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Contractor Employee Data Form for Non Access Cards (COLORED PASSES)

TO BE COMPLETED BY CONTRACTOR’S EMPLOYEE (Employee should be prepared to show CPS Energy documentation validating
personal identifying information provided below (i.e., driver’s license, passport, etc.).

PLEASE PRINT OR TYPE INFORMATION:

DATE: ___________________

CPS Energy Field Rep: ______________________________________________ Phone Ext: ___________________________________

Contractor Company Name: _______________________________________________________________________________________

Work Location(s): _______________________________________________________________________________________________

Contractor Employee Name: __________________________________________E-mail: ______________________________________

Date of Birth: _______________________ Driver License Number/State: ___________________________________________________

Home Address: _________________________________________________________________________________________________

_________________________________ / _______________________ / ___________________________________


(City) (State) (Zip)

Home Phone: (______)_______________________ Mobile Phone: (_____)__________________________________________________

P.O. Number: ____________________ P.O. Start Date: ___________________________ P.O. End Date: ________________________

U.S. Citizen? (Yes or No) If No, please complete the following:

Country of Citizenship: ____________________________________________________________________________________

Passport Type and Number: _______________________________________________________________________________

Date of Passport Issue: ___________ Date of Passport Expiration: _________________________________________________

Type of visa and expiration date: ____________________________________________________________________________

Permanent Resident of the United States? If yes, provide Permanent Resident Number: ________________________________

I hereby certify that the above information is true and correct.

Signature ________________________________________________ Date _________________________

September 09, 2013

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