Attachment_02_Park_ID_Card_App_5-2018.pdf

United States Park Police Liberty District

Identification Card Application & Background Check Request

Administration Only: APPROVED NOT APPROVED Case Number: Date:

Lieutenant Initial/badge: E-Justice Operator Name: Sequence Number:

Check Appropriate Block: RENEWAL APPLICATION ☐ INITIAL APPLICATION ☐

(1) NAME Last First Middle (2) SOCIAL SECURITY NUMBER

(3) SEX RACE HEIGHT WEIGHT HAIR EYES (4) DISTINGUISHING PHYSICAL CHARACTERISTICS (Scars, Marks, Tattoos, Amputations)

(5) CURRENT RESIDENCE ADDRESS Number & Street City State Zip (6) HOME TELEPHONE

(7) MOBILE TELEPHONE (8) DATE OF BIRTH (9) AGE (10) PLACE OF BIRTH (City, State, Country) (11) ARE YOU A

UNITED STATES

CITIZEN?

YES

NO

(12) DRIVER’S LICENSE NUMBER (13) DRIVER’S LIC. STATE (14) DRIVER’S LIC. EXP. DATE (15) NPS FEDERAL GOVT. EMPLOYEE STATUS (IF APPLICABLE)

☐ PERM ☐ TERM ☐ SEASONAL

(16) FATHER’S NAME Last First Middle (17) MOTHER’S MAIDEN NAME Last First Middle

(18) PREVIOUS RESIDENCE ADDRESS Number & Street City State Zip (19) NICKNAMES &/OR ALIAS (Also Known As)

(20) NAME OF EMPLOYER (21) JOB TITLE

(22) IMMEDIATE SUPERVISOR’S NAME & TITLE (23) IMMEDIATE SUPERVISOR’S TELEPHONE

(24) Do you currently possess an Alien Green Card? Alien Card Number (If Applicable)

YES

NO

(25) Have you ever been placed under arrest or charged with any criminal offense (including those expunged or sealed)?

If your answer is YES, please explain in detail on the reverse side of this form.

YES

NO

(26) Have you ever been dismissed or terminated from any job?

If your answer is YES, please explain in detail on the reverse side of this form.

YES

NO

(27) Have you ever worked for any other employer on Liberty Island, Ellis Island, Battery Park and/or Liberty State Park?

If your answer is YES, please provide the name of the employer, dates of employment and reason for leaving on the reverse side of this form.

YES

NO

(28) Have you ever served in the United States Military? Branch of Service (If Applicable)

YES

NO

(29) Are you presently, or have you ever been a member of any organization which advocates or approves of the commission of acts of force and violence, either to overthrow the Government of the United States or which seeks to deny others rights under the Constitution of the United States? If your answer is YES, please explain in detail on the reverse side of this form.

YES

NO

I certify that all of the information I provided is true, correct, and complete in every particular. I understand that false or fraudulent information on or attached to this form may be grounds for being barred from Federal facilities and may be punishable by fine and/or imprisonment as cited in the United States Code, under Title 18 Section 1001. I understand that any information provided may be investigated and I grant authorization to the United States Park Police to access any criminal history information.

SIGNATURE OF APPLICANT DATE OF APPLICATION

REQUIRED - (2) FORMS OF IDENTIFICATION (must be clear and legible):

Federal/State-Issued Photo ID Card State Driver’s License

Valid Social Security Card Passport

This form is prescribed by the U.S. Park Police District Commander for use by those applying for National Park Service identification cards. Any alteration to this form is expressly forbidden. Type or print clearly in all sections below. For questions that do not apply, please respond “N/A” for “Not Applicable”.

EVERY QUESTION MUST BE COMPLETED OR T

HIS APPLICATION WILL NOT BE PROCESSED

Re vi se d

5/

Please add your explanation(s) for questions 25, 26 and 27 below:

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