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BADGE # _______________ <br />City of Eugene <br />Mahlon Sweet Field <br />28855 Lockheed Drive <br />Eugene, Oregon 97402-9500 <br />Eugene Airport <br />541/682.5430 <br />VENDOR/CONTRACTOR APPLICATION <br />Fax: 541/682.6838 <br />www.eugeneairport.com <br />Legal Last Name <br />Legal First NameLegal Middle Name <br /> <br />SSN 4 –Digit Pin Number <br /> - - <br />Airport Use Only <br />TSA No-Fly or Selectee: NO YES Verified: ____________________________ <br />Other Known Names Maiden/Nickname/Aliases _______________________________________________ <br />Home Address ____________________________ City, State, Zip _________________________ <br />Home Phone _____________________________ Alternate Phone __________________ _____ <br />E-mail Address ________________________________________________________________________ <br />Drivers License# ______________________ State __________ Expiration Date _____/_____/______ <br />Other ID as required ________________________ _________ Expiration Date _____/_____/______ <br />(Passport, Alien Registration Number, Non-Immigrant Visa Number) <br />Date of BirthBirth Location <br /> ______________________ ___________________________________ <br />Citizenship CountryGender <br /> __________________ Male Female <br />ÙÙ <br />Race <br />Asian Black Caucasian Latino Native American Unknown <br />Ù ÙÙ ÙÙÙ <br />WeightHeight <br />Eye Color <br /> _______________ <br /> <br />Hair Color Scars <br />__________________ ___________________________________ <br /> <br />ÏÏÏ <br />Access Requested to : North Gate East GA Gate Corral <br />ÏÏ <br /> South Gate Hollis Gate <br /> <br /> <br />Page 1 of 8 <br /> <br />