SOP_NUMBER: 205.09-att-2
TITLE: GCIC-NCIC Consent Form and Contractor/Vendor Information
REFERENCE_CODE: IIA07-0011
DIVISION: Facilities
TOPIC_AREA: Personnel/Standards/Training
EFFECTIVE_DATE: 2024-10-31
WORD_COUNT: 588
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/106036
URL: https://gps.press/sop-data/205.09-att-2/

SUMMARY:
This form is a consent and information document that contractors and vendors working in Georgia Department of Corrections facilities must complete and sign. It authorizes the Office of Professional Standards to conduct background investigations and obtain records related to the contractor's criminal history, driver's history, employment records, and associations with offenders. The form also collects personal contact information, social media accounts, and requires disclosure of any relatives or associates who are incarcerated, on probation/parole, or with whom the contractor has communicated.

KEY_TOPICS: Contractor consent, background investigation, GCIC-NCIC, vendor screening, criminal history disclosure, offender association, personal history investigation, suitability determination, information release authorization, pre-employment records

ATTACHMENTS:
  1. Guidelines for Civilian Construction Workers, Consultants, and Contract Personnel - Acknowledgment Statement
     URL: https://gps.press/sop-data/205.09-att-1/
  2. GCIC-NCIC Consent Form and Contractor/Vendor Information
     URL: https://gps.press/sop-data/205.09-att-2/
  3. Red Photo Identification Card
     URL: https://gps.press/sop-data/205.09-att-3/

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FULL TEXT:
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SOP 205.09
Attachment 2

10/31/2024


Notary


RETENTION SCHEDULE:


Once signed by the contractor/consultant, this form shall be attached to the contract.


**AUTHORAZTION FOR RELEASE OF INFORMATION**


I do hereby authorize a review and full disclosure of all records concerning myself to any duly
authorized agent of the Office of Professional Standards, whether such records are of a public,
private, or confidential nature.


The intent of this authorization is to give my ongoing consent for full and complete disclosure of
all records of my driver's history, criminal history, association with offenders, employment and
pre-employment records, and records of local, state, and federal criminal justice agencies.


I understand that any information obtained by a personal history background investigation,
which is developed directly or indirectly, in whole or in part, upon this release authorization, will
be used in determining my suitability and continuing suitability as a contractor working in a
Georgia Department of Corrections facility. I authorize the disclosure of the aforementioned
personal information to any person(s) deemed by the Office of Professional Standards within
the Georgia Department of Corrections to be a participant in the determination process of
contractor suitability. I also certify that any person(s) who may furnish such information
concerning me shall not be held accountable for giving this information; and I do hereby release
said person(s) from any and all liability which may be incurred as a result of furnishing such
information.


A photocopy of this release form will be as valid as the original form, even though the photocopy
does not contain my original signature.


I have read and fully understand the contents of this Authorization for Release of Personal
Information Document.


**Full Name Printed** **Street Address**


**City/State** **Zip Code**


**Signature** **Date**


BRIAN P. KEMP

_GOVERNOR_


# **GEORGIA DEPARTMENT OF CORRECTIONS**

300 PATROL ROAD | FORSYTH, GA | 31029


**CONTRACTOR/VENDOR**

**INFORMATION**



_TYRONE OLIVER_

_COMMISSIONER_



As a part of the contract with the Georgia Department of Corrections you are required to accurately
complete the information below.


_Last Name, First Name_ _Date_ _Facility_


**Personal Contact Number:** **Home/Alternate Number** :


**Address:** **,**
_Street_ _City_ _State_ _Zip Code_


**Personal Email Address:**


**SOCIAL MEDIA ACCOUNTS**


List all Social Media Accounts that you possess below.


**FACEBOOK** `☐` **YES** ☐ **NO**
_Username as it appears_ **URL**


**INSTAGRAM** ☐ **YES** ☐ **NO**
_Username as it appears_ **URL**


**TWITTER** ☐ **YES** ☐ **NO**
_Username as it appears_ **URL**


# **GEORGIA DEPARTMENT OF CORRECTIONS**

300 PATROL ROAD | FORSYTH, GA | 31029


BRIAN P. KEMP

_GOVERNOR_ **CONTRACTOR/VENDOR**

**INFORMATION**



_TYRONE OLIVER_

_COMMISSIONER_



Do you have any relatives/associates currently on Probation/Parole or in Prison? `☐` **YES** ☐ **NO**
Do any Probationers or Parolees reside in any residence where you reside? `☐` **YES** ☐ **NO**
Do you or have you had any communication _(phone, email, visitation)_ with **ANY** offender? ☐ **YES** ☐ **NO**


**“Offender”** refers to ANYONE who has been convicted of a felony, housed in **ANY** prison in Georgia or
any other state, or currently in Prison or on Probation/Parole.


If you checked **YES** to any of the above questions, complete the information below regarding your
relationship and communication with offenders.










|OFFENDER<br>FIRST/LAST<br>NAME|RELATIONSHIP|FACILITY HOUSED OR<br>PROBATION/PAROLE|DATE LAST<br>COMMUNICATED<br>OR VISITED|LISTED AS<br>CONTACT<br>FOR<br>OFFENDER?<br>Yes or No|
|---|---|---|---|---|
||||||
||||||
||||||
||||||
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**ATTESTATION**


**I** **attest that the above information is true and accurate. By signing**
_(Print Name)_
**this form below, I** **understand that authorization to work in a facility**
_(Print Name)_
**of the Georgia Department of Corrections can be withheld due to false information being reported.**


If you attest that all information has been reported accurately, print and sign below.


_Print First/Last Name_ _Applicant Signature_ _Date_


_Witness (Human Resources) First/Last_ _Witness Signature_ _Date_