CWA CONTRACTOR SECURITY APPLICATION FORM

                                                                                 

 

Applicant’sFull Name__________________________________________                                                                          

 

Address____________________________________________________________________________                          

 

Phone______________________________________________                                                          _______________

 

Sex          Age          Height                 Hair               Eyes_______             

 

Applicant’s Signature______________________________________________________________________________  

 

__________________                                                                                                                                        

 

I,                                                          ___________ , of _________________________________certify that this individual has an occupational need to have escorted access to the property of the Central Wisconsin Airport and request that the airport grant this person permission to enter onto the premises of the airport. The identity of this individual has been verified by two (2) forms of identification, one of which bears the individual’s photograph. 

 

I further certify that I have completed a 10-year employment history check and have verified employment by documentation, by telephone, or in person for the 5 years preceding the date the access investigation was initiated. The results of the investigation disclose that the individual has not been convicted of, or found not guilty by reason of insanity of, the crimes enumerated in 1542.209 (d) (1-28), which is attached. http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?&c=ecfr&tpl=/ecfrbrowse/Title49/49tab_02.tpl

Attached to this request is information about this individual, which he or she filled out as part of this application process.  It includes the individual=s full name, including any aliases or nicknames, all dates, names, phone numbers, and addresses of previous employers. The applicant must offer explanations for any gaps in employment of more than 12 months during the previous 10-year period. The individual will be subject to employment history verification and possibly a criminal history records check to verify any convictions during the previous 10-year period.  Attached also are the records of employment verification.

 

COMPANY MANAGER=S SIGNATURE   __________________________________DATE___________                    

 

                                                                        

                                                                                          CWA USE

SIDA/Security Training Date________________                          

 

Approved by _________________________Date__________                                              

 

Final Disposition Date_____________________                         

           

CWA CONTRACTOR SECURITY APPLICATION FORM (page 2)

                                                                                 

 

 

Applicant’s Full Name                                                                                      Date  ____________                                      

 

                                          

 

The Central Wisconsin Airport requires an employment history background investigation and verification for all contractor employees with access to secured areas of the airport. This investigation will include employment history verification and may include a criminal history records check.  Please provide the following information to assist us in completing the investigation.  Please use additional paper if necessary to answer the questions completely.  All individuals completing this application process may enter the Security Identification Display Area (SIDA) under escort only. Any person found in the SIDA without escort will be prosecuted to the full extent of the law.

 

1. Date of birth (month, day, year):  ____________________                                                                 _____________

 

2. List any nicknames or aliases you have been known by: ______________________________________                      

 

3. List all your employers over the last 10 years.

 

Employer                                Dates of employment                          Address                        Phone

 

 

4. Please explain any gaps in employment of more than 12 months during the previous 10-year period of employment.

 

                                                                                                                                                                     ____________ 

 

5. Have you ever been convicted of a felony?                 If so, what was the felony, and when were you convicted?

 

                                                           __________________________________________________________________