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Exhibit C: FLORIDA Individual Security Form <br />0 FLORIDA INDIVIDUAL SECURITY iNFC3RMATION FORM <br />idenl:itying Infonnation: <br />1 • 2. 3. 4. Mr. MS. MRS. <br />Last Name First Name MI. (Circle One) <br />5. Social Security Number. 6. Position Title: 7. UCB: Yes No <br />S. A'gencyJBusiness: _ 9. Contracted with: 10. Access to Federal Tax InformationYES_NC <br />10a.,Access to SAVE YES NO 10b. Access to AMS YES -NO 10c. AMS ROLE <br />rrae:ex+-rr,�.a-ver,eirxxxexxrxxexx�a�••erax.xexxteyx:rarrxe+,exx rx•�exx••x+reerxx�rx•�•�xearxaren•ei-rsxar+,ea,�•xx•xx,.,,e+,r.,�•axw•exwrsiw rya++••ea,.e,�,>axezxax�••xs,�eexsx,rxra:a,.xraa-..:krr:exx•x,re,e+ax•x�crxew,r: <br />User:ID(st updates: Action Requited: A = ADD C = CHANGE S = SUSPEND D e DELETE R e RESTORE <br />Action R►orker Security. Security Profile Profile, <br />11. Required 12.: User ID 13. _Type 14. Profile Name„ 15. Level 16. Begin Date 17. End Date <br />Site Information:. <br />18. DidtrictJCSE Region: 19. Service -Site County No.: 20. Service -Site Location No.: <br />21.:5uncom # 22., Area CodeA Phone #•, 23: User E -Mail address <br />'z� a ' ` :sem <br />Z4 ; Ar1m>3aistratt�ie>Uiiit Asstgtied;. <br />ab -!i6. 26.:Primary_ Unit Supervisor's ID <br />.<�upieYvisoi's<%�fs�tr►e:`:.'a::,.,.::::>:.- .: - <br />*'P U, <br />30.. Justification? Comments <br />The employee has completed the DCF Security Amareness Training (1'0OV4 and the DCF Security A%mreness Recertification Training (SOOBVu) <br />The employee hasgiewed UMAX <br />31. 32, <br />Signature of Requester, DATE Signature of Administretor or Next Level Supervisor DATE <br />33. 34. <br />Signature ofDisfrict/Region Security Officer DATE <br />35. <br />Signature of OPA/Program Administrator DATE <br />Latt Updated; AtgtstiT.2010 <br />9 <br />Signature of HQTR Security Officer <br />DATE <br />CF M. MayM a)btokles CF113 of OOM(bj 110 may rotbe tied) *tDON Nrmbe r: 5T{o-DDB-0113-p <br />7 1 P a g e <br />V <br />CO <br />