Attach 16 - USCP ID Request.pdf

Is applicant a U.S. Citizen? Yes ___ No ___

If no, country of origin: __________________

If no, the Employment Authorization Document must be attached to request form.

Authorizing office certifies E-VERIFY was completed & that a copy is attached.

Initials of authorized COTR: ______

All E-VERIFY documents must be retained by HCMD.

New Contract Employee Renewal, no FP submitted _____

Initial

Authorizing office certifies a criminal background check was completed and the applicant’s suitability for service to the AOC has been established.

Initials of authorized HR personnel: _______

Date Results Report received: ____________

For AOC HCMD use only:

Pickup date: _________

This completed form must be received by ID Services a minimum of TWO business days prior to the individual reporting for a photo. Proper photo identification must be presented before an ID badge will be issued.

A

Do you have a current or recent House, Senate or Capitol Police ID? KelleyDMigdal

April Davis

9 House 9 Senate 9 USCP

Main Contract name ONLY, no subs

PAUL IRVING

SERGEANT AT ARMS

Office of the Sergeant at Arms

U.S. House of Representatives Washington, DC 20515-6634

ARCHITECT OF THE CAPITOL

ID REQUEST - 116th CONGRESS

CONTRACTOR

Please type the requested information:

9 Social Security Number: __ __ __ - __ __ - __ __ __ __ 9 Passport #/Country:______________________________ (Foreign citizens only)

Legal Name _______________________________________________________________________________ Last Name Legal First Name Middle Initial

AOC Jurisdiction: __________________________________ Div. Phone: __________ Div. Fax: ________

Company Name: _____________________________________

AOC Start/Change Date: _____________________ AOC Expiration Date: _________________________ (Date of application OR start date, if in the future) (Month/Day/Year) (Month/Day/Year) Not to exceed 4/30/2021

Employment Status: Contractor Pay Type: Temporary

Hours of Access: 9 24 Hours 9 Business Hours (5 a.m. to 8 p.m.)

7 days/week 7 days/week

The signatures below certify that this information is correct and accurate. The AOC jurisdiction listed is responsible for the proper and timely return of this ID badge upon expiration and/or termination of contract.

ID badge must be returned to: ID Services, 321 Cannon HOB.

Signature of OSP Authorizing Official Name/Signature of Project Manager/Phone # (required for contractors)

_______________________________________ Contract Name: ___________________ Name/Signature of Office Contact Person

Contract No.:_____________________ All entries must be completed and signatures present before this application will be processed. L This form is VOID if altered, and is VOID after 30 days. Illegible forms will delay processing.

I understand that this Congressional ID is the property of the U.S. House of Representatives and that it is an integral instrument of Congressional Security. I cannot authorize another to use, wear, or possess my issued ID badge. I further acknolwledge that I am responsible for the preservation and correct use of the ID issued in my name. I understand that I AM REQUIRED to surrender my ID badge immediately upon expiration and/or termination of employment.

Additionally, it must be surrendered to authorized Sergeant at Arms employees upon their request.

By signing this form, I acknowledge that I have read and understood this statement, and that I will comply with it.

Signature of Card Holder (required)

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THughes Typewritten Text Return to: ID Services, 321 Cannon HOB, Washington D.C. FAX: 5-0239 OUTSIDE LINE: (202)225-0239 Email: idservices.inboundfax@mail.house.gov

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