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Appendix D: Application for Security Risk Assessment
Pages 167-170

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From page 167...
... Appendix D Application for Security Risk Assessment 6
From page 168...
... If not born in the United States please complete questions on page 2 � Black or African titled Foreign Born Information. Hispanic or Latino Asian/ Native Hawaiian American Indian or Alaska Native Pacific Islander 11.
From page 169...
... Other situations that individuals would have an alien registration number include the following: Employment Authorization cards, Temporary Resident cards, Border Crossing cards, I-94 or Visa numbers. If this n umber is not available please provide an explanation.
From page 170...
... Department of Justice, to elicit information or cooperation from the recipient for use in assessing my suitability to access, possess, use, receive or transfer select agents and toxins. I further authorize release of records, results or information relating to, or obtained in connection with my security risk assessment to laboratories, universities, individuals, or other entities, both pu blic and private, responsible for making security assessments, employment and/or licensing determinations and suitability or security decisions when the information is relevant to an assessment of my suitability to access, possess, receive, use, or transfer agents or toxins I understand that this is a legally binding document and false statements provided by me are violations of federal law and may lead to criminal prosecution or other legal action.


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