Chowchilla, CA Security Forms & DL

Chowchilla, CA Security Forms & DL

STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION
BACKGROUND SECURITY CLEARANCE APPLICATION CONFIDENTIAL - FOR OFFICIAL USE ONLY - CDCR 2311 (06/22)
Last Name, First Name, MI:*
Other names you have been known by:
Date of Birth (Month, Day, Year)*

MonthDayYear
Date
Social Security Number
Gender:*

MaleFemaleNon-Binary
Area Code*
Phone Number*
State Bar #
State ID # or Driver's License #*
State*
Passport # (if no State ID/Driver's License)
Have you ever visited or had a personal relationship with any California Department of Corrections and Rehabilitation inmate or parolee for non-work related reasons?*

NoYes
Are you a former California State Prison inmate?*

NoYes
Have you ever been restricted or denied access to a State Prison?*

NoYes
Have you ever been convicted of a felony?*

NoYes
Please list the date, counties, & violations:*
Are you currently on probation/parole?*

NoYes
Do you have any pending or outstanding charges?*

NoYes
By signing this application, I attest that all of the information provided is true and correct. I acknowledge that prior written consent from the supervising agency is required for any parolee, probationer, or formerly incarcerated person to enter prison grounds. I further understand that, if approved, access is restricted to the designated area(s) and shall be under state employee escort unless otherwise authorized.

In accordance with the Privacy Act of 1974 (PL93-579), providing a SSN is optional. However, any omission of falsification may be cause for denial of access.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
INCARCERATED/PAROLED RELATIVE OR ASSOCIATE NOTIFICATION - CDCR 2189 (Rev. 07/18)
INCARCERATED/PAROLED RELATIVE OR ASSOCIATE NOTIFICATION
In accordance with the California Department of Corrections and Rehabilitation (CDCR) California Code of Regulations, Title 15 Section 3406, andDepartment Operations Manual Section 33010.25.1, this form must be completed each time an employee becomes aware of a relative or person withwhom the employee has/had a personal or business relationship who has been committed or transferred to the jurisdiction of the CDCR.
EMPLOYEE NAME (Last, First, Middle Initial)*
INSTITUTION/FACILITY/PROGRAM AREA*
WORK PHONE NUMBER (Include area code)
WORK ADDRESS
INMATE/YOUTH/PAROLEE INFORMATION
INMATE/YOUTH/PAROLEE NAME (Last, First, Middle Initial)*
DATE OF BIRTH (If known)

MonthDayYear
Date
IDENTIFICATION NUMBER Can be retrieved at http://www.cdcr.ca.gov/Visitors/lnmate_Locator.html*
INSTITUTION/FACILITY/REGION*
RELATIONSHIP TO EMPLOYEE (Relative, personal, or business)*
If the inmate/youth/parolee is transferred to your institution/facility/region, or is currently housed/assigned there, do you view his/her presence as conflicting with your employment caseload or responsibilities?*

YesNoN/A (I do not work at an institution/facility/region.)
If you are required to visit for work-related purposes (e.g., meeting, tour, temporary assignment) the institution/facility/region in which the inmate/youth/parolee is currently housed/assigned, do you view his/her presence as conflicting with your employment caseload or responsibilities?*

YesNo
Explanation:*
Employee's signature*

Clear
Date*

MonthDayYear
Date
Please upload a copy of your Driver's License/ID:*

Cancelof
Should be Empty:

BACKGROUND SECURITY CLEARANCE APPLICATION CONFIDENTIAL - FOR OFFICIAL USE ONLY - CDCR 2311 (06/22)

INCARCERATED/PAROLED RELATIVE OR ASSOCIATE NOTIFICATION - CDCR 2189 (Rev. 07/18)

INCARCERATED/PAROLED RELATIVE OR ASSOCIATE NOTIFICATION

INMATE/YOUTH/PAROLEE INFORMATION