"Collect Background Report for Vendors/Contractors" - Connecticut

Collect Background Report for Vendors/Contractors is a legal document that was released by the Connecticut State Department of Correction - a government authority operating within Connecticut.

Form Details:

  • Released on April 21, 2016;
  • The latest edition currently provided by the Connecticut State Department of Correction;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Correction.

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Download "Collect Background Report for Vendors/Contractors" - Connecticut

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COLLECT BACKGROUND REPORT
Fax to Attention Tracie Gadrow 860-920-3081 – OR-
FOR VENDORS/CONTRACTORS
Email scanned forms to DOC.Collect1@ct.gov
NAME ________________________________________________________ D.O.B. ______________________
(LAST)
(FIRST)
(MI)
(MM/DD/YYYY)
MAIDEN NAME ____________________________________________ SSN ___________________________
HGT. ________ WGT. __________ RACE ____ SEX ____
EYES ___________HAIR ______________
SCARS TATTOOS ___________________________________ VENDOR:_____________________________
DRIVER’S LICENSE # __________________________________________
STATE __________________
CO. CONTACT EMAIL:________________________________________________PHONE: _____________
POSITIVE
NO PRIOR
OFFICIAL USE ONLY – DO NOT COMPLETE:
RESPONSE
CONVICTIONS
FL02 DRIVER INFO ____________
FLQW CT VEHICLE/WANTED INQ.
SPRC CT MASTER FILE
SPSC CT SUSPENSE FILE
OBTS OFF. BASED TRACKING CHECK
FLQH INTERSTATE III CHECK
RT45SS DOC SS CHECK
RT45NM DOC NAME CHECK
FLIQ OUT OF STATE CHECKS
RI
NY
MA
______
CHECK COMPLETED BY _______________________________________________DATE ____________
Comments/Findings:
OFFICIAL USE ONLY:
Arrest
Arresting Agency/Docket
Charge:
Level:
Date
Court Disposition:
Date:
Number:
Misd. or Fel.
Disposed:
*Please note: this form will not be processed if incomplete or illegible*
*Please read and sign below in the presence of a witness*
ACKNOWLEDGEMENT
I, the undersigned, acknowledge and understand that the Connecticut Department of Correction (CTDOC) can deny
any individual entry to any correctional facility administered by the CTDOC at any time.
Signature of Applicant _________________________________________
Date Signed ____________________________________
Signature of Witness __________________________________________
Date Signed _____________________________________
Revised 04/21/2016
COLLECT BACKGROUND REPORT
Fax to Attention Tracie Gadrow 860-920-3081 – OR-
FOR VENDORS/CONTRACTORS
Email scanned forms to DOC.Collect1@ct.gov
NAME ________________________________________________________ D.O.B. ______________________
(LAST)
(FIRST)
(MI)
(MM/DD/YYYY)
MAIDEN NAME ____________________________________________ SSN ___________________________
HGT. ________ WGT. __________ RACE ____ SEX ____
EYES ___________HAIR ______________
SCARS TATTOOS ___________________________________ VENDOR:_____________________________
DRIVER’S LICENSE # __________________________________________
STATE __________________
CO. CONTACT EMAIL:________________________________________________PHONE: _____________
POSITIVE
NO PRIOR
OFFICIAL USE ONLY – DO NOT COMPLETE:
RESPONSE
CONVICTIONS
FL02 DRIVER INFO ____________
FLQW CT VEHICLE/WANTED INQ.
SPRC CT MASTER FILE
SPSC CT SUSPENSE FILE
OBTS OFF. BASED TRACKING CHECK
FLQH INTERSTATE III CHECK
RT45SS DOC SS CHECK
RT45NM DOC NAME CHECK
FLIQ OUT OF STATE CHECKS
RI
NY
MA
______
CHECK COMPLETED BY _______________________________________________DATE ____________
Comments/Findings:
OFFICIAL USE ONLY:
Arrest
Arresting Agency/Docket
Charge:
Level:
Date
Court Disposition:
Date:
Number:
Misd. or Fel.
Disposed:
*Please note: this form will not be processed if incomplete or illegible*
*Please read and sign below in the presence of a witness*
ACKNOWLEDGEMENT
I, the undersigned, acknowledge and understand that the Connecticut Department of Correction (CTDOC) can deny
any individual entry to any correctional facility administered by the CTDOC at any time.
Signature of Applicant _________________________________________
Date Signed ____________________________________
Signature of Witness __________________________________________
Date Signed _____________________________________
Revised 04/21/2016