Exhibit_D_Contractor_Clearance_Form.doc

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 PASSPORT

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 circle:

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 UK? Please circle:

Yes

No

(Please PROVIDE a copy of relevant documents)

12.

National Insurance number:

13. Other National ID and number (e.g. social security):

14. Present Address in full including postcode: _________

Contact telephone number:

15. Name and details of current employer:

Name:

Address:

Postcode:

Telephone Number:

Your Job Title:

How long have you been employed by this company:

16. Please list all of the countries where you have ever resided since birth, apart from the United Kingdom (please include full addresses – use additional pages if required):

Address:

Telephone:

From:

____(month/year) Until: ____

____(month/year)

17. PARENTS DETAILS:

FATHER:

First and middle names:

Place of birth:

MOTHER:

First and middle names:

Maiden name: ______________________________________________________________

Place of birth:

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

Please circle:

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 circle:

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 circle:

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 circle:

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 circle:

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:

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:

REVISED 04/2008