Required Information

For the

Security Assurance Check (SAC) Request

(To Be Completed by Student Applicant)

Please mail or fax this information to the Student Internship Coordinator at Post.

1. Full Name: ____________________________________

2. Social Security Number: ____________________________________

3. Place of Birth (POB): ____________________________________

4. Date of Birth: ____________________________________

5. Current Street Mailing Address: ____________________________________

_____________________________________

_____________________________________

6. Phone Number: _____________________________________

7. E-Mail Address: _____________________________________