Download Statement of Eligibility to Handle Select Biological Agents or Toxins

Statement of Eligibility to Handle Select
Biological Agents or Toxins
Pursuant to 18 U.S.C. §175b, as added by the USA Patriot Act of 2001
Full Name, including maiden name (if applicable)
Home Address (number and street or P.O. Box number)
City, town or post office, state and ZIP code
Date of Birth
Place of Birth
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Yes
No
1.
Are you under indictment for a crime punishable by imprisonment
for a term exceeding 1 year?
2.
Have you been convicted in any court or received deferred
adjudication for a crime punishable by imprisonment for a term
exceeding 1 year?
3.
Are you a fugitive from justice?
4.
Do you use any controlled substance (as defined by § 102 of the
Controlled Substances Act (21 U.S.C. § 802)) unlawfully?
5.
If you are not a citizen or permanent resident of the United States,
are you a national of any of the following countries: North Korea,
Libya, Iran, Iraq, Cuba, Syria, or the Sudan?
6.
Are you illegally or unlawfully in the United States?
7.
Have you ever been adjudicated as a mental defective or been
committed to any mental institution?
8.
If you were ever a member of the United States Armed Services,
were you dishonorably discharged?
9. If you are a citizen of a country or countries other than the United States, list
all countries of which you are a citizen:
List all countries from which you hold current passports:
List all passport numbers and expiration dates:
If you entered the United States under a visa, give visa type, number and
expiration date:
I,
(print your name)
hereby affirm that the above answers are truthful, correct, and complete, to the fullest extent of
my personal knowledge. I understand that if my status changes so that an answer given above
would change, I have an obligation to notify my supervisor of any change in status. I understand
that if I answered yes to any of the above questions, I am ineligible for employment, study, or
research in an area in which a select agent listed in 42 CFR §72.6(j) and not exempt pursuant to
42 CFR §72.6(h) is stored, used, disposed of, or present. I understand that, even if I answered no
to all of the above questions, I am subject to federal criminal statutes codified at 18 USC §175
pertaining to biological weapons. The penalties for violation of these statutes include a fine,
imprisonment up to life, or both. I also understand that a background check may be performed to
verify the answers given above and hereby consent to all inquiries necessary to achieve
appropriate verification.
(Signature)
(Date)
Return Completed Form To: 'LUHFWRU+XPDQ5HVRXUFHV
Box 13039