State of Alabama Department of Corrections
Alabama Criminal Justice Center
301 South Ripley Street
P. O. Box 301501
Montgomery, AL 36130-1501
(334) 353-3883
WAIVER AND AUTHORIZATION TO RELEASE INFORMATION
TO WHOM IT MAY CONCERN:
This constitutes my consent and authorization for the disclosure or furnishing of any relevant and necessary personal information or records, whether the records are of a public, private or confidential nature, to the Alabama Department of Corrections (ADOC) by any person, corporation, agency, or association concerning my moral character, education, financial transactions, medical history, employment records, criminal records, driving records, military service records, and any other information as may be relevant and necessary for a determination on my suitability as an employee, volunteer, visitor, vendor, or contract employee with ADOC. I authorize and request the full release of the information, without any reservation, throughout the duration of my association with ADOC. Your reply will be used to assist the ADOC in making a determination on my suitability.
I understand my rights under Title 5, United States Code, Section 552A, the Privacy Act of 1974, and waive those rights with the understanding that information furnished will be used by the Alabama Department of Corrections (ADOC) in conjunction with the department's employment, volunteer, or, visitation policies and/or other security matters and that this information is the sole property of the ADOC regardless of the outcome of this investigation. I fully understand that I shall not be entitled to have disclosed to me the contents of any of the documents, records, and other information provided.
I hereby release the persons, corporations, agencies, associations and their employees, agents, and representatives both individually and collectively, from any and all liability for damages of whatever kind, which may result because of compliance with this authorization and request.
PRINTED NAME
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ALIAS NAMES (Also Known As, Maiden Names or Nicknames)
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To:
All Applicants
From:
The Alabama Department of Corrections (ADOC), Personnel Division
Subject:
Prison Rape Elimination Act (PREA) Compliance
Federal law and Alabama Department of Corrections (ADOC) administrative regulations prohibit the hiring of anyone who has been convicted, criminally or civilly, of inappropriate sexual behavior, involving an individual who was incarcerated or otherwise unable to come and go from a facility without restriction. The same regulations also prohibit the hiring of persons who were involved in similar crimes in the community. Omissions of fact may be grounds for disciplinary action, up to and including termination, should such omissions be discovered after appointment.
Have you ever been employed at such an institution (businesses such as nursing homes and child care facilities would be among the employers of note)?
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Yes
No
If yes, Facility Name:
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Address:
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Position Held and Dates of Employment:
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Name and Phone Number of Contact:
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If you were employed at more than one such facility, please utilize the space below to respond to the same set of questions for each such employer.
If yes, Facility Name:
Address:
Position Held and Dates of Employment:
Name and Phone Number of Contact:
Have you ever been accused or charged with inappropriate sexual behavior?
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Yes
No
If yes, provide a clear narrative regarding the incident(s), the allegations, or charges and the outcome(s) of any investigation(s).
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Have you ever engaged in sexual abuse in a prison, jail, lockup, community confinement facility, or other institution?
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Yes
No
If yes, provide a clear narrative regarding the incident(s), the allegations, or charges and the outcome(s) of any investigation(s).
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Have you ever been convicted of engaging or attempting to engage in sexual activity in the community by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse?
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Yes
No
If yes, provide a clear narrative regarding the incident(s), the allegations or charges and the outcome(s) of any investigation.
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Have you ever been civilly or administratively adjudicated to have engaged in the activity described above?
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Yes
No
If yes, provide a clear narrative regarding the incident(s), the allegations or charges and the outcome(s) of any investigation.
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Facility Name:
*
Address:
*
Position Held and Dates of Employment:
*
Name and Phone Number of Contact:
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Second Facility
Facility Name:
Address:
Position Held and Dates of Employment:
Name and Phone Number of Contact:
PERSONAL INFORMATION SHEET
All persons desiring to enter any ADOC facility must complete the following form. The information on this form will be kept confidential. All information is subject to investigation. False or omitted information will result in you being denied approval to enter any/all ADOC facilities. This application is for the specific facility to which request is made.
1. Reason for applying for entry:
2. Facility:
3. Personal Information (Submit a copy of current government agency issued identification):
Name:
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First Name
Middle Initial
Last Name
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
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Format: (000) 000-0000.
Work:
Format: (000) 000-0000.
(Optional) Cell:
Format: (000) 000-0000.
Email:
*
example@example.com
SSN:
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DL #
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DOB:
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Month
-
Day
Year
Date
State
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Are you a U. S. Citizen:
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Yes
No
If No, you are a citizen of:
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In case of emergency, contact:
Name:
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Relation:
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Phone:
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Format: (000) 000-0000.
4. LEGAL DATA:
4a. Have you, your family, or close friend ever been a victim of a crime?
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Yes
No
If Yes, explain information about the crime and the name(s) of the offender(s):
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4b. Have you ever been arrested?
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Yes
No
If Yes, what were the charge(s)?
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Case Number(s):
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County:
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Disposition of case(s):
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4c. Do you have any relatives, or close friends, incarcerated in an ADOC institution?
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Yes
No
Inmate's name(s):
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Inmate's AIS #:
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Inmate's institution:
*
4d. Have you ever been accused or charged with inappropriate sexual activity, sexual abuse and sexual harassment?
Yes
No
If yes, provide a clear narrative regarding the incident(s), the allegations or charges and the outcome(s) of any investigations(s).
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Signature
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DATE
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Month
-
Day
Year
Date
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