PIVOT Application Form

(NOTE: incomplete applications will automatically be rejected).

Date

Prison

PRN

First name

Last name

Known alias AKA

Date of Birth

Age

Marital Status

Ethnicity

Village/Iwi

Lawyer

Phone

Email contact

Active Charges

How long have you currently been on remand?

When was the last time you were in prison?

Year

Length of sentence

Offence

Gang affiliation: (details)

Patched member: No/ Yes details

Are you on any specific medication: No/Yes details:

Emergency contact name:

Relationship to you:

Emergency Phone number

Check the box and submit your form to confirm the accuracy of the provided information and your willingness to comply with the following terms.

I give permission for Pivot Support Services to do any background checks necessary as part of their vetting to determine whether or not the candidate is a good "fit". This may include but not limited to access to my Summary of Facts, Criminal History.

I have permission from the applicant to fill this form out on his behalf. He and I am aware that I have read and understand the rules/regulations/policies of Pivot including FAQ section of our Website. Our no tolerance drug & alcohol policy means that Pivot employs the services of a third party to undertake onsite random urine/oral drug & alcohol testing. We employ the services of a regular random Drug Dog onsite to sniff inside and around the facility for drugs. Any fees or costs must be settled prior to admission into Pivot Support Services.

I Declare that the information I've provided in this form are true and correct and that I accept ALL Pivot rules and regulations.