Area A Power Attachment E - Mount Weather Access Application.doc

MOUNT WEATHER ACCESS APPLICATION

PLEASE READ THE INSTRUCTIONS AT THE BOTTOM BEFORE COMPLETING THIS FORM.

SECTION A – TO BE COMPLETED BY THE RESPONSIBLE COMPONENT AND OFFICE

1. NAME OF RESPONSIBLE COMPONENT AND OFFICE

2. GOVERNMENT POC (LAST, FIRST, MIDDLE)

3. POC PHONE NUMBER

(AREA CODE)

4. SITE(S) TO BE ACCESSED BY INDIVIDUAL

5. FREQUENCY OF ACCESS REQUIRED (CHECK ONE)

FORMCHECKBOX

DAILY FORMCHECKBOX

WEEKLY FORMCHECKBOX

MONTHLY FORMCHECKBOX

OTHER

6. CONTRACT # (IF APPLICABLE)

7. SIGNATURE OF THE POINT OF CONTACT

8. LENGTH OF ACCESS REQUIREMENT

START DATE END DATE

9. GOVERNMENT INFORMATION SYSTEMS

ACCESS REQUIRED

YES FORMCHECKBOX

NO FORMCHECKBOX

SECTION B – TO BE COMPLETED BY PRIMARY CONTRACTOR (IF APPLICABLE)

1. COMPANY / CONTRACTOR NAME

2. SIGNATURE

3. DATE

SECTION C – TO BE COMPLETED BY APPLICANT

1. FULL NAME (LAST, FIRST, MIDDLE)

2. SOCIAL SECURITY NUMBER

3. DATE OF BIRTH (MONTH/DAY/YEAR)

4. PLACE OF BIRTH (CITY, STATE, COUNTRY)

5. PRESENT ADDRESS (STREET ADDRESS, CITY, STATE, ZIP CODE)

6. WORK TELEPHONE

7. MOBILE TELEPHONE

8. NAME AND ADDRESS OF EMPLOYER (COMPANY)

9. NAME OF SUPERVISOR & PHONE #

10. SEX (CHECK ONE) FORMCHECKBOX

MALE FORMCHECKBOX

FEMALE

11. DRIVERS LICENSE # AND STATE

12. DO YOU HOLD A U.S. CITIZENSHIP STATUS?

FORMCHECKBOX

YES (CHECK ONE) FORMCHECKBOX

NO

13. ARE YOU A NATURALIZED CITIZEN?

FORMCHECKBOX

YES (CHECK ONE) FORMCHECKBOX

NO

14. IF YES, Provide Naturalization Date/Alien #

IF Not a U.S. Citizen, Provide Alien Registration #

THIS RELEASE WHEN PRESENTED BY A DULY AUTHORIZED REPRESENTATIVE OF THE U.S. DEPARTMENT OF HOMELAND SECURITY (DHS) WILL CONSTITUTE MY CONSENT AND AUTHORITY TO EXAMINE AND OBTAIN COPIES AND ABSTRACTS OF RECORDS, AS WELL AS RECEIVE STATEMENTS OF INFORMATION CONCERNING MY BACKGROUND. SPECIFICALLY, I HEREBY AUTHORIZE THE RELEASE OF FEDERAL/STATE/LOCAL POLICE & CRIMINAL RECORDS TO DHS BY APPLYING MY SIGNATURE ON THE DESIGNATED LINE BELOW. THIS AUTHORIZATION IS GIVEN IN CONNECTION WITH THE INVESTIGATIVE PROCEDURES BEING CONDUCTED RELATIVE TO MY CONTRACTUAL SERVICES WITH THE DEPARTMENT OF HOMELAND SECURITY, AND/OR ACCESS TO SECURE AREAS OCCUPIED BY THE DHS COMPONENTS.

PRIVACY ACT STATEMENT: ALL INFORMATION REQUESTED ON THE PERSONNEL ACCESS APPLICATION AND RELEASE STATEMENT IS COLLECTED UNDER AUTHORITY DERIVED FROM 18 USC 3056 AND EXECUTIVE ORDER 9397. THE ROUTINE USES OF INFORMATION REQUESTED INCLUDE REFERRAL TO OTHER FEDERAL, STATE AND LOCAL AGENCIES FOR DETERMINING SUITABILITY FOR ACCESS TO SECURE AREAS, AND/OR SENSITIVE, UNCLASSIFIED MATERIAL OF THE U.S. DEPARTMENT OF HOMELAND SECURITY. SUBMISSION OF THE INFORMATION IS VOLUNTARY, HOWEVER, FAILURE TO PROVIDE INFORMATION REQUESTED MAY PROHIBIT PROCESSING AND CAUSE DENIAL OF ACCESS TO SECURE AREAS OR SENSITIVE MATERIAL PROTECTED BY THE U.S. DEPARTMENT OF HOMELAND SECURITY. DISCLOSURE OF YOUR SOCIAL SECURITY NUMBER IS VOLUNTARY. THE INFORMATION IS USED TO IDENTIFY AND SEPARATE INDIVIDUALS WITH SIMILAR OF IDENTICAL NAMES OR INITIALS. REFUSAL TO DISCLOSE YOUR SOCIAL SECURITY NUMBER WILL BE NO CAUSE FOR DENIAL OF ANY RIGHT, BENEFIT, OR PRIVILEGE PROVIDED BY LAW.

NOTE: I UNDERSTAND THAT ANY FALSE STATEMENT ON ANY PART OF MY APPLICATION MAY BE GROUNDS FOR DENYING ME ACCESS INTO DEPARTMENT OF HOMELAND SECURITY CONTROLLED FACILITIES, AND/OR GROUNDS FOR PROSECUTION UNDER TITLE18 USC 1001.

15. SIGNATURE OF APPLICANT

16. DATE

INSTRUCTIONS

1. Please type or print clearly with a dark ballpoint pen

2. To apply for access into U.S. Department of Homeland Security controlled facilities, all applicants must complete this form in its entirety. (Failure to properly complete this form can result in contractual delays and/or non-admittance into U.S. Department of Homeland Security controlled facilities)

3. Section C must be completed and signed by individual applying for access. Form will then be returned to your Government POC

4. The Government POC must complete Section A, sign and forward form to: Mount Weather Security, 19844 Blue Ridge Mountain Road, Mt. Weather, VA 20135 or FAX 540-542-2608

5. If there are any questions regarding this form, please telephone the office listed above at 540-542-2091 / 540-542-2139

Paperwork Reduction Act Notice. Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. We try to create forms and instructions that are accurate, can be easily understood, and which impose the least possible burden on you to provide us with information. The estimated average time to complete and file this Access Application is 10 minutes per application. If you have comments regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the Office of Records Management, Information Resource Management, Federal Emergency Management Agency, 500 C St. S.W., Washington, D.C., 20472.