Exhibit 8 - FTC-SEM-017a Badge Application.pdf

FTC-SEM-017a - front (revised 9/08) NOTE: Previous versions of this form are no longer acceptable

FOR OFFICIAL USE ONLY

Federal Law Enforcement Training Center Badge Application Form for Contractors

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 Number 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. Applicant’s Full Name: _____________________________________________________________________________________________________________ Last First Middle Aliases Used (Nick names, maiden names, etc.): _______________________________________________________________________

2. Residential Address: Street and House Number: ___________________________________________________________________

City, State and Zip Code: ___________________________________________________________________

3. Country/Countries of Citizenship: ______________________________________________________________________________ List more than one if applicable If U.S. citizen through acquisition, derivation or naturalization, provide certificate number: _______________________________

4. Place of Birth:

U.S. City and State:

OR

Foreign Country (City and Country):

5. Gender: Male Female 6. Birth Date: ____________________ Month Day Year

7. Social Security Number: ________-______-__________

8. Driver’s License: ________________ _________________________________ State/Country Number

9. If born outside the United States and its outlying possessions, please identify status:

U.S. Citizen U.S. Citizen (naturalized)

National of the U.S. (including Indian, Eskimo and Aleutian) Permanent Resident. A#: _________________________

Employment Authorization Card Holder. A#: _________________ Border Crosser Card Holder. #: ____________________

Non-immigrant status: I-94 #: ______________________________ Other status: ___________________________________

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

Attached: Copy of Passport ____________ _____________________ _________________ Country of Issue Passport Number Expiration Date

Copy of U.S. Visa ________________________ _______ _________________ Visa Number Visa Type Expiration Date

Copy of Permanent Resident/Resident Alien Card Copy of Employment Authorization Card

Border Crosser Card Other document verifying non-immigrant status

11. Race/Ethnicity: (Check one or more boxes.)

American Indian or Alaska Native Hispanic or Latino Asian

Native Hawaiian or Other Pacific Islander Black or African American White Other __________________

12. Have you been arrested for any misdemeanor or felony offenses in the last 7 years? Yes No

If yes, please explain: ___________________________________________________________________________________________

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

Applicant’s Signature: ___________________________________________________________________ Date: ___________________

Applicant’s Printed or Typed Name: ____________________________ Office Phone: ______________ Cell Phone: _____________

Cannot be a post office box address. For rural or star route address, provide directions to residence on a separate sheet and attach.

If no passport exists, insert “None” in provided space.

If no visa exists, insert “None” in provided space.

mbcorpus Typewritten Text

SECTION J - EXHIBIT 8

FTC-SEM-017a – back (revised 9/08) Previous versions of this form are no longer acceptable

FOR OFFICIAL USE ONLY

Federal Law Enforcement Training Center Badge Application Form for Contractors – continued (page 2)

SECTION B – To be completed by Contractor or Contractor’s Representative

14. Employer Information: (Prime or subcontractor may complete)

Prime Contractor: ____________________________________________ Subcontractor: _______________________________________________ Applicant Position/Title: _______________________________________

15. Contract Information:

Contract/Purchase Order Number: _____________________ Contract End Date: _________________________________ Contract for: ______________________________________

16. Applicant Work Schedule:

Full time Regularly Scheduled Work Term of Employment less than 6 months Other: ___________________________ Part time Intermittently Scheduled Work Term of Employment 6 months or more

17. Applicant Start and End Dates:

Applicant to begin working as soon as application approved. Applicant to begin work on: ________________________

Applicant to end work on: ____________________________ Applicant to continue working without specific end date.

18: Type of Badge Requested:

New badge– never before issued for this applicant Reissue for expired badge New employment; applicant has held badge previously at a FLETC Reissue for lost badge (fee paid; receipt attached.)

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

Contractor’s Signature: _____________________________________________________________________ Date: _______________

Contractor’s Printed or Typed Name: ___________________________ Office Phone: _____________ Cell Phone: _____________ SECTION C – To be completed by Federal Employee Sponsor (Contracting Officer or Contractor Officer’s Technical Representative)

19. Type of Badge Requested:

Contractor PIV (IT) – Moderate Risk (5C) Contractor PIV (Non-IT) – Moderate Risk (5N) Contractor - Less than 6 months Access

Contractor PIV (IT) – Low Risk (1C) Contractor PIV (Non-IT) – Low Risk (1N) Contractor - Intermittent Access Note: Contractor PIV (IT) refers to contractors who work on IT systems. Contractor PIV (Non-IT) refers to contractors who may or may not have access to the FLETC network.

20. Dates Requested: Requested Start Date: _________________ Requested Expiration Date: ___________________

21. I certify that the information provided is true and accurate to the best of my knowledge. If I am not a FLETC employee, I certify that 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.

Sponsor Signature: _____________________________________________________________________ Date: ___________________ Sponsor’s Printed or Typed Name: _____________________________ Office Phone: ______________ Cell Phone: _____________ SECTION D – To be completed by FLETC Personnel Security Registrar

22. Type of Badge to be Issued: Contractor PIV Contractor TI Contractor FV Approved Start Date: _________________ Approved Expiration Date: ___________________

Security Specialist Signature: __________________________________________________________________ Date: _____________ Security Specialist’s Printed or Typed Name: _______________________________________________ Phone: __________________ SECTION E – To be completed by Security Personnel Issuing Badge

23. Identification Proof Provided by Applicant:

Acceptable forms of identification include: For (a) or (b): U.S. Passport (unexpired or expired); Unexpired foreign passport with I-551 stamp or attached Form I-94 indicating unexpired employment authorization; Permanent Resident Card or Alien Registration Receipt Card with photograph (Form I-551); Unexpired Temporary Resident Card (Form I-688A); Unexpired Employment Authorization Document issued by DHS that contains a photo (Form I-688B); Driver’s License or ID card issued by state or outlying possession of the U.S. provided it contains a photograph; ID card issued by federal, state or local government agencies or entities, provided it contains a photograph; or Military Dependent’s ID Card.

For (b) only: U.S. Social Security Card issued by the Social Security Administration (must not be marked invalid for employment and must not be laminated); Certificate of Birth Abroad issued by Department of State (Form FS-545 or Form DS-1350); Original or certified copy of a Birth Certificate issued by a state, county, municipal authority or outlying possession of the U.S. bearing an official seal; U.S. Citizen ID Card (Form I-197); or ID Card for Use of Resident Citizen in the U.S. (Form I-179).

(a) Type: _____________________________________________ Number: __________________________________________ Expiration: ________________________________________

(b) Type: _____________________________________________ Number: __________________________________________ Expiration: ________________________________________

Badge Issued by (Signature): _____________________________ Phone: ____________________ Date: _____________ mbcorpus Typewritten Text

SECTION J - EXHIBIT 8