HSHQPD-17-Q-00003_Attachment_NCIC_Form.pdf

Date:

Date of Visit:

Name (Last, First, Middle) US Citizen

Country of Origin

Place of Residence

Date of Birth (mm /dd/yyyy)

*Social Security Number

Telephone Number Gender

Please e-mail this document to PlumIslandSecurity@st.dhs.gov *For your personal security, please DO NOT send your personal identifiable information (the information contained within this document) to any other number or e-mail address. The information provided in this form is used by law enforcement personnel only.

For questions or concerns, please contact:

PIADC Federal Officer (631) 323-3390 or PlumIslandSecurity@st.dhs.gov

NCIC Form File Plan # 403-258-003c Rev. Date: 7/22/15

For Official Use Only This document contains sensitive information exempt from mandatory disclosure under the Freedom of Information Act, 5 U.S.C 552(b)

(2). Do not release without prior approval by the Department of Homeland Security.

TYPE ONLY in the table below (handwritten forms will NOT be accepted)

Name of PIADC Sponsor

Plum Island Animal Disease Center National Crime Information Center (NCIC) Form

For all NCIC forms, allow 5 working days for processing prior to visitor arrival

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