<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 0%" />
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<col style="width: 5%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 7%" />
<col style="width: 4%" />
<col style="width: 0%" />
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<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 0%" />
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<col style="width: 2%" />
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<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="36"><p>Federal Deposit Insurance Corporation</p>
<p><strong>EMPLOYEE/CONTRACTOR IDENTIFICATION CARD
REQUEST</strong></p></td>
</tr>
<tr class="even">
<td colspan="36"></td>
</tr>
<tr class="odd">
<td colspan="36"><strong>INSTRUCTIONS:</strong> Please print legibly
when completing this form. All requested building and floor access
levels must be specified. Failure to identify individual floors will
result in this form being returned without action. Supervisors must
approve all access levels. Return the completed form to the FDIC
Security Office, Room F1C-3A. For Service Centers and Regional Offices,
please return this completed form to the Facilities Manager or other
designated official. Upon receipt of the completed form, the Security
Office, Facilities Manager, or other designated official will call and
make an appointment with you to take your picture and issue you an FDIC
Identification Card.</td>
</tr>
<tr class="even">
<td colspan="36"><strong>SECTION I - EMPLOYEE/CONTRACTOR
INFORMATION</strong></td>
</tr>
<tr class="odd">
<td colspan="16">NAME <em>(Last, First, MI)</em></td>
<td colspan="20">SOCIAL SECURITY NUMBER <em>(Last 4-digits)</em></td>
</tr>
<tr class="even">
<td colspan="16">     </td>
<td colspan="20">    </td>
</tr>
<tr class="odd">
<td colspan="7">OFFICE PHONE NUMBER</td>
<td colspan="9">DIVISION/OFFICE</td>
<td colspan="20">BUILDING/ROOM NUMBER</td>
</tr>
<tr class="even">
<td colspan="7">     </td>
<td colspan="9">     </td>
<td colspan="20">     </td>
</tr>
<tr class="odd">
<td colspan="7">HEIGHT</td>
<td colspan="9">WEIGHT</td>
<td colspan="20">DATE OF BIRTH</td>
</tr>
<tr class="even">
<td colspan="7">     </td>
<td colspan="9">     </td>
<td colspan="20">     </td>
</tr>
<tr class="odd">
<td colspan="36"><strong>SECTION II - TYPE OF BADGE REQUIRED</strong>
<em>(Check the appropriate boxes.)</em></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="4"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="3"><p> FDIC Employee</p>
<p> Car Pool</p>
<p> Day Care Center</p></td>
<td colspan="7"> New</td>
<td colspan="11"> Other <em>(specify)</em></td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td colspan="7"> Replacement - LOSS</td>
<td colspan="21">     </td>
</tr>
<tr class="odd">
<td colspan="7"> Replacement - THEFT</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="8"> Contractor</td>
<td colspan="7"> Access Card (1700/1730)</td>
<td colspan="4" rowspan="2"></td>
<td colspan="4" rowspan="2"></td>
<td colspan="5" rowspan="2"></td>
<td colspan="3" rowspan="2"></td>
<td colspan="3" rowspan="2"></td>
<td colspan="2" rowspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="5"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="36"><strong>SECTION III - WASHINGTON METRO AREA
ACCESS</strong></td>
</tr>
<tr class="odd">
<td colspan="36"></td>
</tr>
</tbody>
</table>

  ---------------- -------------- --- --- --- -- ------- -- -------- ---------- ------------- ------------ -----------------
  Standard *(All                                                                                           
  Buildings)*                                                                                              
  Special                                                                                                  
  *(specify)*                                                                                              
                                                                                                           

  **SECTION IV -                                                                                           
  REGIONAL                                                                                                 
  OFFICE/FIELD                                                                                             
  OFFICE/SERVICE                                                                                           
  CENTER ACCESS**                                                                                          

                                                                                                           

  List the                                                                                                 
  geographical                                                                                             
  area,                                                                                                    
  building(s), and                                                                                         
  applicable floor                                                                                         
  numbers, to                                                                                              
  which access is                                                                                          
  required below.                                                                                          

                                                                                                           

                   Geographical                                                                            
                   Area                                                                                    

                                                                                                           

  BUILDING(S)                                               FLOOR               BUILDING(S)                FLOOR

                                                                                                                

                                                                                                                

                                                                                                                

                                                                                                                

                                                                                                                

                                                                                                                

                                                                                                                

  **SECTION V -                                                                                            
  CONTRACTOR                                                                                               
  INFORMATION**                                                                                            

  COMPANY NAME                                                       CONTRACT                 CONTRACT     
                                                                     NUMBER                   EXPIRATION   
                                                                                              DATE         

                                                                                                           

  FDIC OVERSIGHT                                                                              OFFICE PHONE 
  MANAGER\'S NAME                                                                             NUMBER       
  *(Please print)*                                                                                         

                                                                                                           

  FDIC OVERSIGHT                                                                              DATE         
  MANAGER\'S                                                                                               
  SIGNATURE                                                                                                

                                                                                                           

  **SECTION VI -                                                                                           
  SUPERVISOR                                                                                               
  APPROVAL AND                                                                                             
  ADMINISTRATIVE                                                                                           
  VERIFICATION**                                                                                           

  SUPERVISOR\'S                                                                               OFFICE PHONE 
  NAME AND TITLE                                                                              NUMBER       
  *(Please print)*                                                                                         

                                                                                                           

  SUPERVISOR\'S                                                                               DATE         
  SIGNATURE                                                                                                

                                                                                                           

  ADMINISTRATIVE                                                                              DATE         
  OFFICER\'S                                                                                               
  SIGNATURE                                                                                                

                                                                                                           
  ---------------- -------------- --- --- --- -- ------- -- -------- ---------- ------------- ------------ -----------------

FDIC 1620/01 (9-01)

  ---------------------------------------------- ------------------------
  **SECTION VII - RECIPIENT\'S DECLARATION AND   
  SIGNATURE**                                    

  I understand that this card is the property of 
  the Federal Deposit Insurance Corporation, an  
  agency of the United States of America. Any    
  counterfeiting, forgery, tampering or misuse   
  is a criminal offense (U.S. Code Title 18 §499 
  and 701). Furthermore, I understand that any   
  false statement made in relation to this       
  identification card request is a criminal      
  offense (U.S. Code, Title 18 §1001).           

  EMPLOYEE/CONTRACTOR\'S SIGNATURE               DATE

                                                      

  FOR SECURITY OFFICE USE ONLY                   

                                                 

  **PRIVACY ACT STATEMENT**                      

  Collection of this information is authorized   
  by 12 U.S.C. § 1819 and Executive Order 9397.  
  The information requested on this form will be 
  used by FDIC personnel to issue you an FDIC    
  Identification Card for certain FDIC programs  
  and for access to FDIC facilities. Your Social 
  Security Number (SNN) is requested to further  
  ensure record accuracy and to differentiate    
  you among others with similar or identical     
  names. Disclosure of this information may also 
  be made in accordance with the \"routine uses  
  of records\" listed in the FDIC\'s Financial   
  Information Management Records, #30-64-0012,   
  including disclosure to: the General           
  Accounting Office for inspection by auditors;  
  appropriate Federal or State agencies for      
  enforcement if a violation or possible         
  violation of civil or criminal law is          
  apparent; a court, magistrate, or              
  administrative tribunal when the FDIC is a     
  party to the proceeding or has a significant   
  interest in the proceeding; the U.S. Office of 
  Personnel Management and other appropriate     
  agencies or offices to the extent disclosure   
  is necessary to carry out government-wide      
  personnel management, investigatory, and       
  adjudicatory functions: a congressional office 
  in response to an inquiry made at the request  
  of the individual; the Internal Revenue        
  Service, the Social Security Administration,   
  State and local tax authorities; the FDIC      
  Office of the Inspector General for audit      
  purposes; a consultant, person or entity who   
  contracts or subcontracts with the FDIC, to    
  the extent necessary for the performance of    
  the contract or subcontract; and to the        
  Department of the Treasury, or another party   
  for the purpose of collecting or assisting in  
  the collection of a delinquent debt owed to    
  the FDIC. Completing this form is voluntary.   
  However, failure to provide all of the         
  requested information (including your SSN) may 
  delay or prevent the FDIC from issuing you an  
  FDIC Identification Card.                      
  ---------------------------------------------- ------------------------

FDIC 1620/01 (9-01) Page 2