Doc 3532-V - Consent For Release Of Criminal History Records - Nevada Department Of Corrections Page 2
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2.
CRIMINAL HISTORY:
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ALL arrests must be listed, whether there was a conviction or not. You must also list arrests in
other states and countries. Do not exclude anything; any omission of an arrest is sufficient reason for denial.
Have you EVER been arrested? Yes
or No
Have you EVER been convicted of a Felony, Gross Misdemeanor or Misdemeanor? Yes
or No
If yes to either of the above, complete the following and attach additional sheets if necessary.
Charge
Disposition
Date of Arrest
City/State
Charge
Disposition
Date of Arrest
City/State
Charge
Disposition
Date of Arrest
City/State
Charge
Disposition
Date of Arrest
City/State
4.
Have you EVER been incarcerated in a Correctional Facility/Prison? Yes
or No
If yes, what Facility/Prison (s) and state: ______________________________________________________________
Are you currently on Probation? Yes
or No
If yes, in what state?
5.
Do you or have you ever visited or corresponded with an inmate incarcerated in any Correctional Facility or
Prison?
Yes
or No
6.
Do you know or correspond with anyone on parole/probation? Yes
or No
If yes to the above questions, complete the following section and attach additional sheets if necessary.
Name and Inmate Number
Relationship
Indicate whether you visit or write
7.
Authorization
Chapter 179A100 of the Nevada Revised Statutes permits an Agency of Criminal Justice to obtain records of criminal history regarding
a prospective employee. Consent is not required in order to obtain information reflecting only convictions. Consent is required in order to
obtain a complete record of criminal history.
The applicant, contractor or volunteer’s signature on this consent form will permit the Department of Corrections to obtain complete
information regarding arrests, detention, indictments, information or other formal criminal charges and disposition of charges, including
dismissals, acquittals, convictions, sentences, correctional supervision and release.
This information will be used only for purposes of determining volunteer eligibility. Chapter 179A of NRS prohibits an employer
from dissemination of this information.
Applicant’s Signature
Date
Agency Authorization for Records Check
Date
For Official Use Only
Application Review
Approved
Denied
Signature of Authorized Personnel
Date
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DOC 3532-V (4/2013)
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