PWS_Attch_S016_1.pdf

United States Park Police Liberty District

Identification Card Application & Background Check Request

This form is prescribed by the U.S. Park Police District Commander for use by applicants for National Park Service Identification Cards. Any alteration to this form is expressly forbidden. Type or print clearly in all sections below. For questions that do not apply, respond “N/A” for Not Applicable.

EVERY SECTION #1-32 MUST BE COMPLETED OR THIS APPLICATION WILL BE RETURNED

Re vi se d

/2

Check Appropriate Block: RENEWAL APPLICATION ☐ INITIAL APPLICATION ☐

(1) NAME Last First Middle

(2) SOCIAL SECURITY NUMBER

(3) SEX RACE HEIGHT WEIGHT HAIR EYES

(4) DISTINGUISHING PHYSICAL CHARACTERISTICS (Scars, Marks, Tattoos, Amputations)

(5) CURRENT RESIDENCE ADDRESS Number & Street City State Zip

(6) HOME TELEPHONE

(7) MOBILE TELEPHONE

(8) DATE OF BIRTH

(9) AGE

(10) PLACE OF BIRTH (City, State, Country)

(11) ARE YOU A

UNITED STATES

CITIZEN?

YES

NO

(12) DRIVER’S LICENSE NUMBER

(13) DRIVER’S LIC. STATE

(14) DRIVER’S LIC. EXP. DATE

(15) NPS FEDERAL GOVT. EMPLOYEE STATUS (IF APPLICABLE)

☐ PERM ☐ TERM ☐ SEASONAL

(16) FATHER’S NAME Last First Middle

(17) MOTHER’S MAIDEN NAME Last First Middle

(18) PREVIOUS RESIDENCE ADDRESS Number & Street City State Zip

(19) NICKNAMES &/OR ALIAS (Also Known As)

(20) JOB DESCRIPTION

(21) EMAIL ADDRESS

(22) NAME OF EMPLOYER ON LIBERTY ISLAND OR ELLIS ISLAND

(23) IMMEDIATE SUPERVISOR’S NAME & TITLE

(24) IMMEDIATE SUPERVISOR’S TELEPHONE

(25) Do you currently possess an Alien Green Card? Alien Card Number (If Applicable)

YES

(26) Have you ever been dismissed or terminated from any job? If your answer is YES, please explain in detail on the reverse side of this form.

(27) Have you ever been placed under arrest or charged with any criminal offense?

If your answer is YES, please explain in detail on the reverse side of this form.

YES

(28) Have you ever served in the United States Military? Branch of Service (If Applicable)

(29) Are you dependent upon the use of narcotic(s) or other controlled dangerous substance(s)?

If your answer is YES, list within this box:

YES

NO

(30) Are you presently, or have you ever been a member of any organization which advocates or approves of the commission of acts of force and violence, either to overthrow the Government of the United States, which seeks to deny others rights under the Constitution of the United States? If your answer is YES, please explain in detail on the reverse side of this form.

YE

S

I certify that all of the information I provided is true, correct, and complete in every particular. I understand that false or fraudulent information on or attached to this form may be grounds for being barred from Federal facilities and may be punishable by fine and/or imprisonment as cited in the United States Code, under Title 18 Section 1001. I understand that any information provided may be investigated and I grant authorization to the United States Park Police to access any criminal history information.

(32)

SIGNATURE OF APPLICANT DATE OF APPLICATION

(31) REQUIRED - (2) FORMS OF IDENTIFICATION:

Federal/State-Issued Photo ID Card State Driver’s License

Valid Social Security Card Passport

Administration Only: APPROVED NOT APPROVED Case Number: Date:

Lieutenant Initial/badge: E-Justice Operator Name: Sequence Number:

Attachment S016

NATIONAL PARK SERVICE

STATUE OF LIBERTY NATIONAL MONUMENT AND ELLIS ISLAND

POST IV VISITOR ACCESS FORM

Please contact Jennifer Getter, Confidential Assistant to the Superintendent if you have any questions regarding this form - (212) 363-3206 x101

REQUEST DATE (s): **

Please PRINT Clearly! √ Check all that apply

ARRIVAL

TIME

LAST NAME

FIRST NAME

ORGANIZATION

VEHICLE MAKE/MODEL/

STATE/LICENSE #

Use a new form for additional names

NOTES:

Point of Contact Name/Department:

Phone #/ Radio #:

Date:

All requests must be submitted no later than 3:00 PM daily.

Form must be completely filled out. Any missing information may delay your visitor's entrance into Post IV.

* If parking, ALL vehicles must have a parking pass.

** If visitor(s) need access for more than one week, an application for an ID must be submitted to the USPP.

NATIONAL PARK SERVICE STATUE OF LIBERTY NATIONAL MONUMENT AND ELLIS ISLAND

MIO VISITOR ACCESS FORM

Please contact Jennifer Getter, Confidential Assistant to the Superintendent if you have any questions regarding this form - (646)356-2102

REQUEST DATE (s): **

Please PRINT Clearly!

BOAT

LAST NAME

FIRST NAME

ORGANIZATION

Use a new form for additional names

NOTES:

Point of Contact Name/Department:

Phone #/ Radio #:

Date:

Form must be completely filled out. Any missing information may delay your visitor's entrance.

** If visitor(s) need access for more than one week, an application for an ID must be submitted to the USPP.