WASHINGTON COUNTY CORRECTIONAL FACILITY

VOLUNTEER CLEARANCE CHECK INFORMATION

Please print the following information legibly. Enter N/A in any space that does not apply. All information will be maintained confidentially, but must be provided in order to complete check. Falsification or omission of pertinent information will be considered as justification for disapproval.

Former WCCF Employee: (Check here) _______________

Category: (Check one)

_____ VENDOR (Construction, Food delivery, Service, Repairs, etc) _____ OFFICIAL VISITOR (PA Prison Soc.)

_____ CONTRACT SERVICE PROVIDER (CSP)	_____ MENTOR PROGRAM

_____ VOLUNTEER PROGRAM	_____ ORGANIZATION

_____ PUBLIC VISITOR (Religious Ministry) _____ INMATE VISITOR (provide inmate # in

_____ PUBLIC VISITOR (Government, Criminal Justice Agency, etc)	purpose of visit field)

_____ PUBLIC VISITOR (Entertainment, Activities, Sports, Guest Speaker) _____ OTHER (identify) ________________

_____ COMMONWEALTH EMPLOYEE

Initial Clearance Request: □

Renewal Request: □

Purpose of Visit ______________________________________________________________

Organization/Agency/Company/ProgramName:______________________________________________________	Abbreviation if applicable(________)

Subcontracted to:__________________________________________________ Title or Position_____________

Last	First	Complete

Name _________________________________Name __________________________ Middle Name _______________

List all previously used names :_____________________________, ______________________________

Date of Birth: _____ _____ __________ Social Security Number: ________ - _____ - _________or Passport #____ ________________ Alien Registration #______________ Visa # ___________

Sex _______ Race (circle) W B I A Height ____ ft ____ in Weight ____ lbs Eye Color ________ Hair Color_______

Current Address: _________________________________________________________________________________

Prior Address: ___________________________________________________________________________________

Place of Birth ________________________, _______ E-mail Address ______________________________________

Home Phone: ( ) _____________ -__________________ Alternate Phone: ( ) ______________ - _________________

Current Driver’s License Info: State _____ Operator

_____ ID only license List OLN Number _______________Valid: Yes / No

Previous Licenses (list all states & #’s that apply) State _______ Operator/Non-Operator Number____________

Identify names, relationships and locations of any relatives or close friends confined in any DOC Facility ______________________________ ______________________________ ______________________________________ ______________________________________

I confirm that all information contained on this clearance request

has been verified by me to be complete and accurate

Signature ______________________________________________Date____________________________

_

Requesting Staff Member: ______________________________________ Emp #:________ Date of Request______

Specific Event or Access: ___________________________________Period of Access Require_________________

Security Office approving staff member signature____________________________ Facility _______Date ________