NOTE: By signing, the SUPERVISOR'S NAME (please print)

supervisor is certifying that

the application has been

reviewed for accuracy.

AA SIGNATURE

 DISAPPROVED

 DISAPPROVED

DATE ASD RECEIVED PARKING SPACE 

ARE YOU CURRENTLY RECEIVING TRANSIT ARE YOU ASSIGNED A GOVERNMENT-OWNED VEHICLE?

SUBSIDY FUNDING?

YEAR

U.S. DEPARTMENT OF AGRICULTURE

FOOD SAFETY AND INSPECTION SERVICE

 GOVERNMENT PAID PARKING APPLICATION

 FOR NON-BARGAINING UNIT EMPLOYEES

SECTION 1 (to be completed by employee)

NAME (Last) (First) SSN (last 2 digits only) BUILDING ROOM

WORK ADDRESS (include telephone number) CITY STATE ZIP CODE

VEHICLE(s)

OF PRIMARY

APPLICANT

MAKE COLOR LICENSE TAG # STATE REGISTERED

YES NO

TYPE OF SPACE APPLYING FOR:

SINGLE OCCUPANCY (specify):

CARPOOL*

IF SO, DO YOU HAVE AN APPROVED HOME-TO-WORK AUTHORIZATION ON FILE?

VANPOOL*

IN A BRIEF SUMMARY, PLEASE PROVIDE A JUSTIFICATION OF DUTIES THAT WARRANTS SPECIAL CONSIDERATION TO USE FSIS APPROPRIATED FUNDS TO PROCURE A PARKING SPACE ASSIGNMENT

FOR OPERATIONAL EFFICIENCY. (If more space is needed, please attach a separate sheet).

YES NO YES NO

IF APPLYING FOR A SINGLE OCCUPANCY, WHAT 

ELIGIBILITY CATEGORY ARE YOU APPLYING FOR

(check one):

AT THE REQUEST AND INTEREST OF FSIS

HOLD A POSITION IN CERTAIN FIELD LOCATIONS

WHERE FSIS HAS EXPERIENCED EXTREME

DIFFICULTY RECRUITING OR RETAINING

(Specify position title below):

* Carpool/Vanpools: 

 Please provide

 information for 

 each rider on

 page 2)

APPLICANT'S SIGNATURE DATE SUPERVISOR'S SIGNATURE DATE

SECTION 2

(OAS /MWSD

USE ONLY) 

MWSD SIGNATURE

DISTRICT MANAGER or DIRECTOR SIGNATURE DATE

DATE

FSIS FORM 2450-7 (07/11/2013)

INSTRUCTIONS:

1. Application must be fully completed by employee before consideration is given. 

2. Employee must obtain approval & signature from their District Manager or Director, 

 AA, and FSIS Administrator before submitting a single occupancy application. 

3. Carpool/Vanpools: Please provide information on riders - page 2.

4. Submit application to: OAS/PMB, 5601 Sunnyside Ave Mail Drop 5230, Beltsville,

 MD 20705; Fax: (301) 504 - 4231; or Scan copy to GovtPaidParking@fsis.usda.gov ** See Privacy Act Statement on Page 2.

APPROVED

DISAPPROVED

APPLICATION: OAS SIGNATURE

DATE

FSIS ADMINISTRATOR SIGNATURE DATE

APPROVED

APPROVED

DISAPPROVED

APPROVED

 FOR SINGLE OCCUPANCY APPLICATION
FULL NAME SSN (last 2

digits only)

FEDERAL AGENCY 

(if other than FSIS)

WORK ADDRESS 

(include telephone number)

Is the rider

receiving Transit

Subsidy Funding? 

* CARPOOL/VANPOOLS: Please provide the following information for each rider.

Section 6311 of Title 5, United States Code, authorizes collection of this information The following information is being provided in compliance with the Privacy Act of 1974 (Public Law 93-579). The primary use of the requested

information is to process a request for government paid parking. This information may also be shared with appropriate Federal, State, local or foreign agencies when relevant to civil, criminal or regulatory investigations, or

prosecutions. 

When the employee identification number is your Social Security Number (SSN), collection of this information is authorized by Executive Order 9397. Furnishing the information on this form, including your SSN, is voluntary, but

failure to do so may result in delay or suspension of processing this request 

** PRIVACY ACT STATEMENT