EXHIBIT D Contractor Application for Certification.pdf

EXHIBIT D - SGVA11Q000207

Page 1 REVISED 05/2009

APPLICATION FOR CONTRACTOR CERTIFICATION

All questions on the application form must be answered fully and completely. Any false statements on this form will result in rejection of your application. Further information may be requested by the Regional Security Office in order to complete the security certification process.

ALL APPLICANTS MUST PROVIDE A COPY OF THEIR APPROVED ID1

(See attached list of approved forms of identification)

1. Title (Dr, Mr, Mrs, Miss, Ms, other):

2. Last name:

3. First and middle names (where applicable):

4. Name at birth, if different from above:

5. Have you ever been known by any other names? Please circle: Yes No

If yes, please give name:

6. Sex, please check: Male Female

7. Date of birth:

Day: Month: (write in full) Year:

8. Place of birth (town, country):

9. Present nationality:

10. Nationality at birth:

11. Are you legally entitled to work in the Switzerland? Please check: Yes No

(Please PROVIDE a copy of relevant documents)

12. National ID number:

13. Present Address in full including postcode:

Canton: City/Town: PostCode:

Country:

Contact telephone number:

14. Name and details of current employer:

Name

Address:

For contract drivers, see page 5 for list of approved forms of identification

Page 2 REVISED 05/2009

Canton: City/Town: PostCode:

Country:

Telephone number:

Your Job Title:

How long have you been employed by this company:

15. Name and details of previous employers (past 5 years):

Name

Address:

Canton: City/Town: PostCode:

Country:

Telephone number:

Your Job Title:

How long have you been employed by this company:

16. Please list all of the countries where you have resided apart from Switzerland (please include full addresses – use additional pages if required):

Name

Address:

Canton: City/Town: PostCode:

Country:

Telephone number:

From: (month/year) Until: (month/year)

17. PARENTS DETAILS:

FATHER:

Last name:

First and middle names:

Date of birth:

Place of birth:

MOTHER:

Last name:

Page 3 REVISED 05/2009

First and middle names:

Date of birth:

Place of birth:

18. Have you EVER been arrested, detained, cautioned or convicted by any police or military authority either in Switzerland or abroad (to INCLUDE spent convictions and Road Traffic violations)?

Please check: Yes No

19. Have you ever been involved in act of sabotage, espionage, treason, terrorism or any other act whose aim is to overthrow any government of alter the form of government by unconstitutional means?

Please check: Yes No

20. Have you ever associated or sympathized with any persons who have committed or are attempting to commit sabotage, espionage, treason, terrorism or any other act whose aim is to overthrow any government of alter the form of government by unconstitutional means?

Please check: Yes No

21. Are you or any of your family members or associates – members of any organization dedicated to the violent overthrow of any government or is intent on causing damage or harm to any citizen and or property which engages in illegal activities?

Please check: Yes No

22. Have you or any of your family engaged in any acts designed to overthrow any government by force or harm any citizens and/or property?

Please check: Yes No

If you have answered YES to any of the above, please provide details below (FAILURE TO

COMPLETE IN FULL COULD RESULT IN DISQUALIFICATION FROM THE POSITION FOR WHICH YOU HAVE APPLIED):

DECLARATION:

I declare that the information I have given is true and complete to the best of my knowledge and belief.

I understand that any false statement or deliberate omission in the information I have given in this application will disqualify me for security certification.

SIGNATURE: DATE:

Page 4 REVISED 05/2009

DEPARTMENT OF STATE

Washington, D. C. 20520

AUTHORITY FOR RELEASE OF INFORMATION

TO WHOM IT MAY CONCERN:

I hereby authorize any Special Agent or Investigator of the United States Department of State, or any Investigator or duly accredited representative of the United States Office of Personnel Management bearing this release, or a copy thereof, within one year of its date, to obtain any information from schools, residential management agents, employers, criminal justice agencies, credit agencies or individuals, relating to my activities. This information may include, but is not limited to, academic, residential, achievement, performance, attendance, personal history, disciplinary, arrest and conviction records, and credit information. I hereby direct you to release such information upon request of the bearer.

I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature, which may at any time result to me on account of compliance, or any attempts to comply, with this authorization. Should there be any question as to the validity of this release, you may contact me as indicated below.

Full Name:

Other Names used:

Current Address:

Telephone:

Signature: __________________________________________

Date:

Page 5 REVISED 05/2009

Documentation for Contractors

The U.S. Mission is requiring the following information for each contractor:

Swiss citizens:

Provide a legible full copy of identification (ID) or Passport.

French citizens:

Provide a legible full copy of French National identification (ID) or Passport and work permit currently if effect.

Citizens from all other countries:

Provide legible copies of Passport and working and/or residence permit(s)

Provide a legible original copy extracted from the criminal record to indicate any and all information concerning any criminal record.

Note: On 1 January 2000, a Swiss central, fully automated criminal record replaced the criminal records kept manually by the cantonal and the federal authorities. Since 1 July 2000, the Federal Office of Justice (FOJ) has kept the criminal record, which will therefore be the only authority from which an extract from the central criminal record can be obtained.

If you require a Swiss extract from the criminal record, you can order:

http://www.bj.admin.ch/bj/fr/home/dokumentation/medieninformationen/2007/2007-03- 26.html

French citizens/Residents in France:

Extract from the French criminal record https://www.cjn.justice.gouv.fr/cjn/b3/eje20

Business owners and Managers require providing also the following original documents:

BUSINESS REGISTRATION « EXTRAIT DU REGISTRE DE COMMERCE » –

http://rc.ge.ch/

CREDITORS OFFICE CERTIFICATE / ATTESTATION DE NON – POURSUITE

https://www.geneve.ch/opf/ecommerce/non_poursuite/ecommerce_1.asp?id_Article=26

All documentation stated above shall be provided in full, and be forwarded directly to:

U.S. Mission

RSO

11 route de Pregny 1292 Chambésy, Geneva, http://www.bj.admin.ch/bj/fr/home/dokumentation/medieninformationen/2007/2007-03-26.html http://www.bj.admin.ch/bj/fr/home/dokumentation/medieninformationen/2007/2007-03-26.html https://www.cjn.justice.gouv.fr/cjn/b3/eje20 http://rc.ge.ch/ https://www.geneve.ch/opf/ecommerce/non_poursuite/ecommerce_1.asp?id_Article=26