Fd-961 Bioterrorism Preparedness Act; Entity/individual Informa

FD-961 (Rev. 04-01-2014)

OMB No. 1110-0039 (Exp. xx-xx-20xx)

FEDERAL BUREAU OF INVESTIGATION
BIOTERRORISM PREPAREDNESS ACT: ENTITY / INDIVIDUAL INFORMATION
18 U.S.C. Section 1001 states that knowingly and willfully falsifying or concealing a material fact is a felony that may result
in fines or imprisonment for not more than 5 years or both.
Please answer all questions or put “none” or “not applicable” in the space provided.
Section I: Entity Information
1.

Legal Name of Entity and Entity Registration Number (AGRXXXXXX or CDCXXXXXX):

2.

Address (Street, City, State, Zip Code):

Section II: Individual Information
3.

Unique Identifying Number (UIN Supplied by Sponsor):

4.

Full Name (Last, First, Middle):

4a.

Aliases/Maiden Name:

5.

Date of Birth (MM/DD/YYYY):

6.

Social Security Number:

7.

Residence Address (Number, Street, City, State, Zip Code):

7a.

Do you have any additional states of residence?

7b.

If yes, list all additional states of residence.

8.

Sex:

9.

Ethnicity:

9a.

Race (Mark all races that apply):
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or Other Pacific Islander
e. White

10.

Place of Birth (City and State or Foreign Country):

Male

Yes

Female
Hispanic or Latino

Not Hispanic or Latino

Country or Countries of Citizenship:
Renounced Country or Countries of Citizenship:

No

11.

Foreign Place of Birth Information: (If born in the U.S., proceed to Section III. If a U.S. Citizen Born Abroad,
attach a copy of the born abroad certificate and proceed to Section III.)
Alien Registration Number or Admission Number (9-11 digits):
Current Immigration Status and Expiration:
Mother’s Full Maiden Name:
Father’s Full Name:
Date and Place of Entry:
Immigration Status at Entry:

Section III: Certification Questions
12a.

Are you under indictment or information in any court for any crime for which the judge could imprison you for more
than one year?
Yes
No
Unsure

12b.

Have you been convicted in any court for a crime for which the judge could have imprisoned you for more than one
year even if you received a shorter sentence including probation?
Yes
No
Unsure

12c.

Are you a fugitive from justice?
Yes
No
Unsure

12d.

Are you an unlawful user of any controlled substance (as defined in Section 102 of the Controlled Substance
Act [21 U.S.C. 802])?
Yes
No
Unsure

12e.

Have you ever been adjudicated as a mental defective or been committed to any mental institution? .
Yes
No
Unsure

12f.

Are you an alien illegally or unlawfully in the United States?
Yes
No
Unsure

12g.

(I) Are you an alien (other than an alien lawfully admitted for permanent residence) who is a national of a State
Sponsor of Terrorism; or (II) acts for or on behalf of, or operates subject to the direction or control of, a government or
official of a State Sponsor of Terrorism?
Yes
No
Unsure

12h.

Have you served in the Armed Forces?
Yes
No
Unsure

12i

Have you been discharged from the Armed Forces of the United States under dishonorable conditions?
Yes
No
Unsure

12j.

Are you a member of, act for or on behalf of, or operate subject to the direction or control of a terrorist organization
(as defined in Section 212 of the Immigration and Nationality Act [8 USC 1182])?
Yes
No
Unsure

Section IV: Certification and Consent of Applicant
By signing this form, I certify that the above certification answers are true, correct and complete. I understand that
making of a false oral or written statement is a crime.
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, as well as medical records including mental health history.
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 from the date on which this form is signed.
I further authorize the U. S. Department of Justice to disclose the results and records or information supporting such results
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; and any agency contractors assisting in the determination of risk.
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, in accordance with the U.S.
Department of Agriculture and Department of Health and Human Services regulatory authority.
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 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.
Printed Name:
Date:
Signature
Section V: Certification of Responsible or Alternate Responsible Official
As the Responsible or Alternate Responsible Official, I certify that I have reviewed this form in its entirety for
completeness and legibility. Furthermore, I have reviewed the certification questions (Section III) and discussed
any issues with the applicant and, based upon my review, have determined that all certification questions have been
answered prior to transmitting this information to the FBI for the Security Risk Assessment. For any questions
answered "yes" or "not sure" the applicant must provide additional information or supporting documentation.
Printed Name:
Date:
Signature

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