UNITED STATES? (If no, provide the following information) YES NO

Country(ies) of citizenship

Alien Registration Number

Date and Place Issued

If a Naturalization Citizen, provide the following information.

Page 2 of 3 CSO FORM 005 (REV. 05/06)

Naturalization Number

Date and Place Issued

8. DID YOU GRADUATE FROM HIGH SCHOOL? If you have a GED high school equivalency, answer yes.

YES (If “YES,” give month and year graduated.)

(MM/DD/YY)

NO

WRITE THE NAME AND LOCATION (City and State) OF THE LAST HIGH SCHOOL YOU

ATTENDED OR WHERE YOU OBTAINED YOUR GED HIGH SCHOOL EQUIVALENCY.

9. CAN YOU READ, WRITE, AND SPEAK THE ENGLISH LANGUAGE? YES NO

10. DO YOU HAVE A CURRENT DRIVER’S LICENSE? IF YES, FROM WHAT STATE?

YES NO STATE

IF “YES,” HAVE YOU MAINTAINED A SAFE DRIVING RECORD FOR THE PAST 5

YEARS? (IF “NO,” PLEASE PROVIDE AN EXPLANATION BELOW.)

IF NO, CAN YOU OBTAIN A VALID STATE DRIVER’S LICENSE? (IF NO, EXPLAIN

WHY.) YES NO

11. HAVE YOU AT LEAST 3 CALENDAR YEARS OF VERIFIABLE EXPERIENCE AS A

CERTIFIED LAW ENFORCEMENT OFFICER OR ITS MILITARY EQUIVALENCY AND

YOUR APPOINTMENT AS A LAW ENFORCEMENT OFFICER INCLUDED GENERAL

ARREST AUTHORITY? (Note: Experience does not have to be consecutive.) YES NO

12. DID YOU COMPLETE OR GRADUATE FROM A CERTIFIED FEDERAL, STATE,

COUNTY, LOCAL OR MILITARY LAW ENFORCEMENT TRAINING ACADEMY OR

PROGRAM THAT PROVIDED INSTRUCTION ON THE USE OF POLICE POWERS IN AN

ARMED CAPACITY WHILE DEALING WITH THE PUBLIC? YES NO

ATTENTION CONTRACTOR: You must verify the applicant’s arrest authority and obtain a copy of the applicant’s training certificate or diploma prior to submitting the applicant’s package to the United States Marshals Service. If the applicant did not receive a training certificate or diploma, a letter from the training department or agency may suffice. This letter must indicate that the applicant was employed as a law enforcement officer and that the department or agency did not or does not issue certificates or diplomas upon completion of such training.

Page 3 of 3 CSO FORM 005 (REV. 05/06)

TO BE COMPLETED BY THE CONTRACTOR ONLY

1. Was the applicant’s employment history verified? YES NO

2. The applicant’s employment history was verified through which agency or department representative?

Immediate Supervisor Personnel Office Other (Provide the person’s name and title below.)

3. Did you discuss the applicant’s character, qualifications, and work record? YES NO

4. If possible, would the agency (ies) rehire the applicant? YES NO

ADDITIONAL COMMENTS:

13. APPLICANT’S SIGNATURE, CERTIFICATION, AND RELEASE OF INFORMATION

I have completed this statement with the knowledge and understanding that any or all items contained herein may be subject to investigation and I consent to the release of information concerning my capacity and fitness by employers, educational institutions, law enforcement agencies, and other individuals and agencies, and other authorized employees of my potential employer, who is under contract with the Federal Government (United States Marshals Services) for that purpose.

CERTIFICATION: I certify that all of the statements made by me are true, complete, and correct to the best of my knowledge and belief, and are made in good faith.

APPLICANT’S SIGNATURE DATE (MM/DD/YY)

14. CONTRACTOR’S SIGNATURE AND CERTIFICATION STATEMENT

I hereby certify that I have been authorized by my employer, to conduct a complete and thorough preliminary background check on the subject applicant, whom my employer is seeking to hire, and/or provide as a qualified candidate for a CSO position. I also certify that the findings resulting from the preliminary background check have been stated in a true, complete, and accurate manner.

SIGNATURE OF CONTRACTOR’S REPRESENTATIVE DATE (MM/DD/YY)