United nations nations unies




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UNITED NATIONS



NATIONS UNIES

Security and Safety Service

New York
APPLICATION FOR GROUNDS PASS




Section 1 - GENERAL INFORMATION – TO BE COMPLETED BY ALL APPLICANTS

(Do not leave fields of information blank unless otherwise indicated)

FIRST NAME :

M. I. :

LAST NAME :

     

     

     

Room No.:

     

Ext.:

     

Nationality:

     

Place of Birth:

     

Date of Birth: (Day/Month/Year)

     

Eye Color:

     

Hair Color:

     

Height:

     

Weight:

     

Sex:

Home Address While Working at Headquarters: ( Street, Apt. No., City and ZIP Code)

Telephone No.:

Mobile No.:



     

     

     

Emergency Contact: (FIRST, MI, LAST NAME)

Telephone No.:

Mobile No.:

     

     

     

Permanent Address : (Street , City, ZIP Code and Country) :

     



Section 2 - TO BE COMPLETED BY EXECUTIVE OFFICE OR OHRM

Department:

Division:

Title:

Index No.:

Type of Contract:

OHCHR

HRTD

NGO

     

     

EOD :      

(Day/Month/Year)



Duty Station:      

Type of Pass: Staff  Affiliate  Retiree  Intern  Others 

Reason for Request: New  Renewal  Status Change  Replacement 

Expiration Date

(Day/Month/Year)



01/08/2012

(Duration of contract or otherwise) NOTE: No erasures, alterations or amendments in this field will be accepted by the Pass and Identification Unit

Name of Authorized Signatory:

     

     

     







LAST

FIRST NAME

M.I.

Signature:








     



Room No.:

     

Telephone No.:

     




Date (Day/Month/Year)














Section 3 - TO BE FILLED IN BY CONSULTANTS/AFFILIATES

(Outside Contractors Only)

Name of Company:      

Address of Company

(Street, City, State, Country):



     

Telephone No.:

     




I certify that the above information is true and correct and that it is my responsibility to update general information where applicable. I understand that I must wear this grounds pass visibly while accessing the United Nations Headquarters premises in New York and to surrender my grounds pass when requested to do so by an officer of the Security and Safety Service. I understand that I will be required to surrender my grounds pass when I am separated from service or suspended from duty in the context of disciplinary proceedings. I also understand that this grounds pass is for the intended purpose of permitting access to the United Nations premises in New York and not for any other purpose. This grounds pass is non-transferable and misuse will result in its confiscation.

Signature of Applicant: __________________________________________________ Date: ______________________



(Day/Month/Year)


SSS.160 (11-06)


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