Federal Deposit Insurance Corporation employee/contractor identification card request




Yüklə 47.68 Kb.
tarix16.04.2016
ölçüsü47.68 Kb.

Federal Deposit Insurance Corporation

EMPLOYEE/CONTRACTOR IDENTIFICATION CARD REQUEST




INSTRUCTIONS: Please print legibly when completing this form. All requested building and floor access levels must be specified. Failure to identify individual floors will result in this form being returned without action. Supervisors must approve all access levels. Return the completed form to the FDIC Security Office, Room F1C-3A. For Service Centers and Regional Offices, please return this completed form to the Facilities Manager or other designated official. Upon receipt of the completed form, the Security Office, Facilities Manager, or other designated official will call and make an appointment with you to take your picture and issue you an FDIC Identification Card.

SECTION I - EMPLOYEE/CONTRACTOR INFORMATION

NAME (Last, First, MI)

SOCIAL SECURITY NUMBER (Last 4-digits)

     

    

OFFICE PHONE NUMBER

DIVISION/OFFICE

BUILDING/ROOM NUMBER

     

     

     

HEIGHT

WEIGHT

DATE OF BIRTH

     

     

     

SECTION II - TYPE OF BADGE REQUIRED (Check the appropriate boxes.)










































 FDIC Employee

 Car Pool



 Day Care Center

 New

 Other (specify)

     

 Replacement - LOSS

     

 Replacement - THEFT




























 Contractor

 Access Card (1700/1730)





































SECTION III - WASHINGTON METRO AREA ACCESS







 Standard (All Buildings)  Special (specify)      

SECTION IV - REGIONAL OFFICE/FIELD OFFICE/SERVICE CENTER ACCESS




List the geographical area, building(s), and applicable floor numbers, to which access is required below.










Geographical Area

     

























BUILDING(S)

FLOOR

BUILDING(S)

FLOOR

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

SECTION V - CONTRACTOR INFORMATION

COMPANY NAME

CONTRACT NUMBER

CONTRACT EXPIRATION DATE

     

     

     

FDIC OVERSIGHT MANAGER'S NAME (Please print)

OFFICE PHONE NUMBER

     

     

FDIC OVERSIGHT MANAGER'S SIGNATURE

DATE




     

SECTION VI - SUPERVISOR APPROVAL AND ADMINISTRATIVE VERIFICATION

SUPERVISOR'S NAME AND TITLE (Please print)

OFFICE PHONE NUMBER




     

SUPERVISOR'S SIGNATURE

DATE




     

ADMINISTRATIVE OFFICER'S SIGNATURE

DATE




     

FDIC 1620/01 (9-01)


SECTION VII - RECIPIENT'S DECLARATION AND SIGNATURE

I understand that this card is the property of the Federal Deposit Insurance Corporation, an agency of the United States of America. Any counterfeiting, forgery, tampering or misuse is a criminal offense (U.S. Code Title 18 §499 and 701). Furthermore, I understand that any false statement made in relation to this identification card request is a criminal offense (U.S. Code, Title 18 §1001).

EMPLOYEE/CONTRACTOR'S SIGNATURE

DATE




     

FOR SECURITY OFFICE USE ONLY




PRIVACY ACT STATEMENT

Collection of this information is authorized by 12 U.S.C. § 1819 and Executive Order 9397. The information requested on this form will be used by FDIC personnel to issue you an FDIC Identification Card for certain FDIC programs and for access to FDIC facilities. Your Social Security Number (SNN) is requested to further ensure record accuracy and to differentiate you among others with similar or identical names. Disclosure of this information may also be made in accordance with the "routine uses of records" listed in the FDIC's Financial Information Management Records, #30-64-0012, including disclosure to: the General Accounting Office for inspection by auditors; appropriate Federal or State agencies for enforcement if a violation or possible violation of civil or criminal law is apparent; a court, magistrate, or administrative tribunal when the FDIC is a party to the proceeding or has a significant interest in the proceeding; the U.S. Office of Personnel Management and other appropriate agencies or offices to the extent disclosure is necessary to carry out government-wide personnel management, investigatory, and adjudicatory functions: a congressional office in response to an inquiry made at the request of the individual; the Internal Revenue Service, the Social Security Administration, State and local tax authorities; the FDIC Office of the Inspector General for audit purposes; a consultant, person or entity who contracts or subcontracts with the FDIC, to the extent necessary for the performance of the contract or subcontract; and to the Department of the Treasury, or another party for the purpose of collecting or assisting in the collection of a delinquent debt owed to the FDIC. Completing this form is voluntary. However, failure to provide all of the requested information (including your SSN) may delay or prevent the FDIC from issuing you an FDIC Identification Card.

FDIC 1620/01 (9-01) Page 2


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©azrefs.org 2016
rəhbərliyinə müraciət

    Ana səhifə