InfraGard Application Submitted: Personal Information Cell: Email: Birth Date Citizen By Birth Citizenship Documentation: Passport Nbr: Date Issued: | Expired: Citizenship Cert Nbr: Date Issued: Location: Naturalization Nbr: Date Issued: Location: DoS Document Nbr: Date Completed: Issue Location: Birth: Country: SSN: Helpdesk Code Word: Business Information Title: Managing Partner Phone ii Fax: Website: Fax: Additional Information Critical Infrastructure: Information Technology EFTA00173921

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InfraGard Do you or have you had a security clearance? No Have you applied for InfraGard membership before and been denied? No Were you previously an InfraGard member? No Have you ever been arrested for, charged with, OR convicted of a felony or misdemeanor, even if expunged from your record? Yes A DUI 20 years ago in Illinois in the town of Glenview Have you ever served in the military? No Were you discharged from the military? Were you ever subject of a court martial while in the military? No Are you unemployed? No Other —— _ are affiliated with: Why do you want to join InfraGard? How did you hear about infraGard? Colleague EFTA00173922

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InfraGard & Standardized Record Checks for InfraGard Applicants APPLICANT INFORMATION Name: ae DOB: SSN: CLEARANCE CHECK (SCATTERED CASTLES or JPAS) Conducted by: Date: Applicant Response: No Results: CITIZENSHIP CHECK Conducted by: | Date: Applicant Response/POB: Citizen By Birth / chicago, IL, Results: DRIVER'S LICENSE CHECK & PHOTO Conducted by: | Date: DL (State) | Results: DIVS(SENTINEL AND LEGACY ACS) Conducted by: Date: Results: MILITARY SERVICE (if necessary) Conducted by: | Date: Applicant Response: No Results: KNOWN CONCEALED CARRY PERMIT (Office Discretion) Conducted by: Date: __ Yes _._ No [| Application Meets Standards for Approval, document to Sentinel [] Recorded in IGN [| Approve with derogatory information, see FD-1057 C] Deny, see FD-1057 Date Reviewing Authority EFTA00173923