Attachment 12a - FTC OSPR 17 - Badge Application form for Contractors.pdf

Badge Application Addendum for Non-U.S. Citizens, Lawful Permanent Residents and Naturalized U.S. Citizens

Information provided by those completing this form may be used to conduct background checks on the applicant in accordance with FLETC Directive 71-01, Access Control. Privacy Act Statement: This information is provided in accordance with the Privacy Act of 1974 (5 USC 552a). Authority for this information is 5 USC 301, 5 USC 4101 et seq., Executive Order No. 11348, and Department of Homeland Security Delegation 7050. Disclosure of this information is voluntary.

Failure to provide requested information may result in denial of access to the FLETC property.

TO BE COMPLETED BY APPLICANT

1. Applicants Full Name:

(Last, First, Middle)

Aliases Used (nicknames, maiden names, etc):

2.Country of Citizenship:

(List more than one if applicable)

Place of Birth:

(City, State and/or Country)

3. Status:

US Citizen (Naturalized)

Permanent Resident Provide A#

Non-Immigrant Status Provide I-94#

Employment Authorization Card Holder Provide A#

Border Crossing Card Holder Provide Card#

Other Status Indicate:

4. Non-US Citizens must provide copies of documentation related to their status in the US, including employment authorization, passport and visa.

ATTACHED:

if no Passport or Visa exists, insert "None" in provided space

Copy of Passport

Country of Issue: Passport Number:

Date:

Copy of Visa

Visa Number: Visa Type: Date:

Copy of Naturalization Certificate

Copy of Permanent Resident/Alien Card

Copy of Employment Authorization Card

Border Crossing Card

Other document verifying non-immigrant status

5. I certify the information provided is true and accurate to the best of my knowledge. I acknowledge that knowingly or willingly falsifying information in the document is a violation of 18 US Code Section 1001.

Applicant's Signature: Date:

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