UNITED NATIONS un.gif (1169 bytes) NATIONS UNIES

Security and Safety Service
New York

APPLICATION FOR GROUNDS PASS

Section I - General Information - to be completed by all applicants
(Do not leave fields of information blank unless otherwise indicated)
1. Have you ever been issued a grounds pass at United Nations Headquarters (New York)? Yes __   No __
If "Yes" state type of pass and duration:
2. Are you currently in possession of a valide United Nations grounds pass? Yes __   No__
If "Yes" state type of pass and duration:
3. Family Name
(family name as appears in national passport or valid US driver's license or state identification card bearing a photo)
4. Given Name
(given name(s) as appears in national passport or valid US driver's license or state identification card bearing a photo)
5. Date of Birth
(Day-Month-Year)		  
6. Place of Birth
(City & Country)		  
7. Present Nationality(ies)
(indicate the name of Country of present nationality. Note for staff members, consultants and interns: In case of dual nationalities, enter the nationality submitted to respective UN offices.)
8. Sex Female: __     Male: __
9. Eye Color Brown: __   Blue: __  Green: __   Hazel: __  Grey: __  Other: __
10. Hair Color Brown: __   Blue: __  Green: __   Hazel: __  Grey: __  Other: __
11. Height
(Metric Unit cm or approximate U.S. equivalent in feet and inches - 0.39 inch = 1 cm).
12. Weight
(Metric Unit kg or approximate U.S. equivalent in pounds - 2.2 pounds = 1 kg).
13. Permanent Address Street Address:
City:
State/Province:
Postal Code:
Country:
14. Local Address Street Address:
City:
State/Province:
Postal Code:
(Indicate local address in the Greater New York Metropolitan Area. If same as above write "same" in box.)
15. Telephone Number
(Indicate personal telephone or cellular phone number where you may be contacted outside of normal business hours (9:30 a.m. - 5:30 p.m.))
16. Person to notify in the event of an emergency Name:
Telephone:
17.

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 the 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.35(10-02)