Att 12 FTC-SEM-17 Badge Ap.pdf

1. Applicants Full Name Last First Middle

Aliases Used (nicknames, maiden names, etc.)

2. Residential Address: Street and house number:

Mailing Address (if different):

City, State and Zip Code:

3. Country of Citizenship:

If not a U.S. Citizen by Birth, you must complete and attach required Addendum ( ) Attached FTC-SEM-17 Addendum

4. Race/Ethnicity: 5. Gender: ( ) Male ( ) Female ( ) American Indian or Alaska Native ( ) Hispanic or Latino ( ) Asian ( ) Native Hawaiian or Other Pacific Islander 6. Date of Birth: __________________________ ( ) Black or African American ( ) White Month Day Year

( ) Other: ____________________

8. Driver's License Number: _______________________________ State: ______________

9. Have you been ARRESTED for any misdemeanor or felony offenses in the last seven (7) years? ( ) YES ( ) NO

If yes, please explain: __________________________________________________________________________

10. Type of Badge Requested:

( ) New Badge - never before issued for this applicant ( ) Reissue for expired badge ( ) New employment; applicant has held badge previously at FLETC ( ) Reissue for lost badge (Fee paid, receipt attached)

Applicant's Signature: Date:

Home or cell phone number: Email:

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

12. Employer Information 13. Contract Information:

Prime Contractor: ____________________________ Contract/PO Number:________________________ Subcontractor: ______________________________ Contract End Date: __________________________ Applicant Position/Title: ______________________ Contract Description: _______________________

14. Applicant Work Schedule: 15. Applicant Start and End Dates:

( ) Full Time Applicant to begin work on: _________________________________ ( ) Part Time ( ) Temporary/Intermittent Applicant to end work on: __________________________________

Contractor's Printed Name: ______________________________________Office/Cell Number: ___________________

Contractor's Signature: Date:

7. Social Security Number: _______________________

11. I certify that 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.

16. I certify that 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.

List more than one if applicable.

Federal Law Enforcement Training Center

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

Badge Application Form

FTC-SEM-17 (revised Jan 10) Replaces FTC-SEM-17 and FTC-SEM-17a, Sept 08, which is obsolete.

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Continued (Page 2) SECTION C - To be completed by Sponsor (Must be a Federal Employee)

17. Sponsor Information:

Name: ______________________________________ Agency: ______________________

(Last) (First) Office/Cell Number: __________________________________

18. Type of Access Requested: 19. Background Investigation Requirement Code:

( ) Contractor ( ) 1N Staff/Contractors with no access to PII ( ) FLETC Government Staff Member ( ) 5N Staff/Contractors with access to PII (Work assignment must be FLETC Location) ( ) 5C IT Staff/Contractors with Administrator Privileges ( ) Partner Organization Government Staff Member ( ) 3C IT Staff with Top Secret Clearance (Work Assignment must be FLETC Location) ( ) 3N Security Staff with Top Secret Clearance ( ) Visitor ( ) Vendor ( ) Retired Staff ( ) Name check and fingerprint check

20. Dates Requested:

Requested Start Date: Requested Expiration Date:

Sponsor Signature: Date:

SECTION D - To be completed by FLETC Personnel Security Registrar

22. Type of Badge to be Issued:

( ) FLETC Staff Card Approved Start Date: _______________________________ ( ) FLETC Partner Organization Staff Card ( ) Contractor Approved Expiration Date: ___________________________ ( ) Visitor ( ) Vendor ( ) PIV ( ) FLETC Staff Card - Retired Fingerprinting Required: ( ) YES ( ) NO

Security Registrar's Name: _________________________________

Security Registrar's Signature: ______________________________ Date:

SECTION E - To be completed by Security Personnel Issuing Badge

23. Identification Provided by Applicant: *

(a) Type: _______________________________ (b) Type: ______________________________________

Number: _____________________________ Number: ____________________________________

Expiration: ____________________________ Expiration: ___________________________________

24. Fingerprints submitted to OPM: __________________

Badge Issued by ____________________________________________________ Date: _______________________ (Printed Name) (Signature)

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 with one acceptable identification for (a) above: 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).

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.

(DATE)

*Acceptable forms of identification include:

FTC-SEM-17 (revised Jan 10) Replaces FTC-SEM-17 and FTC-SEM-17a, Sept 08, which is obsolete.

For Official Use Only

Federal Law Enforcement Training Center Badge Application Form

Addendum for Non-U.S. Citizens, Legal Permanent Residents and Naturalized U.S. Citizens

TO BE COMPLETED BY APPLICANT

1. Applicant's 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 and Country)

3. Status:

( ) U.S. Citizen (Naturalized)

( ) Permanent Resident A# _________________________________

( ) Non-Immigrant Status I-94# _______________________________

( ) Employment Authorization Card Holder A# _____________________________

( ) Border Crossing Card Holder # _____________________________

( ) Other Status: __________________________________________

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

Attached: ( ) Copy of Passport __________ ____________ ___________ If no passport exists, insert "None" in provided space. Country of Issue Passport Number Expiration Date

If no Visa exists, insert "None" in provided space.

( ) Copy of U.S. Visa __________ _____________ _____________ Visa Number Visa Type Expiration Date

( ) Copy of Permanent Resident/Resident Alien Card

( ) Copy of Employment Authorization Card

( ) Border Crossing Card

( ) Other document verifying non-immigrant status

5. I certify that 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: ______________

FTC-SEM-17 (revised Jan 10) Replaces FTC-SEM-17 and FTC-SEM-17a, Sept 08, which is obsolete.

For Official Use Only

FTC-SEM-17