Doc 3532-V - Consent For Release Of Criminal History Records - Nevada Department Of Corrections
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2NEVADA DEPARTMENT OF CORRECTIONS
CONSENT FOR RELEASE OF CRIMINAL HISTORY RECORDS
Southern Administration Volunteer
Northern Administration Education
PO Box 7011
Volunteer Programs
3955 W. Russell Rd.
Carson City, NV 89702
Las Vegas, NV 89118
Please PRINT Legibly
VOLUNTEER TYPE: Circle one: Education Staff or Teacher ● Student Intern
● Faith Based/Religious ● Other (specify) ______________
1.
NAMES AND ADDRESSES
Applicant Name:
Last
First
MI
Please complete this questionnaire in its ENTIRETY. **ANY omission or false statement is SUFFICENT REASON FOR
DENIAL.**
List any other names (alias) you are known by. Include your maiden name and any nicknames (if applicable). (Failure to include all
names will result in denial.)
Current Physical Address:
Full Street
City
State
Zip
Current Mailing Address:
Full Street
City
State
Zip
Previous Address:
Full Street
City
State
Zip
Home Phone Number (
)
Cell Phone Number (
)
Email address:
List any other states you have lived in; if none enter N/A:
Occupation or Business:
Employer:
Business Phone: (
)
Contact Name:
Have you ever worked for the Nevada Department of Corrections?
Yes
No
If Yes, When?
Position? ____________________________________________________
Have you EVER worked or volunteered in any prison, jail, lockup, community confinement facility, juvenile facility,
or other institution?
Yes
No
I f Yes, When?
Where?
IDENTIFIERS
2.
Drivers License and/or ID number:
State:
Date of Birth:
Place of Birth: __________________________
Age:
SSN:
Gender:
Male
Female
Race:
Marital Status:
Married
Single
Height:
Weight:
Hair Color:
Eye Color:
Scars, Marks or Tattoos; if none enter N/A:
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DOC 3532-V (4/2013)
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