MISSISSIPPI DEPARTMENT OF CORRECTIONS
APPLICANT RELEASE OF INFORMATION
To Whom It May Concern:
The Mississippi Department of Corrections will conduct a background investigation to verify information that you have
provided in conjunction with your application for employment. **This information will be used every five years to conduct
a criminal background review.** In order to conduct the investigation, the following information is required.
Social Security #: Date of Birth: Race: Sex:
State Issued: ____________________________
Current Address: _________________________________________________________________________________
Street Apt # City
____________________________________________________________________________________
State Zip Code
Have you ever been arrested and/or convicted of a crime?
Yes_____ No________ If yes: Date:
Charge: City: State: ____________________
Have you ever been associated with a street gang? __ Yes __ No If yes, what gang? _____________________
Do you have any tattoos on your body? __ Yes __ No If yes, what does it stand for? _______________________
__________________________________________________________________________________________
In order that the investigation can be completed, I hereby authorize the Mississippi Department of Corrections
and any of its authorized employees to receive and collect information from any previous employer, law
enforcement agency, educational institution, or persons named by me as references.
Applicant (Print) Name Applicant Signature Date
11/12
03-14-F1
Revised: 08/07/2019
Job Location Availability:
Select a 1
st
, 2
nd
, and 3rd choice of any county and an institution listed below where you prefer to work.
_______ _______ _______ _______ _______ _______ _______ ______ _______ ______ _______
Forrest Harrison Hinds Leflore Madison Noxubee Pascagoula Pike Quitman Rankin Wilkinson
___Central MS Correctional Facility (CMCF) ___ Mississippi State Penitentiary (MSP) ___ South MS Correctional Institution (SMCI)
NOTE: Your application will be processed by your selection preference according to the job availability.
TO BE COMPETED BY CORRECTIONAL OFFICER APPLICANTS ONLY
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