Contractors Security Clearance Form.pdf

(Lobbyist: $50.00 payable by CHECK / MONEY ORDER OR CREDIT CARD - payable to: "Maryland Capitol Police" - NO CASH ACCEPTED)

Current State Ethics Registration Attached: Yes No (COMAR 19A.07.01.04 Registration with Commission)

MARYLAND CAPITOL POLICE

ID REQUEST FORM

Name(Print): Last: __________________________________ First: _________________________ Middle: ____________________

Date of Birth: _______________________ Race: ___________ Sex: __________ Height: _________ Weight: _________ SSN#: (last four)__________________

Driver's License # ____________________________________ State: ____________ Phone #: (Home/Cell) ____________________________________________

Home Address:________________________________________________________________________________________________________________

Agency / Employer: ___________________________________ Address: _____________________________________________________

Division/Office: ______________________________________________________________ Office Phone #: _________________________

New Damaged Stolen Lost Renewal Transfer

Applicant Signature: _______________________________________________________ Date: _______________________

Disapproved Approved Reviewing Officer's Signature: ________________________________

For Office Use Only:

Agency Pay Check Money Order Amt. _____________

Card #: FRONT ________ ___ BACK____________ Inv. # _____________________________ Document #: _____________________________________

SCPC Signature: _______________________________________________________________________________ Date: ________________________________

State Employee Non Employee Contractor

(Contractors: $15.00 payable by CHECK / MONEY ORDER OR CREDIT CARD - payable to: "Maryland Capitol Police" - NO CASH ACCEPTED)

Company: __________________________________ Address: __________________________________________________________

Company Phone: ___________________________________________ Fax: _______________________________________________

Project #: ________________________________ Building: ________________________________ Task: _________________________

Agency/Sponsor Name/Title: _______________________________________________________________________________________

Agency/Sponsor Signature: ______________________________________________ Phone: __________________________________

Billing Information for agency payment: ___________________________________________________________________

Replacement cost for any category of lost State ID card is $50.00. Replacement cost of 2nd lost card is $100.00. Replacement cost of 3rd lost card is $250.00 Only Checks, money orders, or credit cards will be accepted and should be payable to: "Maryland Capitol Police." CASH WILL NOT BE ACCEPTED. A photo ID, such as a Maryland Driver’s License, Maryland MVA Identification Card, Passport, or Current Military ID card must be shown to process this request.

APPLICANT INFORMATION: ATTACH COPY OF APPLICANT’S DRIVER’S LICENSE – (Make sure photo is clear and light enough to identify the individual)

STATE EMPLOYEE INFORMATION:

LOBBYIST NON-LOBBYIST INFORMATION:

N-Lobbyist

SCPC Signature: _______________________________________________________________________________ Date: ________________________________

MCP Form 2 (02/19)

Is the applicant, under Maryland law, permitted to carry a firearm? Yes No

If Yes, is it required for the applicant’s work-related responsibilities? Yes No Permit #: _____________________

State law, Code of Maryland Regulations, COMAR 04.05.01.03B states: “Except for official purposes and by authorized personnel, an individual on the property may not carry open or concealed firearms, explosives, incendiary devices, or dangerous or deadly weapons.” Under COMAR 04.05.01.01A, “property means State public buildings, improvements, grounds, and multiservice centers under the jurisdiction of the Department of General Services.”

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ID Coordinator: __________________________________________ Signature: ________________________________________________

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Date of Request:__________________

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Name Change

PRINTED FULL NAME ID COORDINATOR MUST SIGN APPLICATION

CONTRACTOR / NON-EMPLOYEE INFORMATION:

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STATE OF MARYLAND

MARYLAND CAPITOL POLICE

AUTHORIZATION OF RELEASE OF INFORMATION

I, __________________________________________________________________________ hereby authorize a review and full disclosure of all criminal records, or any part thereof, concerning myself by/to any duly authorized agent of the Maryland Capitol Police, whether the said records are public or private, and including those which may be deemed to be of privilege or confidential nature. The intention of this authorization is to provide information which will be utilized for investigative resource material.

I agree to indemnify and hold harmless the person to whom this request is presented and his agents and employees, from and against all claims, damages, losses and expenses, including reasonable attorney fees arising out of or complying with this request.

I further understand that in the event my application is disapproved, the sources of confidential information cannot be revealed to me. A photocopy of this release form will be valid as an original hereof, even though the said photocopy does not contain an original writing of my signature.

FIRST MIDDLE LAST RACE SEX DATE OF BIRTH

ADDRESS CITY, STATE ZIP SOCIAL SECURITY NUMBER

APPLICANT SIGNATURE DATE

WITNESS SIGNATURE DATE

MCP Form 2 (02/19)

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