Appendix D
Application for Security Risk Assessment

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Appendix D Application for Security Risk Assessment 6

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6 APPENDIX D FBI Form FD-961 Bioterrorism Preparedness Act: Entity / Individual Application FD-961 (Rev. 08-31-06) OMB No. 1110-0039-Exp 08-31-09 Reset Form FEDERAL BUREAU OF INVESTIGATION BIOTERRORISM PREPAREDNESS ACT: ENTITY / INDIVIDUAL INFORMATION Section I: Entity Information (Identical to that indicated on the CDC or APHIS registration application ) 1. Legal Name of Entity: 2. Address: (Not a post office box) Street City County State Zip Code 3. Type of Entity: Public Government Other (i.e. Non-Profit, Private Academic, and Commercial) *** Indicate if you are a corporate officer, board of director, and/or stock holder. Section II: Individual Information 4. Full Name (Last, First, Middle) 5. Date of Birth 6. Social Security Number (Month, Day, Year) 4a. Aliases/Maiden Name: Male � 7. Residence Address: (No., Street, City, State, Zip Code) 8. Sex: Female � 9. Place of Birth (City, State or Foreign Country) 10. Race: White *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. Unique Identifier Number (Supplied by APHIS or CDC): 12. Certifications (All questions must be answered "Yes" or "No" in the box provided) *Title 18 Section 1001 of the U.S. Code provides that knowingly falsifying or concealing a material fact is a felony that may result in fines or imprisonment for not more than 5 years or both. 12a. Are you under indictment or information in any court for a 12b. Have you been convicted in any court for a crime, for felony, or any crime, for which the judge could imprison you for which the judge could have imprisoned you for more than one � Yes � year, even if you received a shorter sentence including more than one year? No � � probation? Yes No 12c. Are you a fugitive from justice? 12d. Are you an unlawful user of any controlled substance (as defined in Section 102 of the Controlled Substance Act � Yes � � No [21 U.S.C. 802])? Yes No 12e. Have you ever been adjudicated as a mental defective or been 12f. Are you an alien illegally or unlawfully in the United committed to any mental institution? If yes, a complete copy of States? medical records regarding the commitment will be required. � Yes � � Yes � No No 12g. Are you an alien who has been lawfully admitted for 12h. Have you been discharged from the Armed Services of permanent residence or a naturalized citizen? If yes, please the United States under dishonorable conditions? � Yes � � Yes � No complete page 2 of the application. No I certify that the above answers are true, correct and complete. I understand that the making of a false oral Date: or written statement is a crime. Signature 12/10/2009 1 Save Form Print Next Page

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6 APPENDIX D Previous Page Foreign Born Information This page must be completed by any individual answering YES� to question 12g of page 1. All questions MUST be answered. Be sure to A include all alien or admission numbers for question 9. 13. Country of Citizenship: Mother's Full Name: 14. Father's 15. Full Name: 16. Date of Entry to the United States: 17. Place of Entry: 18. Immigration Status at Entry: 19. Current Immigration Status: 20. Date Status Expires, if Applicable: 21. Alien Number or Admission Number (9-11 digits): Alien registration numbers are issued by the Bureau of Immigration and Customs Enforcement for individuals who are granted perm anent legal resident or a naturalized citizen status in the U.S. 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. If born to US citizen serving a military or diplomatic post in a foreign country please provide a copy of the US born abroad birth certificate. 2 Save Form Print Next Page

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0 APPENDIX D Previous Page Section III: Consent By signing this form, I hereby authorize the U.S. Department of Justice to obtain any information relevant to assessing my suitability to access, possess, use, receive or transfer select agents and toxins from any relevant source, including, but not limited to, individuals, public sources, and government sources. This information may include, but is not limited to, biographical, financial, law enforcement and intelligence information. I further authorize any individuals having information pertinent to such an assessment to release such information to a duly accredited representative of the U.S. Department of Justice. The authorization set forth in this paragraph is valid for five (5) years fr om the date on which this form is signed. I further authorize the U.S. Department of Justice to disclose any records, results or information relating to, or obtained in connection with, my security risk assessment to: the U.S. Department of Agriculture; the Department of Health and Human Services; any age ncy contractors assisting in the determination of risk; and responsible officers or other appropriate personnel of pertinent entities. I further authorize the release of records, results or information relating to, or obtained in connection with my security risk assessment to any law enforcement or intelligence authority or other federal, state or local entity with relevant jurisdiction where such information reveals a risk to human, animal and/or plant health or national security. I further authorize disclosure of records results or information relating to, or obtained in connection with my security risk assessment to organizations or individuals, both public and private, if deemed necessary, in the sole discretion of the U.S. 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. 12/10/2009 _______________________________________________________ __________________________ PRINTED NAME DATE Save Form Print _______________________________________________________ SIGNATURE 3