DOC 560 NDOC Contractor Background Check Application Form .pdf

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 )