Attachment 8 FTC-OSPR-17 Badge Application Form.pdf

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

BADGE APPLICATION

PRINT ALL ANSWERS UNLESS SIGNATURE REQUESTED

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.

SECTION A - To be completed by Applicant

1. Applicants Full Name:

(Last, First, Middle)

Aliases Used (nicknames, maiden names, etc):

2. Residential Address: Street Address:

City, State, Zip code:

3. Driver's License: State Driver's License #:

4. Country of Citizenship (List all that apply):

If not a U.S. Citizen by Birth, you must complete and attach required Addendum.

Place of Birth (City and State):

5. Race/Ethnicity: American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White Other

6. Gender:

Male Female 7. Date of Birth: 8. Social Security #:

9. Have you been ARRESTED (Including dismissed charges) in the last seven (7) years? Yes No

If YES, please explain:

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

Applicant Signature: Home or cell phone number:

Date: E-mail

SECTION B - To be Completed by Contractor or Contractor's Representative if Applicant is Contractor Employee

1. Employer Information:

Prime Contractor: Contract Number:

Subcontractor: Applicant Job Title:

2. Applicant Work Schedule: Full Time Part Time Temporary/Intermittent

3. Applicant Work Start Date: Work End Date:

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

Signature: Printed Name:

Date: Office/Cell Number:

SECTION C - To be Completed by Sponsor (Must be a Federal Employee)

1. Sponsor Name: Agency:

E-mail Address: Office/Cell Number:

2. Type of access requested for Applicant:

(Staff work assignment must be FLETC location)

Contractor Vendor Child Care Credit Union Visitor FLETC Retired Staff

FLETC Staff PO Staff PO Contractor PO Retired Staff (Must be sponsored by PO Agency)

3. Relationship to Applicant (if a visitor):

4. Network access required Yes No

5. I certify the information provided is true and accurate to the best of my knowledge. If I am not a FLETC employee, I certify my agency has conducted the required background checks or investigations on any individual I am sponsoring. I acknowledge that knowingly or willfully falsifying information in the document is a violation of 18 US Code Section 1001.

Signature: Date:

FTC-OSPR-17 (8/17) Page 1 of 2

SECTION D - To be completed by FLETC Personnel Security

1. Background Investigation Requirement Code:

1N Staff/Contractors with no access to PII

5N Staff/Contractors with access to PII

5C IT Staff/Contractors with Administrator Privileges

3C IT Staff with Top Secret Clearance

3N Security Staff with Top Secret Clearance

NCIC Name Check

FINGERPRINTS REQUIRED

2. Types of Badge to be Issued:

PIV Badge Initiate E-QIP

Contractor

Visitor

Vendor

Retired Staff

PO Staff

FLETC Staff

Approved Start Date: Approved Expiration Date:

OSPR Name: OSPR Signature:

Date:

NOTES:

SECTION E - To be completed by Security Personnel Issuing Badge

1. Identification Provided by Applicant:

(a) Type:

Number:

Expiration:

(b) Type:

Number:

Expiration:

2. Date Fingerprints Submitted to OPM:

Badge Issued By:

Print Name:

Signature:

Date:

FTC-OSPR-17 (8/17) Page 2 of 2