IrlfraGard
Application
Submitted:
Chapter:
Personal Information
Home:
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:
Drivers License:
SSN: Helpdesk Code Word:
Business Information
Title: Managing Partner
Phone
Fax:
Email
Webs! e.
Fax:
Additional Information
Critical Infrastructure: Information Technology
1
EFTA00173921
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 organizations you are affiliated with:
Why do you want to join InfraGard?
How did you hear about infraGard? Colleague
EFTA00173922
InfraGard
Standardized Record Checks for InfraGard Applicants
APPLICANT INFORMATION
Name: DOB: SSN:
CLEARANCE CHECK (SCATTERED CASTLES or JPAS)
Conducted by: I Date:
Applicant Response: No
Results:
CITIZENSHIP CHECK
Conducted by: I Date:
Applicant Response/POB: Citizen By Birth / chicago, IL,
Results:
DRIVER'S LICENSE CHECK & PHOTO
Conducted by: Date: DL(State):
Results:
• MPLETE RIMINAL HI Ts RY N I III Wants and Warrants and State Records
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
Deny. see FD-1057 Date Reviewing Authority
3
EFTA00173923