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

FD-961 (Rev. 02-16-2018)

OMB No. 1110-0039 (Exp. xx-xx-xxxx)
INSTRUCTIONS

Questions concerning completion of the FD-961 Form can be directed to BRAG at 304-625-4900.
Accessing the FD-961 Form and Instructions
The FD-961 Form and these instructions are accessed at the FBI, Criminal Justice Information Services (CJIS) Division web page at www.fbi.gov. A link to
the form is located under resources.
Requesting Fingerprint Cards
Fingerprint card packages can be obtained by faxing a request to the CJIS Division at 304-625-3984. The request should include the following: entity name,
point of contact, mailing address, contact's telephone number and quantity of requested bioterrorism fingerprint card packages. The fingerprint card can also
be printed out from the Criminal Justice Information Services (CJIS) Division web page at www.fbi.gov. A link is located at the bottom of the resources
section and is labeled Standard Fingerprint Form (FD-258).
Completion of Fingerprint Cards
The fingerprint card packet consists of two fingerprint cards, general instructions, fingerprint instructions, and a pre-addressed return envelope. The
following fields should be completed on the fingerprint cards: residence, employer and address, name, aliases, citizenship, social security number, sex, race,
height, weight, eye color, hair color, date of birth and place of birth. The applicant must have the two fingerprint cards printed by a local law enforcement
agency. The individual or entity must arrange for this service. In most instances, law enforcement offices will charge a fee for this service. The two
fingerprint cards and completed FD-961 Form must be submitted to the FBI as one package for the security risk assessment to be completed. The FBI may
request a second set of prints to process in the event that the initial two fingerprint cards are rejected from the Integrated Automated Fingerprint
Identification System for image quality.
Requirements for New or Inactive Applicants
For applicants that do not have an active Security Risk Assessment (SRA) on file with the Bioterrorism Risk Assessment Group (BRAG), the FD-961 Form
and two legible fingerprint cards must be completed and mailed as one package to:
Bioterrorism Risk Assessment Group, BTC 2
Assistant Director
Criminal Justice Information Services Division
Criminal Justice Information Services
Federal Bureau of Investigation
-- OR -Federal Bureau of Investigation
1000 Custer Hollow Road
PO Box 4142
Clarksburg, WV 26306
Clarksburg, WV 26302-9922
Requirements for Active Applicants
If the applicant has an active SRA on file with BRAG, the FD-961 Form can be completed and emailed to BRAG at FD961@leo.gov. Please ensure that the
photo is scanned according to the digital image requirements on page 3 of the FD-961. Fingerprint cards are not required; however, BRAG reserves the right
to request additional fingerprint cards if necessary.
Federal Select Agent Program (FSAP) Information
Please refer to the APHIS/CDC National Select Agent website at www.selectagents.gov or contact your APHIS or CDC Representative for questions
regarding the FSAP. General guidance can be found at the website including who requires an SRA, obtaining a Unique Identifying Number (UIN),
expediting an SRA, and other frequently asked questions.
Completion of FD-961 Form
Please note that incomplete, expired (Rev. 10-19-2015 and earlier) or outdated forms (signature date exceeds 90 days) will not be processed.
1. All questions on this form must be answered. If no response is necessary or applicable indicate this on the form (enter “N/A” or “not applicable”). If
you find that you cannot report an exact date, approximate or estimate the date to the best of your ability and indicate this by marking “APPROX.” or
“EST.”
2. Type or legibly print your answers.
3. All names must be given in the following format: last, first, middle.
4. All telephone numbers must include area code.
5. Forms submitted prior to a foreign national’s entry into the U.S. will return an immigration check result of "no record of legal entry into the U.S." The
SRA will be completed and the individual will be identified as a restricted person (unlawful or illegal alien). If a foreign national will be in the U.S.
briefly and completion of the SRA is urgent, an expedited SRA request can be submitted to APHIS or CDC once the individual enters the country.
6. Initial pages 1-4 of the FD-961, either typed or handwritten and sign page 5. The RO/ARO must sign page 5 of the FD-961 prior to it being submitted
to BRAG for processing.
7. If you need additional space for any questions on the FD-961 attach a blank piece of paper with your answers and include your name and UIN.
Use the following decision charts to help in answering questions 11 and 12.
Ethnic Categories (“Hispanic or Latino” and “Not Hispanic or Latino”)

Hispanic or Latino: An indication that the person traces his or her origin or descent to Mexico, Puerto Rico, Cuba, Central and South
America, and other Spanish cultures, regardless of race.
Racial Categories

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central
America), and who maintains cultural identification through tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This area includes,
for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
Islands.

White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Section III: Certification Questions
18 U.S.C. § 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.
22a – 22i: Answer all questions with a "yes", "no" or “unsure” in the boxes provided. FD-961 Forms with questions left blank will not be processed.
If the applicant is not sure how to answer any question, they should check "not sure". For any questions answered “yes” or "not sure", the applicant must
provide additional information or supporting documentation to assist BRAG in processing the SRA. This information can include court documents, arresting
agency information, arrest date, charges, etc. For medical documentation the applicant should contact the medical facility, sign a release and have the
medical facility mail the documentation directly to BRAG.

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22a. Indictment - Includes an indictment or information in any court, under which a crime punishable by imprisonment for a term exceeding 1 year may be
prosecuted, or in military cases to any offense punishable by imprisonment for a term exceeding 1 year which has been referred to a general court-martial.
An information is a formal accusation of a crime, differing from an indictment in that it is made by a prosecuting attorney and not a grand jury.
22b. Crime punishable by imprisonment for a term exceeding 1 year - Any Federal, State or foreign offense for which the maximum penalty, whether or
not imposed, is capital punishment or imprisonment in excess of 1 year. What constitutes a conviction of such a crime shall be determined in accordance
with the law of the jurisdiction in which the proceedings were held. Any conviction which has been expunged or set aside or for which a person has been
pardoned shall not be considered a conviction.
22c. Fugitive from justice - Any person who has fled from any state to avoid prosecution for a felony or a misdemeanor; or a person who leaves the state to
avoid giving testimony in any criminal proceeding; or a person who knows that misdemeanor or felony charges are pending against such an individual and
who leaves the state of prosecution and does not appear before the prosecuting tribunal. Fugitives from justice do not include individuals who are charged
with crimes and there is no evidence that they left the state. A person is not a fugitive from justice merely because he or she has an outstanding civil traffic
citation.
22d. Unlawful user of or addicted to any controlled substance - A person who uses a controlled substance and has lost the power of self-control with
reference to the use of controlled substance; and any person who is a current user of a controlled substance in a manner other than prescribed by a licensed
physician. Such use is not limited to the use of drugs on a particular day, or within a matter of days or weeks before, but rather that the unlawful use has
occurred recently enough to indicate that the individual is actively engaged in such conduct. A person may be an unlawful current user of a controlled
substance even though the substance is not being used at the precise time the person seeks access to biological select agents and toxins. An inference of
current use may be drawn from evidence of a recent use or possession of a controlled substance or a pattern of use or possession that reasonably covers the
present time, e.g., a conviction for use or possession of a controlled substance within the past year; multiple arrests for such offenses within the past 5 years
if the most recent arrest occurred within the past year; or persons found through a drug test to use a controlled substance unlawfully, provided that the test
was administered within the past year. For a current or former member of the Armed Forces, an inference of current use may be drawn from recent
disciplinary or other administrative action based on confirmed drug use, e.g., court-martial conviction, non-judicial punishment, or an administrative
discharge based on drug use or drug rehabilitation failure.
Controlled Substance – A drug or other substance, or immediate precursor, as defined in section 102 of the Controlled Substances Act, 21 U.S.C. 802. The
term includes, but is not limited to, marijuana, depressants, stimulants, and narcotic drugs. The term does not include distilled spirits, wine, malt beverages,
or tobacco, as those terms are defined or used in Subtitle E of the Internal Revenue Code of 1954, as amended.
NOTE: The use of any controlled substance (including marijuana) is illegal at the federal level even though it may be legalized in your state.
22e. Adjudicated as a mental defective – (a) A determination by a court, board, commission, or other lawful authority that a person, as a result of marked
subnormal intelligence, or mental illness, incompetency, condition or disease: (1) is a danger to himself or to others; or (2) lacks the mental capacity to
contract or manage his own affairs. (b) The term shall include (1) a finding of insanity by a court in a criminal case; and (2) those persons found
incompetent to stand trial or found not guilty by reason of lack of mental responsibility pursuant to articles 50a and 72b of the Uniform Code of Military
Justice, 10 U.S.C. 850a, 876b.
Committed to a mental institution – A formal commitment of a person to a mental institution by a court, board, commission, or other lawful authority. The
term includes a commitment to a mental institution involuntarily. The term includes commitment for mental defectiveness or mental illness. It also includes
commitments for other reasons, such as for drug use. The term does not include a person in a mental institution for observation or a voluntary admission to a
mental institution.
Mental institution – Includes mental health facilities, mental hospitals, sanitariums, psychiatric facilities, and other facilities that provide diagnoses by
licensed professionals of mental retardation or mental illness, including a psychiatric ward in a general hospital.
22f. Alien – Any person not a citizen or national of the United States.
Alien illegally or unlawfully in the United States - Aliens who are unlawfully in the United States are not in valid immigrant, nonimmigrant or parole status.
The term includes any alien (a) who unlawfully entered the United States without inspection and authorization by an immigration officer and who has not
been paroled into the United States under section 212(d)(5) of the Immigration and Nationality Act (INA); (b) who is a nonimmigrant and whose authorized
period of stay has expired or who has violated the terms of the nonimmigrant category in which he or she was admitted; (c) paroled under INA section
212(d)(5) whose authorized period of parole has expired or whose parole status has been terminated; or (d) under an order of deportation, exclusion, or
removal, or under an order to depart the United States voluntarily, whether or not he or she has left the United States.
22g. – (i) An alien (other than an alien lawfully admitted for permanent residence) who is a national of a country as to which the Secretary of State has made
a determination that such country has repeatedly provided support for acts of international terrorism or, (ii) any individual (regardless of nationality) that acts
for or on behalf of, or operates subject to the direction or control of, a government or official of the countries listed below.
State Sponsor of Terrorism
Designated Date
Syria
12-29-1979
Iran
01-19-1984
Sudan
08-12-1993
Democratic People’s Republic of Korea (North Korea)
11-20-2017
22h. Discharged under dishonorable conditions - Separation from the U.S. Armed Forces resulting from a dishonorable discharge or dismissal adjudged by
a general court-martial. The term does not include any separation from the Armed Forces resulting from any other discharge, e.g. a bad conduct discharge.
22i. Terrorist organization - An organization (i) designated by the Secretary of State as a foreign terrorist organization (ii) otherwise designated by the
Secretary of State in consultation with or upon the request of the Attorney General or the Secretary of Homeland Security as a terrorist organization; or (iii)
that is a group of two or more individuals, whether organized or not, which engages in, or has a subgroup which engages in terrorist activity [as defined in 8
U.S.C. 1182 (a)(3)(B)]
Section VII: Certification and Consent of Applicant
By signing, the applicant certifies that all questions on the FD-961 are true, correct and complete. Also, the applicant's signature gives consent to the U.S.
Department of Justice to complete the SRA. The printed name must be legible. The signature date must be current (occurring within the last 90 days).
Digital and electronic signatures are not acceptable. The applicant is required to initial or type their initials at the bottom of each page (except page 5) of the
FD-961 where indicated.
Section VIII: Certification of Responsible or Alternate Responsible Official
By signing, the RO or ARO certifies that the completed FD-961 Form was reviewed for completeness, legibility, and that the certification questions have
been reviewed and handled accordingly. Digital and electronic signatures are not acceptable. Please include an email address for requests for additional or
incomplete information.

FD-961 (Rev. 02-16-2018)

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

1a. State

2. Entity Registration Number
3. Are you registered at more than one (1) entity?

Yes

No

4. If you are registered at more than one (1) entity please list all additional entities, the state and their Registration Numbers.

Section II: Individual Information
5. Unique Identifying Number (UIN Supplied by Sponsor)
6. Position
7. Name

If you have only initials in your name, use them and state (IO)
If you have no middle name, enter "NMN".

If you are a "Jr.," "Sr.," "II," etc. enter this in the box labeled Suffix, or
enter "N/A"

7a. Last Name

7b. Suffix

7c. First Name
7d. Middle Name
7e. Aliases/Maiden Name (Last, First, Middle)

7f. Nicknames
8. Date of Birth (MM/DD/YYYY)
10. Sex

Male

Female

9. Social Security Number
11. Hispanic or Latino

Not Hispanic or Latino

12. Race (Mark all races that apply):
American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Asian

White

Black or African American

Unknown

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

14. Have you lived in any state other than the one listed in question 13 since the age of 18?

Yes

No

14a. If yes, list all previous states of residence.
15. Place of Birth (City and State or Foreign Country)
16. Country or Countries of Citizenship
17. Renounced Country or Countries of Citizenship
18. Home Phone Number(s)

19. Cell Phone Number(s)

20. Driver's License Number and Issuing State
21. List all email addresses

Applicant's Initials __________

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FD-961 (Rev. 02-16-2018)

OMB No. 1110-0039 (Exp. xx-xx-xxxx)
Section III: Certification Questions

22. NOTE: If you mark “yes” or “unsure” for questions 22a – 22i you must attach a statement and any supporting documentation to
the FD-961 in order for the SRA to be processed.
22a.

Are you under indictment or information in any court for any crime for which the judge Yes
could imprison you for more than one year?

No

Unsure

22b.

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

22c.
22d.

Are you a fugitive from justice?
Are you an unlawful user of any controlled substance (as defined in Section 102 of the
Controlled Substance Act [21 U.S.C. 802])
NOTE: The use of any controlled substance (including marijuana) is illegal at the
federal level even though it may be legalized in your state.
Have you ever been adjudicated as a mental defective or been committed to any
mental institution?

Yes
Yes

No
No

Unsure
Unsure

Yes

No

Unsure

22f.
22g.

Are you an alien illegally or unlawfully in the United States?
(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
Yes

No
No

Unsure
Unsure

22h.

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

Yes

No

Unsure

22i.

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

22e.

Section IV: Citizenship/Foreign Place of Birth
23.

Mark the box that reflects your current citizenship status.
I am a U.S. citizen or national by birth in the U.S. or U.S. territory/possession. (Proceed to Section V)
I am a U.S. citizen, but I was NOT born in the U.S. (Answer 23a, 23b)
I am not a U.S. citizen. (Answer 23a, 23c)

23a.

Your Mother's Maiden Name

23b.

If you are a U.S. citizen, but were not born in the U.S., provide one or more of the following proofs of your citizenship.
Naturalization Certificate (Where were you naturalized?)
Court
City
State
Certificate Number
Month/Day/Year Issued
Citizenship Certificate (Where was the certificate issued?)
City
State

Certificate Number

Month/Day/Year Issued

State Department Form 240 Report of Birth Abroad of a Citizen of the United States (Attach a copy of the certificate)

23c.

Month/Day Year
Give the date the form was perpared
and give an explanation if needed
If you are an alien, provide the following information:
State
Place you entered the City

Explanation

Date you entered

Alien Registration Number

United States

Applicant's Initials __________

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FD-961 (Rev. 02-16-2018)

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Section V: Photograph

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)

Applicant's Initials __________

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FD-961 (Rev. 02-16-2018)

OMB No. 1110-0039 (Exp. xx-xx-xxxx)
Section VI: 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; 42 U.S.C. §
262a; 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 identification records (including fingerprints and photographs)
are generally authorized under 28 U.S.C. 534. Providing your biographic information and associated biometrics
(e.g. fingerprints, photograph) is voluntary; however: failure to do so may affect completion or approval of your
application. During the application process and for as long as you remain in the Select Agent Program, the FBI will
use the information you provide to search criminal, immigration, national security and other relevant electronic
databases.
Routine Uses:
During the processing of this application and for as long thereafter as your biographic and biometric information is
retained, 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: 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. 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.

Applicant's Initials __________

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Section VII: 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. By signing below I am certifying that I have
reviewed this document in its entirety (pages one through five) and they are accurate and complete.
Printed Name: ________________________________________________________________________________________
Date:_________________________________________________________________________________________________
Signature: ____________________________________________________________________________________________

SectionVIII: Certification of Responsible or Alternate Responsible Official
As the Responsible or Alternate Responsible Official, I certify that I have reviewed this formin 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 RiskAssessment. For any questions
answered "yes" or "not sure" the applicant must provide additional information or supporting documentation.
Printed Name: ________________________________________________________________________________________
Date: __________________________________ Email: ________________________________________________________
Signature: ____________________________________________________________________________________________

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