Fillable Services Division Security Background Check Application Applicant Information (Maricopa County Telecommunications)

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Services Division Security Background Check Application Applicant Information (Maricopa County Telecommunications)

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The Services Division Security Background Check Application Applicant Information (Maricopa County Telecommunications) form is 2 pages long and contains:

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  • 17 check-boxes
  • 44 other fields

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File type: PDF

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Rev: 10/14/2019
Maricopa County Security
Services Division
Security Background Check Application
Applicant Information
COMPANY NAME:
EMPLOYEE LAST NAME:
FIRST:
MIDDLE:
LIST ANY NAMES THAT HAVE BEEN USED IN THE PAST:
DATE OF BIRTH:
PLACE OF BIRTH:
DRIVER’S LICENSE #:
STATE ISSUED BY:
Addresses
APPLICANT’S RESIDENTIAL ADDRESS:
STATE:
ZIP:
Have you lived at this address for 10 or more years? (check one):
YES
NO
If “no”, please provide previous address below:
PREVIOUS ADDRESS:
CITY:
STATE:
ZIP:
HAVE YOU LIVED IN ANY ARIZONA COUNTIES OTHER
THAN MARICOPA?
YES
NO
If “yes”, please list:
HAVE YOU LIVED OUTSIDE OF ARIZONA?
YES
NO
If “yes”, please list City, County, and State:
Criminal History
Have you ever been convicted of a crime? (check one):
YES
NO
If “yes”, please provide details below:
CHARGE:
YEAR:
CITY/STATE:
CHARGE:
YEAR:
CITY/STATE:
CHARGE:
YEAR:
CITY/STATE:
CHARGE:
YEAR:
CITY/STATE:
Rev: 10/14/2019
Disclaimer and Signature
I hereby authorize Maricopa County Security Services Division to conduct a Criminal History/Records check and Warrants check for the purpose of issuing a
Maricopa County Contractor ID Card. I understand that, should this card be issued to me, it will be displayed only when I am on/in a Maricopa County facility and
that it should only be used to access Maricopa County facilities for official purposes related to my employment.
I agree that the information provided on this application is accurate and that any false information provided may result in the non-issuance of an ID card or the
loss of such privileges.
Signature of Applicant:
Date:
Areas of Access Needed (FOR COUNTY USE)
Hours of Access: ☐ Business Hours ☐ 24 Hour
Access Schedule: ☐ Monday – Friday ☐ Monday – Sunday ☐Other (Specify): _________
*List of Buildings (include building name or address and specify access areas):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
I HAVE CONFIRMED THAT THE REQUESTED ACCESS IS APPROPRIATE AND NECESSARY IN ORDER FOR THE APPLICANT TO FULFILL THEIR
CONTRACTUAL OR VOLUNTEER DUTIES.
I HAVE VERIFIED THAT THIS APPLICATION IS COMPLETE AND THAT A COPY OF THE APPLICANT’S DRIVER’S LICENSE OR GOVERNMENT ISSUED
ID HAS BEEN SUBMITTED ALONG WITH THIS APPLICATION. I UNDERSTAND THAT INCOMPLETE APPLICATIONS WILL BE REJECTED.
County Authorized Signature:
Print Name:
Department:
Date Submitted:
FOR SECURITY SERVICES USE ONLY
HIGHER REVIEW NEEDED?
YES
NO
BACKGROUND CHECK COMPLETED BY:
HIGHER REVIEW COMPLETED:
APPROVED
DENIED
SIGNATURE OF REVIEWER:
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Services Division Security Background Check Application Applicant Information (Maricopa County Telecommunications)

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Completed 18 July 2020

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