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Security Clearance Form - Superior Court Of California, County Of Los Angeles - 2009

Superior Court of California, County of Los Angeles

(Alternative Dispute Resolution/ADR)

SECURITY CLEARANCE

Please note that full and complete responses to all questions are required and will

be carefully evaluated and verified. A completed Security Clearance form must have the

following information:

All identifying information (i.e. name, date of birth, social security number,

driver’s license number or CA ID and expiration date);

A response to every question is mandatory;

Signature and date

First Name: ________________________ Last Name: ______________________

Phone

Number: ________________ address (if any): ______________________________

Program Name: ______________________________________________________

Program Coordinator/Contact name: ______________________________________

Please complete and mail the original form to the address listed below:

Los Angeles Superior Court

Alternative Dispute Resolution

111 N. Hill St., Room 113

Los Angeles, CA 90012

Attn: Volunteer/Internship Programs

As part of the security background you will be required to be finger printed (Live Scan) by

the Los Angeles Superior Court. Fingerprints are sent to State and Federal agencies for a

check of criminal record history. Any false statement or omission of a material fact on

this form will cause forfeiture of all rights to employment, participation as volunteer, intern,

an extern or as a contractor with the Superior Court of California, County of Los Angeles.

Security Clearance (Revised October 2009)

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Security Clearance Form - Superior Court Of California, County Of Los Angeles - 2009