Security Clearance

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UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF CALIFORNIA
YADOR J. HARRELL
PROBATION OFFICE
CHIEF U.S. PROBATION OFFICER
450 Golden Gate Avenue
Suite 17-6884; P.O. Box 36057
San Francisco, CA 94102-3487
TEL: (415) 436-7540
FAX: (415) 436-7572
SECURITY CLEARANCE
All persons employed or contracted for service within the confines of the United States District Court are
subject to screening and clearance for security purposes. Accordingly, all such persons are required to
complete the following information for submission to the United States Probation Office for review and
verification.
1. NAME: ______________________________________________________________________________
(Last)
(First)
(Full Middle Name)
Any other names used? If so, please list: __________________________________________________
2. AGE:__________ RACE:______________ DATE OF BIRTH:____________GENDER:______________
If you have used any other dates of birth, please list:___________________________________________
3. PLACE OF BIRTH: _____________________________________________________________________
(City)
(State)
4. SOCIAL SECURITY NUMBER:_________________________________________________________
Any other social security numbers used? If so, list:___________________________________________
5. CURRENT DRIVER’S LICENSE NUMBER AND STATE: ______________________________________
Ever held a Driver’s License in another state? If so, list:_______________________________________
6. Height: _______
Weight: ________
Eye Color: _____________
Hair Color: _______________
7.
Have you ever been arrested? ___No ____Yes
If yes, list all arrests, dates, arresting agency, charge and resulting action:
____________________________________________________________________________________
Submission of false or incomplete information as required may result in refusal of clearance and result in your
not being allowed to perform services within the confines of the United States District Court, and may result
in punitive action for providing false statements to the United States Government.
CONSENT TO RELEASE INFORMATION
_______________________________________
________________________________________
Signature
Date
_______________________________________
_______________________________________
Witness’ Signature
Date

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