Example of a Filled Out
Users' Identification Verification Form

                         Fermilab                        

 

 

Name:

Swietzer

John

James

Last                                                           First                                                     Middle

 

University or Institution Name:                                                              Telephone:

Florida State University

850-644-XXXX

 

 

Experiment/Department:

Exp. / Dept.	Spokesperson	Home Institution Contact	Contact Telephone
DØ	Womersley/Weerts	Sharon Hagopian	850-644-4777

 

Email Address (Internet):

jswietzer@fnal.gov

jswietzer@hep.fsu.edu

Fermilab                                                                                Home Institution

 

Do you want to subscribe to:                 Users’ Organization email distribution list?                     Yes    No X

                                                            Graduate Student Association email list?                        Yes    No X

 

 

Date of Birth: 3 Jan 1842__ City/State of Birth: Vienna____________________Country: Austria_______

                        Mo./Day/Yr.

 

U.S. Social Security Number:________________________Passport Number:876543_____________________

                               

Drivers License Number:_________________________________State/Country: ________________________

 

Professional Class:  (Circle One)

  Physicist (Ph.D.) XXX                             Graduate Student                  Undergraduate

  Computer Programmer                    Engineer                               Technician

  Other (Specify):                                         

 

Experiment/Office Location: Off-site_____________________________________________

 

Fermilab Phone Extension: None_______________________Mail Station: 357_____________            (over)

                                                                                                                                                           

Local Residence Address:_____________________________________________Telephone:_______________

 

Name of Spouse: ______________________________________________  Here   Not Here

 

IN CASE OF EMERGENCY, PLEASE NOTIFY:

 

Name	Relationship	Address	Telephone

 

 

FAMILY MEMBERS:

List the name, relationship, date of birth, and citizenship of any family members who have accompanied you here or who may join you here at a later date.

Name	Relationship	Date of Birth	Citizenship

 

Non-U.S. Citizens

 

Country of Citizenship: Germany________________________________   Male: X   Female: 

 

Are you an Immigrant Alien (U.S. Resident)?            Yes: X      No: 

 

SAFETY COMPLIANCE:

I have viewed A Few Words About Safety, the 25 minute safety video for users, have read Chapter II, “The Basics: What Every Experimenter Needs to Know,” from the Procedures for Experimenters.  I hereby accept responsibility for complying with the safety practices contained herein and I understand that failure to comply with these procedures may be cause for the laboratory to deny me access to its research facilities.

 

 

Signed:_______________________________________ Date: _____________________

 

 

FERMILAB COMPUTER SECURITY POLICY:

This document may also be found at http://security.fnal.gov/policies/cpolicy.html along with any updates. Guidance for computer security at Fermilab is at http://www-dcd.fnal.gov/computersecurity.  I have received and read the Fermilab Policy on Computing dated ___________________(may be found on last page of policy).

 

 

Signed: _______________________________________ Date:_____________________

 

 

Have Your IB Representative sign here to verify your signature

 

USER VALIDATION:  _________________________________________________________

                                                 Spokesperson/Division/Section Head

 

 

                                                         For Office Use Only