FD-961 FBI Bioterrorism Preparedness Act: Entity/Individual Inf

FD-961 (Rev. xx-xx-xxxx) OMB No. 1110-0039 (Exp. xx-xx-xxxx)

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.

For clarification on how to answer the questions see the FD-961 Instructions.

Section I: Entity Information

1. Legal Name of Entity

________________________________________________________________________________________________

2. Entity Application Number (AGRXXXXXX or CDCXXXXXX):

_____________________________________________________________________________________________________

3. Entity Address (Street, City, State, Zip Code):

_____________________________________________________________________________________________________

Section II: Individual Information

_{4. Unique Identifying Number (UIN Supplied by Sponsor): ____________________________________________}

_{5a. Last Name: _________________________________________________________________________________}

_{5b. First Name: ________________________________________________________________________________}

_{5c. Middle Name} ________________________________________________________________________________

_{5d. Aliases/Maiden Name (Last, First, Middle)}

_{6. Date of Birth (MM/DD/YYYY):}

_{7. Social Security Number (optional):}

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

8a. Have you lived in any state other than the one listed in question 8 since the age of 18? Yes No

_{8b. If yes, list all previous states of residence.}

_{9. Home Phone Number(s) _________________________________________________________________________}

_{10. Cell Phone Number(s) ________________________________________________________________________}

_{11. List all email addresses __________________________________________________________________________}

12. Sex: Male Female

For clarification on ethnicity and race (questions 13 and 14) refer to the FD-961 Instructions.

13. Ethnicity: Hispanic or Latino Not Hispanic or Latino

14. Race (Mark all races that apply):

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

_{15. Place of Birth (City and State or Foreign Country): ______________________}

_{Country or Countries of Citizenship: ___________________________________________________________}

Renounced Country or Countries of Citizenship: _________________________________________________

16. 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

NOTE: If you mark “yes” or “unsure” for questions 12a – 12i you must attach a statement and any supporting documentation to the FD-961 in order for the SRA to be processed.

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 been discharged from the Armed Forces of the United States under dishonorable conditions?

Yes No Unsure

12i. 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: Attach a current photo of yourself and write your name and UIN on the back of the photo.

Attach

photo

here

You must provide one photo with your application. To avoid processing delays, we recommend you use a professional photo service. Your photo must be:

• In color

• Printed on matte or glossy quality paper

• 2 x 2 inches (51 x 51 mm) in size

• Sized such that the head is between 1 inch and 1 3/8 inches (between 25 and 35 mm) from the bottom of the chin to the top of the head

• Taken within the last 6 months to reflect your current appearance

• Taken in front of a plain white or off-white background

• Taken in full-face view directly facing the camera

• Taken with a neutral facial expression (preferred) or a natural smile, and both eyes open

While we recommend you use a professional passport service to ensure your photo meets all the requirements, you may take the photo yourself. Hand-held self portraits are not acceptable. Photos must not be digitally enhanced or altered to change your appearance in any way. If you take the photo yourself with a digital camera, the digital image must adhere to the following specifications:

Dimensions: The image dimensions must be in a square aspect ratio (the height must be equal to the width). Minimum acceptable dimensions are 600 x 600 pixels. Maximum acceptable dimensions are 1200 x 1200 pixels.

Color: The image must be in color in sRGB color space which is the common output for most digital cameras.

If you want to scan an existing photo, in addition to the digital image requirements, your photo must be:

• 2 x 2 inches (51 x 51 mm)

• Scanned at a resolution of 300 pixels per inch (12 pixels per millimeter)

Section V: Privacy Act Statement

Authority:

Collection of this information is authorized under Public Law 107-188; 18 U.S.C. § 175b; 28 U.S.C. § 534; 28 CFR § 0.85; 7 CFR Part 331; 9 CFR Part 121; 42 CFR Part 73.

Principal Purpose:

The information collected on this form will be used for the principal purpose of conducting a security risk assessment to determine if you may possess, receive, access, use and/or transfer select agents and toxins. As part of this assessment, the collected information may also be used to assist in determining approval, denial, revocation or renewal of a certificate of registration issued by Department of Health and Human Services (HHS) or U.S. Department of Agriculture (USDA) for possession, use and transfer of select agents and toxins.

The FBI's acquisition, preservation, and exchange of fingerprints and associated information are generally authorized under 28 U.S.C. 534. The civil fingerprint records contained in Next Generation Identification (NGI) are only available to Department of Justice (DOJ) components when there is a need for the information in order to perform official duties, pursuant to 28 U.S.C. § 534 and 5 U.S.C.§ 552a(b)(1). Civil fingerprint data within NGI will also be shared with federal, local, state, and tribal agencies as permitted by applicable Federal and State statutes, Federal and State executive orders, or regulation or order by the Attorney General. Information is shared with authorized noncriminal justice agencies and entities for employment suitability checks, permits, identity verification, and licensing in accordance with applicable laws, regulations and policies. Providing your fingerprints and associated information/biometrics is voluntary; however: failure to do so may affect completion or approval of your application.

Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI's NGI system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses:

During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system, the FBI’s Central Records System, and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, access clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Social Security Account Number:

Your Social Security Account Number (SSAN) is requested under Public Law 107-188, 7 CFR Part 331, 9 CFR Part 121 and 42 CFR Part 73, which authorize the Attorney General to collect names and other identifying information in the security risk assessment process and to check criminal, immigration, national security and other electronic databases. Because other people may have the same name and birth date, your SSAN will be used to facilitate accurate identification and to help eliminate the possibility of misidentification of individuals for whom a security risk assessment or database check is being conducted. Completion of this form and provision of your SSAN is voluntary. However, failure to provide the requested information may delay or result in the denial of your security risk assessment.

PAPERWORK REDUCTION ACT NOTICE

The information required on this form is in accordance with the Paper Work Reduction Act of 1995. The purpose of this information is to assist the FBI in national security risk assessments for entities and individuals having access to selected toxins as required by the Public Health Security and Bioterrorism Preparedness Response Act of 2002. The completion of this form is mandatory in order to obtain approval for access to select agents and toxins. The average burden cost per person to complete the form is estimated to be $15.44 with the average burden hours per person estimated to be 1.5 hours.

Section VI: 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.

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 consent to the dissemination of my information, as needed, in support of law enforcement and national security efforts to protect public health and safety more generally .

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 VII: 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: __________________________________ Email:} ________________________________________________

Signature: ________________________________________________________________________________________

Applicant’s Initials __________ Page 11 of 11 RO/ARO Initials__________