AGREEMENT between BROWARD COUNTY and Cummings ...

Badging Requirements and Ramp Driving Privileges
Exhibit 2
Page 336 of 379
FINGERPRINT APPLICATION FOR CRIMINAL HISTORY RECORD CHECK
Sponsor
Company: ________________________________________
Contracted
Company:________________________________________
Company Address:
________________________________________________
________________________________________________
Employee‟s Full Name:
________________________________________________
(First) (Middle) (Last)
Aliases and Nicknames (including maiden name, previously
married names, etc., if applicable):
________________________________________________
________________________________________________
________________________________________________
Date of
Birth:____________________________________________
Eye Color:_____________
Hair Color:________________
Height:_________________ Weight: __________________
______________________
Gender
_______________________
Race
______________________________________________________
Country of Citizenship
______________________________________________________
Place of Birth
______________________________________________________
Current Home Address
______________________________________________________
City
______________________________________________________
State
Zip Code
______________________________________________________
Employee Signature: (see affidavit below)
The information I have provided is true, complete, and correct
to the best of my knowledge and belief and is provided in good
faith. I understand that a knowing and willful false statement
can be punished by fine or imprisonment or both (Section 1001
of Title 18 of the United States Code).
______________________________________________________
Authorized Signatory Signature
Date of Application: ________________________________
AFFIDAVIT: This applicant acknowledges that the Transportation Security Administration (TSA) has determined that
a withheld adjudication, whether through a guilty plea or a plea of nolo contendre (no contest), constitutes a
conviction for the purpose of unescorted access to the AOA (49 CFR Part 1542). I also accept that upon receipt of a
directive from the TSA or a modification to the regulation, my unescorted access to the secure area of the Airport
may be denied or revoked.
_______________________________________________________________________________________________________________
BILLING (allowable only to companies authorized by BCAD Finance Department)
___________________________________________
Authorized Signatory Signature for Billing
Date
________________________________
Fingerprint Fee: Electronic Submission $27.00
Ink-Rolled Hard Card $31.00
Payment Method: Cash $ __________
Check $ __________
No.________
Billing $ __________
BCAD USE ONLY: Initials of Trusted Agent _________ Fingerprint Date ___________Transaction #__________
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