Attachment.No.8.Contractor.Security.Form.doc

Attachment 7

JUSTICE PRISONER & ALIEN TRANSPORTATION SYSTEM

CONTRACTOR SECURITY BACKGROUND INFORMATION

ACCESS OF NON-JPATS PERSONNEL TO JPATS FACILITIES

Please type or print and complete all items.

1. Full Name (Last, First, Middle)

1a. Other Names Used (Maiden & Alias)

2. Place of Birth

2a. Date of Birth (Mo/Day/Yr)

3. Sex

4. Race

5. Social Security Number

[ ] Male [ ] Female

6. U.S. Citizenship

[ ] By Birth

[ ] Naturalized

[ ] Other

6a. Location Naturalized

6b. Date Naturalized

7. Company Name & Address

8. Residence (Beginning with current and working backward 7 years)

9. Drivers license number and state of issue:

10. Arrest(s): Have you ever been arrested, taken into custody, held for investigation or questioning, or charged by any law enforcement authority within the last 10 years?

[ ] Yes

[ ] no

10a. If your answer is yes, give details below:

Date

Charge

Police Agency

Disposition

CERTIFICATION

I certify that the statements made by me on this form are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I understand that this information may be used for a records check performed by/for the Justice Prisoner and Alien Transportation System.

Signature

Date

PRIVACY STATEMENT

The primary use of this information is to conduct a background investigation to determine eligibility of the named individual to work/perform services on a Government facility. Furnishing the information on this form for the above stated purpose is voluntary, but failure to do so may result in disapproval of the individual to have access to work/perform services on a Government facility. No additional disclosures of this information may be made for other than the stated purpose.

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