Attachment 2(I) - CSO-234.pdf

- 1 - Form CSO-234

Rev. 06/06

The U.S. Government is authorized to ask for this information under Section 3301 of Title 5 and Section 3101 of Title 44 of the U.S. Code. We ask for your Social Security number to keep our records accurate, because other people may have the same name and birth date. Executive Order 9397 also asks Federal agencies to use this number to help identify individuals in agency records.

Review the form in its entirety prior to answering any questions. Be sure that you understand the questions and your responses prior to completion of the form.

This form will be used in processing your application. We use the information from this form primarily as the basis for an initial background investigation that will be used to determine your qualifications (to include law enforcement qualifications), suitability and eligibility for a clearance to work for the U.S. Government under contract.

Asking you for this information is in compliance with the Privacy Act of 1974. The information you give us is for Official Use Only; is protected from unauthorized disclosure. The U.S. Marshals Service may share some information with Federal and other sources to get additional information about you. We may also give some of the information to Federal, State, and local agencies checking on law violations or for other lawful purposes.

Giving us the information we ask for is voluntary. However, we may not be able to complete your investigation, or complete it in a timely manner, if you don't give us each item of information we request. This may affect your employment or clearance prospects to work for the U.S. Government under contract.

TYPE OR LEGIBLY PRINT YOUR ANSWERS. We cannot accept your form if it is not legible. All questions on this form must be answered. If no response is applicable, indicate this by entering “N/A.” Follow all form instructions fully, or we cannot process your form.

STATE CODES. Use the State Codes (two letter abbreviations) used by the Post Office, if you cannot spell out the state. Do not abbreviate names of cities.

USE 5 OR 9 - DIGIT ZIP CODES. If you do not know a ZIP Code, a ZIP Code directory is available at all Post Offices at www.usps.com. Please use them.

DATES. When providing dates, use YYMMDD. For example, June 8, 1988, would be 980608 and January 1988 would be 8801.

ADDITIONAL SHEETS. If there is not enough room on the sheets provided, please attach additional sheets so that you can provide as complete an answer as possible. Be sure to indicate the item number corresponding to the item being carried over to the additional sheet. Place your name and social security number on the additional sheet so that it can be readily identified if it should become separated from the form.

SIGNATURE AND DATE. Be sure to sign the forms in black or blue-black ink. Initial and date any changes you make to this form after you sign it.

ANY FORMS THAT ARE RECEIVED INCOMPLETE WILL BE RETURNED. THIS WILL DELAY THE

PROCESSING OF YOUR CASE AND COULD EVEN RESULT IN YOUR NOT BEING SELECTED.

Personal Qualifications Statement (Court Security Officer)

READ THE INFORMATION BELOW PRIOR TO COMPLETING.

WHAT AUTHORITY DO WE HAVE TO ASK YOU FOR THE INFORMATION REQUESTED ON THIS FORM?

HOW DO WE USE THIS FORM?

(Cont'd.)

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Rev. 06/06

DOCUMENTATION. Copies of documents that verify any significant claims or activities should be provided. For example: alien registration; naturalization certificate; originals or certified copies of college transcripts or degrees; high school diploma; professional license(s) or certificate(s); military discharge certificate(s) (DD Form 214); marriage certificate(s); divorce papers; tax returns; passport; and/or business licenses(s).

NAME CHANGES. If you have had a name change from that indicated on the form, you must provide a copy of the documentation of any legal name change. If the name you are currently using is not a legal name, please use your official name as indicated on your birth certificate or marriage license.

EMPLOYMENT. Ensure that you list any previous law enforcement related employment, including military (i.e. Military Police, Master at Arms, etc.). Provide this experience in Section 22-23 whenever it occurred. It does not have to be consecutive. Explain how this experience included general arrest authority in the remarks to this section.

The U.S. Criminal Code provides that knowingly falsifying or concealing a material fact is a felony which may result in fines of up to $ 10,000, or 5 year imprisonment, or both. In addition, Federal agencies generally fire or disqualify individuals who have materially and deliberately falsified investigative forms, and this remains a part of our record for future use. Because the position for which you are being considered is a public trust position, your trustworthiness is a very important consideration in deciding your suitability or eligibility to perform under the contract.

WHAT ARE THE PENALTIES FOR INACCURATE OR FALSE INFORMATION?

HOW DO WE USE THIS FORM? (Cont'd.)

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Mr. Mrs. Miss Ms.

PERSONAL QUALIFICATIONS STATEMENT

(Court Security Officer)

Please Complete the following (Print legibly or Type):

GENERAL INFORMATION

1. NAME

2. PREFERRED TITLE

(Check one)

3. SOCIAL SECURITY NUMBER

4. OTHER NAMES USED (including nicknames, aliases, maiden name, etc.)

StateCity Zip Code

6. CURRENT PHONE

NUMBERS Home (Include Area Code) Office (Include extension if applicable)

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

8. DATE OF BIRTH (YYMMDD)

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

10. Availability Data:

Last First Middle

5. CURRENT ADDRESS

(No. Street, and Apt. No.. if applicable)

a. Date (month year) you will be available to start work

b. Number of hours you will be available to start work each month

c. Days of the week that you can work

d. Are you available to perform temporary guard duties in other cities?

11. CURRENT PHYSICAL CONDITION (Check one): Excellent Good Fair Poor* (*Note: If answer is Poor, provide detailed information in Item 18.)

12. If you understand and can speak and/or read any language other than English, please list and indicate level of proficiency (i.e. poor, average, good, fluent)

13. Are you able to speak fluently, read, and write the English language or the language determined necessary by the U.S. Marshals of the district where you are seeking to perform contract services?

NOYES

14. Do you have a current drivers license?

If so, for what state?

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Rev. 06/06

NOYES15. a. Do you have any physical or mental condition which might interfere with your ability to perform the work required (e.g., epilepsy, diabetes, alcoholism, drug addictions, cataracts, heart (cardiovascular) problems, psychiatric disorders, etc.?

b. Have you ever used any narcotic, depressant, stimulant, hallucinogen (to include LSD or PCP, or cannabis) (to include marijuana or hashish), except as prescribed by a licensed physician?

c. Have you ever been involved in the illegal purchase, possession, or sale of any narcotic, depressant, stimulant, hallucinogen, or cannabis?

d. Has your use of alcoholic beverages (such as liquor, beer, wine) ever resulted in the loss of a job, arrest by police, or treatment for alcoholism?

e. Have you ever been a patient (whether or not formally committed) in any institution primarily devoted to the treatment of mental, emotional, psychological, or personality disorders?

NOTE: If the answer to Question 15 a through e above is Yes, please provide detailed information in Item 18, Prior to award of a contract, you will be required to provide a physician's signed statement that the above condition will not interfere with your ability to perform the work required.

16. Are you now or have you ever been affiliated with any organization, association, movement, group, or combination of persons which advocates the overthrow of our constitutional form of government or which has adopted a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States or which seeks to alter the form of government of the United States by unconstitutional means?

17. To the best of your knowledge, have you ever been the subject of a background investigation (by either Federal, state, local, or private industry) or been given a security clearance?

If your answer is Yes, provide the following information and provide a copy of investigation certification, if available:

Agency requiring the clearance

Type of Investigation (i.e., NACI, LBI, BI, SBI...)

Date Clearance Issued/ Investigation Completed

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19. Current work status (check one):

Employed Full Time Employed Part Time Unemployed Retired

EMPLOYMENT HISTORY

20. Have you ever been employed by the Federal Government?

21. Have you ever been employed by a state or local government?

YES NO

18. Space for detailed answers and continuation of information:

QUESTION NO. ANSWER/COMMENT

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Read the following carefully before signing this certification. A false answer to any question in this statement may be grounds for disqualification and may be punishable by fine or imprisonment (U.S. Code Title 18, Section 1001).

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, to duly accredited investigators, and other authorized employees of the Federal Government 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.

SIGNATURE AND CERTIFICATION STATEMENT

Signature (sign in ink) Date Name (Type/Print)

Name and address of employer's organization Dates employed (month &year)

From To

Salary or earnings

Exact Title of Your Position Name of Immediate Supervisor Area Code Telephone No.

Kind of Business If Federal Service, give series, grade or rank

Description of work (Describe your specific duties, responsibilities, experience conducting felony arrests, use of general arrest authority, and accomplishments in this job)

Avg. No. Hrs. per week

Beginning $ per Ending $ per

No. Employees supervised

22. LAW ENFORCEMENT/FEDERAL EMPLOYMENT

List ALL law enforcement employment, whenever it occurred.

Reason for leaving

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CONTINUATION SHEET

QUESTION NO. ANSWER/COMMENT

Name and address of employer's organization Dates employed (month &year)

From To

Salary or earnings

Exact Title of Your Position Name of Immediate Supervisor Area Code Telephone No.

Kind of Business If Federal Service, give series, grade or rank

Description of work (Describe your specific duties, responsibilities, experience conducting felony arrests, use of general arrest authority, and accomplishments in this job)

Avg. No. Hrs. per week

Beginning $ per Ending $ per

No. Employees supervised

23. LAW ENFORCEMENT/FEDERAL EMPLOYMENT

Print additional pages as necessary.

Reason for leaving

Space for detailed answers and continuation of information (cont'd.):