NCSPA Port Access Card Application REVISED …

1 NCSPA Port Access card Application REVISED 04/10/17 *If you have questions contact the Port Police Department at 910-343-6296 or 910-279-7121 By signing this Application , I certify that the information that I have presented is truthful and that any misrepresentation or falsely given information could result in the revocation of my NCSPA Access card . I have reviewed or attended a presentation and that I understand the federal and state security requirements presented. _____ _____ Signed Date Emergency Contact Information: _____ Name _____ Address _____ City _____ State and Zip Code _____ Telephone Number _____ Relationship to You Employer Information: _____ Name of Employer _____ Phone Number _____ Address _____ City _____ State and Zip Code _____ Employee ID Number _____ _____ _____ Last Name First Name Middle Name _____ Street Address _____ _____ _____ City State Zip Code _____ _____ _____ Date of Birth Drivers License Number State _____-_____-_____ _____-_____-_____ _____-_____-_____ Social Security Number Home Phone Cell Phone ** NOTE ** All port users are required to obtain a NCSPA Port Access card .

2 Port Access Cards will be issued for valid NCSPA business needs ONLY. There is a $ fee associated with the Port Access Cards and for each replacement Port Access card . Port Use Only Port ID card # ___ _____ TWIC card # _____ Alien ID # __ _____ _ TWIC card Expiration Date _____ MSA Training _____ Escort Training _____ Processed By: _____