Attachment A "Vendor Acknowledgement Statement Form" - Georgia (United States)

What Is Attachment A?

This is a legal form that was released by the Georgia Department of Juvenile Justice - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2012;
  • The latest edition provided by the Georgia Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Attachment A by clicking the link below or browse more documents and templates provided by the Georgia Department of Juvenile Justice.

ADVERTISEMENT
ADVERTISEMENT

Download Attachment A "Vendor Acknowledgement Statement Form" - Georgia (United States)

Download PDF

Fill PDF online

Rate (4.8 / 5) 28 votes
Vendor Acknowledgement Statement
Project:______________________________
Project Begin Date: ___________________ Project End Date: ____________________
I understand that I may not possess any weapon or any object that can be made into a weapon, knife,
alcoholic beverage, drug, sexually explicit or obscene material, or any other forbidden items while on
DJJ property.
I understand that the Director of the facility must approve for me to bring a cell phone needed to provide my
service(s) into the facility. I understand that I will not be allowed to photograph any youth or any facility
operations if approved to bring a cell phone into the facility.
I agree that I will not give any of the above items to any youth at the DJJ facility, nor any other
contraband, including but not limited to, cigarettes or other tobacco products, matches, lighters or
money.
PERSONAL DEALINGS WITH YOUTH:
By state law, all information about the youth at this facility, including their identities, is considered confidential
and privileged information. I understand that I must keep any information I may learn about the youth at
this facility confidential.
PROHIBITED ACTIVITIES include, but are not limited to:
Giving tobacco, alcohol or illegal drugs to youth
Giving any item to a youth or accepting any item from a youth
Receiving gifts or favors from youth or their relatives, friends, or acquaintances
Gambling, buying, selling, trading, borrowing, giving or lending goods or money with youth
Using relationships or information obtained on current or former youth to take unfair advantage of the
youth or their relatives, friends, or acquaintances
Engaging in romantic, intimate or sexual relationships, sexual contact or sexual conversation with youth,
or otherwise taking sexual advantage of youth
Moving within the facility without an escort
TOOLS:
No youth will be permitted to access any type of vendor tools.
You must have an inventory of all of the tools entering the facility.
You must take all of your tools and other materials with you when you leave.
The work area must be left as it was found. No trash, nails, wood, screws, etc. can be left behind.
EMERGENCIES:
If you have an emergency while at the facility, please let the nearest security officer know.
If there is a facility emergency while you are here, please follow the instructions of the security officers.
I understand that if I violate any of the above prohibitions or any other rules of the facility that I will be denied
future visits to the facility and may be referred for prosecution, which could result in my imprisonment for 1 to 5
years.
Have you ever been convicted of a crime involving the physical or sexual abuse of a child?
YES
NO
_____________
Vendor’s Printed Name
Signature
Date
_____________
Witness’s Printed Name
Signature
Date
Vendor’s identity verified with picture identification.
Rev. 2/12
Vendor Acknowledgement Statement
Project:______________________________
Project Begin Date: ___________________ Project End Date: ____________________
I understand that I may not possess any weapon or any object that can be made into a weapon, knife,
alcoholic beverage, drug, sexually explicit or obscene material, or any other forbidden items while on
DJJ property.
I understand that the Director of the facility must approve for me to bring a cell phone needed to provide my
service(s) into the facility. I understand that I will not be allowed to photograph any youth or any facility
operations if approved to bring a cell phone into the facility.
I agree that I will not give any of the above items to any youth at the DJJ facility, nor any other
contraband, including but not limited to, cigarettes or other tobacco products, matches, lighters or
money.
PERSONAL DEALINGS WITH YOUTH:
By state law, all information about the youth at this facility, including their identities, is considered confidential
and privileged information. I understand that I must keep any information I may learn about the youth at
this facility confidential.
PROHIBITED ACTIVITIES include, but are not limited to:
Giving tobacco, alcohol or illegal drugs to youth
Giving any item to a youth or accepting any item from a youth
Receiving gifts or favors from youth or their relatives, friends, or acquaintances
Gambling, buying, selling, trading, borrowing, giving or lending goods or money with youth
Using relationships or information obtained on current or former youth to take unfair advantage of the
youth or their relatives, friends, or acquaintances
Engaging in romantic, intimate or sexual relationships, sexual contact or sexual conversation with youth,
or otherwise taking sexual advantage of youth
Moving within the facility without an escort
TOOLS:
No youth will be permitted to access any type of vendor tools.
You must have an inventory of all of the tools entering the facility.
You must take all of your tools and other materials with you when you leave.
The work area must be left as it was found. No trash, nails, wood, screws, etc. can be left behind.
EMERGENCIES:
If you have an emergency while at the facility, please let the nearest security officer know.
If there is a facility emergency while you are here, please follow the instructions of the security officers.
I understand that if I violate any of the above prohibitions or any other rules of the facility that I will be denied
future visits to the facility and may be referred for prosecution, which could result in my imprisonment for 1 to 5
years.
Have you ever been convicted of a crime involving the physical or sexual abuse of a child?
YES
NO
_____________
Vendor’s Printed Name
Signature
Date
_____________
Witness’s Printed Name
Signature
Date
Vendor’s identity verified with picture identification.
Rev. 2/12