APPLICATION Date______________ Date of Birth________________ First Name___________________ MI_________ Last Name____________________________ Business/Organization Name____________________________________________________________ Address______________________________________________________________________________ City_________________________ State__________________ Zip Code___________________ Your Position/Title_____________________________________________________________________ Type of Business______________________________________________________________________ 24 Hour Phone Number_________ Phone Number__________ Extension:__________________ FAX Number _______________ Cell Number____________________________________________ Email Pager Number____________________________________________________________________ Text Messaging Address (optional)_____________________________________________________________________________ Additional Contact Person_______________________________________________________________ Number Non-Security Employees_________________________________________________________ Number Security Personnel______________________________________________________________ Number Armed Personnel_______________________________ Number Peace Officers___________ Retired from Law Enforcement? No Yes (If Yes, Describe below) _____________________________________________________________________________________ Have you ever been convicted of a crime? No Yes (If Yes, Explain below. A local criminal history check will be conducted) _____________________________________________________________________________________ Signature of Applicant__________________________________________________________________ Fax or email completed form to Homeland Security Counter Terrorism Bureau 516-573-8445 or SPIN@pdcn.org 02/08 Nassau County Police Department Homeland Security Counter Terrorism Bureau SECURITY/POLICE INFORMATION NETWORK A Public/Private Sector Partnership Thomas R. Suozz i County Executive Lawrence W. Mulvey Commissioner of Police SPIN