Community, Counseling, And Correctional Services, Inc. Start Program Visitor Application Form

Community, Counseling, And Correctional Services, Inc. Start Program Visitor Application Form - State Of Montana Page 3

COUMMUNITY, COUNSELING & CORRECTIONAL INC.

START PROGRAM

AUTHORIZATION TO CONDUCT AN N.C.I.C. RECORDS CHECK

(NATIONAL CRIME INFORMATION CENTER)

I hereby authorize the Identification Bureau of the Department of Justice, State of Montana, to run an

N.C.I.C. records check on my background and also authorize the release of the results of said records

check to the staff of Community, Counseling & Correctional Services, Incorporated.

I further wish to freely waive my right to any federal or state statutes protecting privileged information and

authorize disclosure of said information to CCCS, Inc.

I also understand that it is the policy of Community, Counseling, & Correctional Services, Inc. to run

background checks on all prospective visitors/sponsors for any of the residents within those community-

based correctional facilities operated by C.C.C.S., Inc. I also understand that the records check must be

completed before any consideration will be given to my request to act in the capacity as an approved

community visitor/sponsor.

Dated this __________day of __________________________, 20

Applicant’s complete & full legal name (printed)_______________________________

Applicant’s complete & full signature_____________________________________

Applicant’s Social Security Number -_______-_____-_________________

Applicant’s Date of Birth________________________________

CCCS, Inc. Staff Signature &Title___________________________________

Revised 10-07-05

Page 3 of 4

Revised 6/05 GS

Community, Counseling, And Correctional Services, Inc. Start Program Visitor Application Form - State Of Montana Page 3