Statement_of_Affiliation_Instructions.pdf

Government the Government

Yes___ No___

UNCLASSIFTED//FOR OFFICIAL USE ONLY

9. Do any of the members of your organization's board of directors (or similar governing body), or officers, executive personnel, general partners, regents, trustees or senior management officials of your organization hold any positions with, or serve as consultants for, any foreign interest?

If yes: Include items i, ii and iii below if answered #9 yes

i) Provide the name, title, citizenship, immigration status and clearance or exclusion status on all such persons.

ii) Identify by name and address, each foreign interest with which such persons serve and indicate the capacity in which he/she is serving.

iii) Include a Statement of Full Disclosure of Foreign Affi liations for every cleared individual who is a representative of a foreign interest.

10. Ts there any other factor that indicates or demonstrates a capability of a foreign interest to control or influence the operations or management of your organization?

L--~~~~~~

If yes: Include items i below if answered #10 yes

i) Describe the foreign involvement in detail, including why the involvement would not be reportable in the preceding questions.

Print Name

' Signature and Date: (Must be signed by a senior official of the company) ....----~ ...... , ----- -----...

Please include company position of signer & date

Completed and signed form must be scanned and emailed to the HPK Construct ion Security Coordinator, Nancy Bryant (nbryant@henselphelps.com).

Please contact Nancy by email or phone (410.305.4784) if you have questions about the SOA process.

UNCLASSIFIED//FOR OFFJCAL USE ONLY Page5

Yes___ No___

Yes___ No___ e1rexwab Highlight e1rexwab Highlight e1rexwab Rectangle