SOW_Exhibit_15.pdf

Exhibit 15

DEPARTMENT OF HOMELAND SECURITY

FEDERAL EMERGENCY RESPONSE OFFICIAL DESIGNATION REQUEST

FOR FEDERAL EMERGENCY RESPONSE OFFICIAL

SECTION I - PERSONAL INFORMATION (Completed by Individual)

FIRST NAME MIDDLE NAME LAST NAME

DATE OF BIRTH SEX HOME ADDRESS

ADDRESS 2 CITY STATE

ZIP HOME PHONE COMPONENT NAME

WORK PHONE NUMBER WORK EMAIL

SECTION II - COMPLETED BY FERO APPROVING AUTHORITY

APPROVAL

FEDERAL EMERGENCY RESPONSE OFFICIAL DESIGNATION

DESIGNATED FERO OFFICIAL NAME DESIGNATED FERO OFFICIAL TELEPHONE FERO OFFICIAL EMAIL ADDRESS

SIGNATURE AUTHORITY DESIGNATED FOR FERO APPROVAL DATE

SECTION III - ACCESS CONTROL OFFICE

FERO STRIPE AUTHORIZED

FERO Designation

CARD NUMBER

ISSUE DATE EXPIRATION DATE STATUS

SIGNATURE DHS OFFICE OF SECURITY REPRESENTATIVE PHONE NUMBER

SIGNATURE OF PHYSICAL SECURITY REPRESENTATIVE PHONE NUMBER

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 5701-5733, §§ 5721-5733; and Executive Order 9397.

PRINCIPAL PURPOSE(S): This information is being collected for the sole purpose of identifying that all requirements have been met to apply for and receive Federal Emergency Response Official Designation.

ROUTINE USE(S): “The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/ALL - 014 Emergency Personnel Location Records System of Records (73 FR 61888, October 17, 2008).”

DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested will prevent the individual from receiving Federal Emergency Response Official Designation.

DHS Form 11000-27 (1/10)