J-_6_Person_Model_Information_Sheet.docx

Person Model Information Sheet (Last updated 1/5/18)

Full Name (as it appears on your ID): First ______________Middle:______________ Last: __________________ Date of Birth: _____________________ (mm/dd/yyyy) Birthplace Country: ________________________ Birthplace State: __________________________ Birthplace City: ___________________________ Social Security Number: ______________________________________________________________ Country of Citizenship: _______________________________________________________________ Home Address: _____________________________________________________________________ Telephone number: ____________________________________ Mobile_____ Home_____ Work_____ Work/personal email:__________________________________________ Non-Forest Service employee type:

Contractor______ Volunteer ______ Affiliate______ Fellow_______ Intern_______ Work Address: ______________________________________________________________________ Government Point of Contact: __________________________________________________________ Previous Federal Employee: Yes _____ No_____ Preferred Credentialing Center (if known): _________________________________________________

THIS SECTION MUST BE COMPLETED

Contract Company Name: _____________________________________________________________ Contractor Address: ____________________________________, City: __________________________ State: ________________________, Zip: _________________________ Dun & Bradstreet (DUNS) Number______________________________________________________ Contact Name: _______________________________________________________________________ Contact Phone Number: _______________________________________________________________ Contract/Agreement Number(s):_____________________________, ___________________________ When this form is completed it must be delivered to Chris Hansen at the Utah Acquisition Support Center (UASC). The form can be delivered in person to UASC, 1749 West 500 South, Salt Lake City, UT 84104, OR it ca be faxed to 801.908.1930. Please notify Chris via email (chansen01@fs.fed.us) if you fax your form.